Endometriosis and Menopause: Symptoms, Risks, and Treatment

After years of living with severe pain that healthcare providers all too often dismiss, many women hope that menopause will bring an end to their endometriosis symptoms — but is that always the case? While symptoms typically improve after menopause, there are rare cases in which they may continue into a woman’s postmenopausal years. This article will explain the science behind why endometriosis symptoms may persist later in life and explore the benefits and risks of available treatment options.

About 10% of reproductive-age women and girls worldwide are affected by endometriosis.⁽¹⁾ It’s a non-cancerous condition where uterine-like tissue grows outside of the uterus, causing scar tissue and lesions to develop. This abnormal tissue growth can also occur on or around the ovaries, cervix, vagina, bladder, bowel, or rectum. Pelvic pain is the most common symptom, particularly during a woman’s period.⁽²⁾

Although less common, postmenopausal endometriosis is estimated to affect between 2% and 4% of women.⁽³⁾ Experts don’t know the exact cause of endometriosis, including postmenopausal endometriosis. However, the condition is believed to be influenced by estrogen levels.

What happens to endometriosis after menopause?

Endometriosis is an estrogen-dependent disease, meaning it’s fueled by estrogen. The ovaries are the main source of estrogen in the female body. As the ovaries produce less estrogen during menopause, many women find that their symptoms go away. 

However, the ovaries aren’t the only part of the body that produces estrogen. Smaller amounts are produced in fatty tissue and the skin. Hormone replacement therapy (HRT) has also been linked to endometriosis, as estrogen therapy can trigger old endometriotic tissue growth. These alternate sources of estrogen may contribute to cases of postmenopausal endometriosis.⁽³⁾⁽⁴⁾

Most cases of postmenopausal endometriosis affect the ovaries. It’s possible that new endometriotic lesions may develop during this phase of life or that existing asymptomatic lesions may become active and cause symptoms. However, it can be hard for experts to tell the difference between the two. Research shows that postmenopausal women, even those up to 80 years old, have experienced pain related to endometriotic lesions.⁽³⁾⁽⁴⁾ 

On the other hand, some postmenopausal women may have lesions but not experience any symptoms at all. Women who have a history of endometriosis symptoms during their reproductive years, signs of prior endometriosis, or obesity may be at an increased risk of the condition.⁽³⁾⁽⁴⁾

Symptoms of Postmenopausal Endometriosis

Symptoms of postmenopausal endometriosis are non-specific, making them easy to confuse with other health conditions. However, knowing the signs can help women recognize potential symptoms later in life.

The following are symptoms of endometriosis that some women may experience after menopause:^(3)(4)(5)(6)

• Pelvic Pain: Pelvic pain may be persistent or recurrent and may feel similar to a muscle spasm. It may also spread to the legs or back.

• Dyspareunia: Women diagnosed with postmenopausal endometriosis often experience pain during sex.

• Intestinal Pain: Intestinal discomfort is a common symptom of postmenopausal endometriosis.

• Ovarian Cysts: Ovarian cysts can indicate postmenopausal endometriosis. However, cysts can develop for other reasons unrelated to endometriosis, making cancer testing crucial.

• Urinary or Bowel Symptoms: Endometriotic lesions affecting the bladder or bowel may cause difficulty urinating or bowel obstructions.

• Abnormal Bleeding: Bleeding may occur from the vagina or rectum.

• Hematuria: Bladder lesions may cause blood in the urine.

Some symptoms of postmenopausal endometriosis may resemble certain menopausal symptoms, including the following: 

• Painful sex 

• Low sexual desire

• Psychological symptoms

However, the following symptoms are considered more specific to menopause than to endometriosis:

• Hot flashes

• Night sweats

• Mood swings

• Vaginal atrophy

The HRT & Endometriosis Question: Evidence-Based Responses

HRT can provide relief for postmenopausal women with endometriosis who are struggling with menopausal symptoms. However, there are potential risks that must be taken into account when deciding if HRT is appropriate for a patient.

Why HRT Can Be a Concern

Supplementing levels of estrogen in the body with HRT may reactivate endometriotic tissue. A doctor will also factor in the risk of malignancy. In approximately 1% of cases, endometriosis lesions may become cancerous. HRT treatment may increase the risk of malignant transformation, although this is more often seen with unopposed estrogen therapy.⁽⁷⁾ 

The Solution: Continuous Combined HRT

While estrogen-only therapy may pose risks for postmenopausal women with endometriosis, adding a progestogen may reduce these health risks. Progesterone is a reproductive hormone naturally produced in the body. While estrogen promotes endometrial cell growth, progesterone suppresses it. Progestogens act on progesterone receptors in endometrial tissue and may help reduce lesion growth.^(4)(7)(8)

The British Menopause Society recommends continuous combined HRT treatment with estrogen and progesterone for women with endometriosis who have a uterus.⁽⁹⁾ This means that the medication is taken daily with no breaks. Continuous combined HRT has been linked with a lower risk of endometriosis recurrence.^(4)(10)

What about after a hysterectomy? 

Whether HRT is appropriate for women with endometriosis who have had a hysterectomy may depend on how much endometriosis tissue is left over after surgery.⁽⁹⁾ Microscopic endometrial cells can also remain. For this reason, continuous combined HRT with estrogen and progesterone is recommended after surgery and for as long as needed to manage symptoms.

Treatment Options for Symptomatic Postmenopausal Endometriosis

While more research is needed on treatments specific to postmenopausal women, surgery and medications are the two main treatment options for women experiencing symptoms of endometriosis after menopause.^(3)(4)(11) 

Surgery: The Primary Approach

Surgery is the primary diagnostic and treatment method for symptomatic postmenopausal women to reduce the risk of endometriosis recurrence and cancer. A laparoscopy should first be performed to get a thorough look at the abdominal organs and rule out cancer. A surgeon will then remove all visible endometriotic lesions. In some cases, the procedure may also include the removal of certain reproductive organs. Surgery is considered highly effective in reducing endometriosis pain symptoms.^(3)(4)(7)

Medical Management

Oral progesterone or a hormonal intrauterine device may be recommended if a patient cannot undergo surgery or if pain symptoms do not resolve after the procedure.⁽³⁾⁽⁴⁾

A doctor may alternatively prescribe aromatase inhibitors (AIs). These drugs suppress estrogen production in the body. They also block aromatase activity in endometriotic lesions, an enzyme that helps convert androgens into estrogens. While scientific evidence is limited, AIs may help decrease the size of lesions and reduce endometriosis symptoms in postmenopausal women who have undergone natural menopause or surgical menopause. However, AIs may produce side effects, including vasomotor symptoms, vaginal dryness, and bone loss.⁽³⁾⁽⁴⁾ 

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, may also be used to treat mild to moderate pain symptoms as needed.⁽²⁾

Finding Support for Postmenopausal Endometriosis

Women who have endured endometriosis throughout their reproductive years may need continued support during postmenopause. A knowledgeable healthcare provider can help women not only manage their symptoms but also safeguard their long-term health. 

Get a direct path to individualized treatment with Winona and start your free visit today.