Endometriosis and menopause

Endometriosis is a chronic gynaecological condition estimated to affect 10% of women and girls of reproductive age globally. Tissue similar to the lining of the uterus grows in other parts of the body and responds to the hormonal changes that occur during a menstrual cycle, resulting in severe pain. Endometriosis can drastically impact an individual’s life yet there is no known cure. Instead, treatment is usually aimed at managing the symptoms.

Adenomyosis is a different condition from endometriosis, however they are often seen together. It is a condition when the womb lining (endometrium) starts to grow in the muscles of the womb (myometrium).

Menopause is a transitional life stage that all women who have periods go through. It occurs due to loss of ovarian function, marks the end of your reproductive years and is characterised by your periods stopping. You can find out more about what happens and its symptoms in our [menopause guide]. You may think, therefore, that once your periods end, the symptoms of endometriosis will also cease. However, this is not always the case.

In this article, we look at how endometriosis and menopause influence one another, along with diagnosis and treatment options.

What is endometriosis?

Endometriosis is a condition where cells similar to those in the womb lining (endometrium) grow in abnormal places in the body including on the ovaries, fallopian tubes, bladder, bowel and sometimes further afield.

This tissue responds to hormones (oestrogen and progesterone) during the menstrual cycle just like the lining of the uterus does. It thickens and breaks down each month. Unlike the uterine lining, however, it cannot flow out of your body through your vagina, which is what happens during your period. This results in pain, which can be debilitating.

Currently, it is not known exactly why this happens, but could be genetic, or due to immunological or hormonal reasons. At present, some of the leading theories on the cause of endometriosis are:

Retrograde menstruation: Where menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity at the time as a period, resulting in endometrial-like cells being deposited outside the womb.
Benign metastasis: A small amount of the endometrial tissue can be spread through the uterine-draining lymph vessels during menstruation.
Cellular metaplasia: When cells change from one type to another. Cells outside the uterus change into endometrial-like cells and start to grow.
Stem cells: Stem cells give rise to the disease, which then spreads through the body via blood and lymphatic vessels.
Immune dysfunction: In some instances, it is thought that the immune system is unable to fight off endometriosis.
Environmental causes: There may be certain toxins, such as dioxin, which can affect the body, the immune system and the reproductive system, leading to endometriosis.

It is difficult to know exactly how many people this condition affects, as symptoms can vary and often it can go undiagnosed. It’s thought that the condition affects between 1 in 10 and 5 in 10 women, around reproductive age.

What is adenomyosis?

Adenomyosis is a medical condition that is different from endometriosis but can often occur alongside it. Tissue which should be on the wall of the endometrium grows in the muscle. This tissue behaves like the tissue in the womb lining, so thickens and bleeds with a woman’s monthly period. This can cause the womb to grow, thicken and become bulky, leading to similar symptoms of endometriosis.

What are the symptoms of endometriosis?

Symptoms of endometriosis can vary in severity and do not always correlate to the amount of endometriosis present in the body. Not everyone with endometriosis experiences symptoms but common symptoms include:

Painful periods
Heavy bleeding during periods
Pain during sex – particularly deep pain which can last hours afterwards
Lower abdominal/pelvic (tummy) pain
Bleeding in between periods
Difficulty in getting pregnant
Fatigue
Bloating or nausea
Pain opening your bowels or passing urine
Depression or anxiety
Blood in stools or urine (although this is rare)

How do you diagnose endometriosis?

Endometriosis can be difficult to diagnose and may take some time, especially as sometimes symptoms can mimic other conditions.

A diagnosis is often made on symptoms alone although occasionally pelvic ultrasound scans, or more accurately MRI scans can provide further insight. It’s worth noting though that a normal scan, does not mean that you do not have endometriosis.

The only way to definitively confirm a diagnosis of endometriosis is through a laparoscopy. This is a keyhole surgical procedure where a camera is inserted into the abdomen to scan the pelvis for the presence of abnormal tissue.

What are the treatment options?

Treatments to manage endometriosis and its symptoms are usually based on the nature and severity of symptoms and take into consideration whether the woman wants to carry a pregnancy in the future. There are several treatments to ease the symptoms of endometriosis, including:

The combined oral contraceptive pill/progesterone-only pill
Mirena (progesterone-releasing coil)
Medications which can induce menopause (Gonadotrophin releasing hormones GnRH analogues e.g. zoladex)
Surgery to remove endometriotic tissue
Hysterectomy (removing womb and/or ovaries)

Can endometriosis get worse during perimenopause?

During perimenopause, which is when the body naturally begins its transition to menopause, oestrogen and progesterone levels fluctuate and gradually decline. As endometriosis is an oestrogen-sensitive disease, these hormonal ups and downs can cause periodic worsening of endometriosis symptoms.

Can you get endometriosis after menopause?

Endometriosis is generally considered a premenopausal condition, with instances of endometriosis and symptoms of the condition often improving during menopause as a result of declining oestrogen levels. However, approximately 2%–4% of postmenopausal women may still experience endometriosis symptoms.

Recurrent endometriosis

While it's rare, endometriosis can recur after menopause. Around 4% of women with moderate to severe endometriosis will see a recurrence after menopause which may appear years or even decades later and be affected by the use and type of menopause hormone replacement therapy.

Malignant transformation

Endometriosis can also transform into malignant tissue after menopause in 0.7-2.5% of women and involves the ovaries in 75% of cases. Although rare, women with endometriosis are four times more likely to develop endometriosis-associated ovarian carcinoma.

Hormone replacement therapy (HRT)

HRT can help treat menopausal symptoms, but it may also reactivate endometriosis or cause malignant transformation in women with a history of the disease. Some studies suggest high recurrence rates if the ovaries are still present and when using oestrogen-only HRT after a hysterectomy.

Will endometriosis go away after menopause?

As endometriosis is oestrogen-sensitive, its symptoms usually diminish or disappear entirely at the onset of menopause. However, 2-4% of women will experience postmenopausal endometriosis symptoms, and it can be reactivated by HRT.

Why does inducing menopause help endometriosis?

The symptoms of endometriosis are caused by the endometrium in the wrong areas (outside the womb) being stimulated and bleeding during the menstrual cycle. By stopping the menstrual cycle with medications, this can stop the symptoms. This is often known as a chemical menopause.

Removing the womb (hysterectomy) and ovaries (oophorectomy) can also help improve symptoms by removing the organs with the abnormal tissue. However, this induces menopause as the ovaries are where oestrogen is produced. This is known as a surgical menopause.

Both chemical and surgical menopause (also known as induced menopause) can lead to menopausal symptoms due to the sudden drop in oestrogen, often more suddenly than natural menopause. The symptoms can sometimes be worse and more dramatic in these situations.

HRT and menopause in women with endometriosis

Generally, those who have induced menopause for the treatment of endometriosis (either surgically or chemically) are younger and therefore would benefit from HRT if they have no contra-indications. This is important to protect against osteoporosis and heart disease.

In addition, it can help with menopausal symptoms such as hot flushes, mood changes, anxiety, low libido, memory loss, hair loss, joint aches and urinary/vaginal symptoms.

Women who have not had induced menopause for endometriosis may want to consider HRT when they are perimenopausal/menopausal for symptom relief.

Any woman with endometriosis who still has a womb should be offered continuous combined HRT. This means taking oestrogen and progesterone every day continuously. This is to ensure that any remaining endometriotic tissue is not flared up causing symptoms. A good option is the Mirena IUS (patch, gel or spray), which controls symptoms and can be used as the progesterone part of HRT.

If you have had a hysterectomy due to endometriosis, it is initially advised to start continuous combined HRT with oestrogen and progesterone every day, until the natural age of menopause (around 51).

Normally if you have had a hysterectomy, you only need oestrogen. However, there is a small risk of inducing a flare-up of any tissue which hasn't been removed, so progesterone is recommended alongside oestrogen for at least a couple of years until the natural age of menopause.

Oestrogen-only HRT can then be considered, as it is thought to be lower risk than combined HRT, but it has to be weighed up with the risk of flaring up endometriosis. It’s a good idea to discuss this with your doctor or menopause specialist.

Tibolone is another option, which is not often used but can be helpful in women with endometriosis. It is a tablet which contains oestrogen, progesterone and testosterone properties which can be helpful in women with a low libido. It has similar risks to oral HRT, which has a small increased risk of stroke, blot clot and breast cancer.

If women have dry vaginal symptoms, then vaginal oestrogen can be used safely in the long term. This comes in the form of a cream or a tablet. You do not need to use progesterone alongside vaginal oestrogen.

Endometriosis can be a debilitating condition, which is why it’s important to diagnose and manage it appropriately. If you have endometriosis and you’re approaching perimenopause or menopause, make sure you flag this to your doctor or menopause specialist so that you get the right care.

At Menopause Care, we have a team of menopause doctors who are experienced in helping women through perimenopause and menopause and managing their symptoms in tandem with other conditions. If you’d like evidence-based advice and an individualised treatment plan, book a consultation with a menopause doctor.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

References