When Endometriosis Meets Menopause: A Recipe for Disaster

“The only thing predictable about menopause is its unpredictability. Factor in widespread misinformation, a lack of research, and the culture of shame around women’s bodies, and it’s no wonder women are unsure what to expect during the menopause transition and beyond.” – Dr. Jen Gunter

Menopause is as unavoidable as puberty, a natural process our bodies undergo as part of the life cycle. Most doctors do not have accurate or thorough information to help guide people through menopause, and there is a communication gap among women where matters of menopause are concerned. Brief references to hot flashes, mood swings, and perhaps a flippant comment about sex being uncomfortable may be shared, but frankly, as a woman of a certain age, the discussions are few and far between.

Where does endometriosis fit in with this discussion? One of the pervasive myths about endometriosis is that menopause cures it and that endometriosis can only exist in those who have reproductive capacity. While endometriosis is considered an inflammatory disease that is estrogen-dependent, this assertion is patently false. Not only can those with endometriosis continue to struggle with the condition post-menopause, people who have never had endometriosis can develop it post-menopause. Actual numbers are difficult to assess due to the persistent lack of research surrounding both endometriosis and menopause, but according to this research article by the National Center for Biotechnology Information, the prevalence of postmenopausal endometriosis ranges from 2-5% of postmenopausal women. Considering the difficulty that exists in terms of recognizing symptoms and diagnosing endometriosis to begin with, this presents the post-menopausal individual with a seemingly insurmountable hurdle should they indeed develop endometriosis.

So what might be driving post-menopausal endometriosis? The general theory is that peripheral estrogen production, meaning estrogen that isn’t being produced within the ovaries, can stimulate the growth of endometrial lesions. This type of estrogen continues to exist in varying levels among post-menopausal people. Layer on top of that the use of hormone replacement therapy (HRT), which stimulates estrogen production, and this can re-activate or activate for the first time the production of endometriosis. Hormone replacement therapy is the gold standard for addressing the myriad symptoms associated with menopause. It can also help to stem the onset of bone density loss and osteoporosis, a common and potentially debilitating condition that can cause bone fragility and more frequent breakage. While most people tolerate HRT well with few to no side effects, some might be at a higher risk for estrogen-related diseases like endometriosis and certain types of cancers.

Additionally, many of the symptoms associated with endometriosis such as gastrointestinal discomfort, bloating, constipation, pelvic floor dysfunction, urinary tract pain, and painful intercourse are common indicators of cancers that tend to affect post-menopausal women at higher rates. These include uterine, ovarian, and bladder cancers. This makes the diagnosis of endometriosis that much more complicated. Doctors are far more likely to order tests to rule out invasive potentially life-threatening cancers than they are to start with the diagnostic laparoscopy needed to identify endometriosis. While this makes sense based on our current medical system, it does mean a delay in or outright failure to diagnose endometriosis among post-menopausal people.

So what can post-menopausal people do? First, those who have a history of endometriosis should have an in-depth discussion with their medical practitioners weighing the pros and cons of HRT usage. If they have had a hysterectomy, there is some indication that the recurrence of endometriosis might be less likely, however, that is not a definitive recommendation. And there is extensive literature suggesting the direct correlation of endometriosis to the development of malignant tumors at the site of the endometrial lesions. Therefore, HRT may be contraindicated in those with a history of endometriosis. Localized vaginal progesterone might be the best alternative for these individuals in managing their menopause symptoms. For those without any kind of history of endometriosis, the risk is relatively low, therefore the use of HRT in managing symptoms is not typically contraindicated.

The bottom line? Just as with endometriosis that occurs amongst pre-menopausal people, if you have symptoms consistent with endometriosis, don’t let your doctor dismiss them. It may be life-saving to get an early diagnosis so as to curtail the potential development of cancer. Beyond that, however, there’s no reason that you should continue to live with debilitating symptoms consistent with endometriosis beyond menopause. Excision surgery is relatively safe for most post-menopausal people and can effectively address the majority of symptoms associated with post-menopausal onset endometriosis.