Endometriosis and Menopause

Endometriosis and menopause are two conditions that are often discussed separately, but for many women they are deeply intertwined. If you have been living with endometriosis, the perimenopause and menopause transition brings a new set of questions, about symptoms, about hormones, about whether treatment is safe, and about what to expect.

Whilst treatment decisions need to be individualised, with specialist input, most women with endometriosis are able to manage this transition effectively and protect their long-term health.

What is endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside it, most commonly in the pelvis, on the ovaries, fallopian tubes, bladder, or bowel. It affects around one in ten women and people with a uterus, and is often under-diagnosed or diagnosed late.

Endometriosis is best understood not simply as a gynaecological problem, but as a multi-system neuroendocrine inflammatory condition. This definition matters because it helps explain the full picture of what living with endometriosis involves:

• It is driven by hormones, particularly oestrogen, which is why it is affected by the menopause transition
• It involves chronic inflammation, which has effects throughout the body, not just in the pelvis
• It can cause changes to the nervous system over time, including central sensitisation, a process in which the pain processing system becomes heightened and more reactive. This means symptoms can persist even when hormone levels fall
• It can affect energy, mood, cognition, bowel and bladder function, and overall quality of life

Many women with endometriosis also have co-existing conditions, including adenomyosis, fibroids, interstitial cystitis, irritable bowel syndrome, anxiety, and depression. Understanding this context is important, because it shapes how the menopause transition is experienced and managed.

What happens to endometriosis at perimenopause and menopause?

Because endometriosis is oestrogen-sensitive, declining oestrogen levels during the menopause transition often lead to a reduction in symptoms over time. For many women, the disease becomes less active after menopause.

However, this is not universal. Some women experience a worsening of symptoms during perimenopause, particularly during the phase of hormonal fluctuation that precedes menopause. This can be confusing and distressing, especially if you had hoped the menopausal transition would bring relief.

After natural menopause, endometriosis lesions typically become inactive, but deep infiltrating disease or previously excised areas may continue to cause symptoms in some women. This is particularly relevant if you are considering hormone replacement therapy.

Adenomyosis, which frequently co-exists with endometriosis, often causes significant symptoms during perimenopause, including heavy bleeding, pelvic pressure, and pain, which can overlap with and compound perimenopausal symptoms.

Surgical menopause and endometriosis

Some women with endometriosis undergo treatment which results in surgical menopause, meaning the ovaries are removed (bilateral oophorectomy), sometimes alongside a hysterectomy, either as a treatment for the disease or as part of wider surgery.

Surgical menopause is different from natural menopause in that the loss of oestrogen is abrupt and complete, rather than gradual. This typically causes more severe and sudden symptoms, and carries greater long-term health risks if left untreated.

HRT is recommended for most women following surgical menopause, at least until the age of 51, in line with guidance from the British Menopause Society (BMS) and NICE. The benefits, for symptoms, bone health, heart health, and cognitive wellbeing, are significant.

The progesterone question

If you have had a hysterectomy, you usually do not need progestogen to protect the womb lining. In most women, this means oestrogen-only HRT is the standard approach following hysterectomy.

However, in women with a history of endometriosis, the picture is more nuanced. BMS guidance recommends that combined HRT should be considered even after hysterectomy, because residual endometriotic tissue may remain in the pelvis and can still respond to oestrogen.

Where combined HRT is used, the type of progestogen matters. Micronised progesterone (Utrogestan) is often a good option, given its more favourable tolerability profile.

HRT and endometriosis: can I take it?

Fear about using HRT is common in women with endometriosis. Many have been told that oestrogen feeds endometriosis and should be avoided. It is understandable that this leaves women reluctant.

The doses of oestrogen used in HRT are considerably lower than the levels the body was naturally producing before menopause. HRT brings oestrogen back to a level closer to what your body was already managing, it does not add oestrogen in the way that might actively drive disease.

The BMS and NICE both support the use of HRT in women with endometriosis going through the menopause transition, typically using continuous combined HRT rather than sequential or cyclical preparations.

Symptoms: what is endometriosis and what is menopause?

One of the most confusing aspects of this period is working out what is driving your symptoms. Symptoms that can be features of both conditions include:

• Fatigue and low energy
• Pelvic and abdominal pain
• Bladder urgency or frequency
• Bowel symptoms, including bloating, cramping, or altered bowel habit
• Mood changes, anxiety, or low mood
• Brain fog and difficulty concentrating
• Sleep disruption
• Changes in libido

A specialist review can help to tease apart what is most likely to be driving different symptoms, and tailor a management plan accordingly.

Emotional and psychological impact

Living with a chronic pain condition and then navigating a significant hormonal transition is not a small thing. Many women with endometriosis have experienced long diagnostic journeys, dismissal, and a complicated relationship with their own body.

Psychological and emotional support is not an add-on to clinical care in this context, it is part of it.

Long-term health considerations

Bone health

Early or surgical menopause without treatment significantly increases the risk of osteoporosis. HRT is the most effective intervention, alongside adequate vitamin D and calcium.

Cardiovascular health

Loss of oestrogen is associated with increased long-term cardiovascular risk, particularly relevant following surgical menopause.

Pelvic floor and genitourinary health

Local oestrogen is safe and effective and is often recommended alongside systemic HRT. Pelvic floor physiotherapy can also be valuable.

Lifestyle support

Lifestyle measures will not replace oestrogen, but they are a genuinely important part of the picture.

Nutrition and inflammation

An anti-inflammatory dietary pattern, rich in oily fish, vegetables, legumes, wholegrains, and good quality fats, supports both conditions.

Movement

Consistent, sustainable movement is more valuable than intensive exercise that feels punishing.

Nervous system support

Practices that support nervous system regulation, including breathwork, yoga, and good sleep, have real relevance given the changes to pain processing seen in endometriosis.

When to seek specialist advice

You should consider a specialist review if:

• You have endometriosis and are experiencing perimenopausal or menopausal symptoms
• You have had a hysterectomy with or without oophorectomy and are unsure about HRT
• You have been told HRT is not suitable for you because of endometriosis
• Your symptoms are poorly controlled or difficult to attribute
• You have had a surgical menopause and are not currently on HRT