Endometriosis & Menopause and Fibroids: What to Know

Endometriosis and uterine fibroids are two of the most common gynecologic conditions and often coexist. Both are largely driven by hormones—especially estrogen—and both can change as you approach and pass menopause. If you are navigating hot flashes, irregular bleeding, pelvic pain, or decisions about hormone therapy, understanding how menopause affects endometriosis and fibroids can help you make informed choices with your clinician.

How menopause changes the landscape

Menopause—defined as 12 months without a menstrual period—brings a natural decline in estrogen and progesterone. Because endometriosis implants and fibroids are hormone-responsive, many people see symptoms improve after menopause. That said, improvement is not guaranteed:

• Endometriosis: Symptoms often lessen after menopause, but endometriotic tissue can persist. Some implants make their own estrogen through an enzyme called aromatase, which can keep inflammation and pain going even when ovarian estrogen is low. Postmenopausal endometriosis is uncommon but recognized, especially in those using estrogen therapy after menopause.
• Fibroids (uterine leiomyomas): Without monthly hormonal stimulation, most fibroids stabilize or shrink, and heavy periods typically stop. However, fibroids can still cause pressure symptoms (pelvic fullness, urinary frequency, constipation) and, less often, postmenopausal bleeding if the uterine lining is affected. Higher body fat (which converts androgens to estrogen) and certain hormone therapies may sustain fibroid activity.

Symptoms you might still notice after menopause

Contact your clinician if you experience any of the following after menopause:

• Vaginal bleeding or spotting: Postmenopausal bleeding always warrants evaluation. While fibroids or hormone therapy may be benign causes, clinicians will rule out endometrial hyperplasia or cancer.
• Pelvic pain or pressure: Ongoing or new pain could be related to persistent endometriosis, fibroids, pelvic floor dysfunction, or other conditions.
• New or enlarging pelvic mass: Any growth after menopause should be assessed with imaging.
• Bowel or urinary changes: Constipation, pain with bowel movements, or urinary urgency/frequency may reflect pressure from fibroids or adhesions from endometriosis.

Hormone therapy (HRT) if you have a history of endometriosis or fibroids

Hormone therapy can be very effective for hot flashes, night sweats, sleep disturbance, and genitourinary syndrome of menopause. If you have a history of endometriosis or fibroids, careful selection and monitoring are key:

• General principle: If you have a uterus, clinicians typically prescribe combined estrogen plus progestin to protect the uterine lining from hyperplasia. Estrogen alone is generally reserved for those who have had a hysterectomy.
• Endometriosis considerations: Even after hysterectomy, some experts recommend including a progestin with estrogen to reduce the risk of stimulating residual endometriotic implants. The lowest effective estrogen dose and a continuous (not cyclic) regimen are often preferred. In select cases of persistent pain, non-estrogen options or add-ons (e.g., localized vaginal estrogen for dryness, not systemic) may be considered.
• Fibroid considerations: Some HRT regimens can increase spotting or slightly enlarge fibroids, particularly early in treatment. Continuous combined therapy, lower-dose transdermal estradiol, or use of a levonorgestrel-releasing intrauterine system (for progestin) may help control bleeding while limiting fibroid stimulation. Close follow-up with pelvic exams and ultrasound as needed is prudent.

HRT decisions should be individualized based on your symptom severity, medical history, cardiovascular and breast cancer risks, and personal preferences.

Evaluation: what to expect

Your clinician will start with your history, a pelvic exam, and targeted testing based on symptoms:

• Transvaginal ultrasound: First-line imaging to assess the uterus, lining (endometrial thickness), ovaries, and the presence/size of fibroids.
• Endometrial sampling: If you have any postmenopausal bleeding, guidelines commonly recommend endometrial biopsy or evaluation of endometrial thickness; thresholds (such as an endometrial stripe ≤4 mm being reassuring) help guide next steps.
• MRI: Helpful when ultrasound is inconclusive, to characterize masses, map fibroids, or evaluate deep endometriosis.
• Diagnostic laparoscopy: Less often needed after menopause but remains the gold standard for confirming endometriosis if imaging and symptoms are inconclusive.

Is there a cancer risk?

Most endometriosis and fibroids are benign. Still, two scenarios deserve attention:

• Endometriosis and ovarian cancer: Large epidemiologic studies show a small increased risk of certain ovarian cancers (clear cell and endometrioid) in people with endometriosis. The absolute risk remains low, and routine screening is not recommended. Report new, persistent symptoms such as pelvic pain, bloating, early satiety, or changes in bowel habits.
• Fibroids vs. uterine sarcoma: Uterine sarcomas are rare, but new or enlarging uterine masses after menopause warrant evaluation. If surgery is planned for a presumed fibroid, current guidance emphasizes careful preoperative assessment; power morcellation is generally avoided in postmenopausal patients due to the risk of spreading an unexpected malignancy.

Treatment options after menopause

Management depends on your symptoms, imaging findings, overall health, and goals:

Endometriosis

• Expectant management: If symptoms are mild and imaging is reassuring, watchful waiting is reasonable.
• Medications: Options may include progestins and, in select refractory cases, aromatase inhibitors under specialist care (with bone protection strategies). Nonsteroidal anti-inflammatory drugs (NSAIDs) can help with pain. Systemic estrogen-only therapy is generally avoided when active endometriosis is suspected.
• Surgery: For persistent pain or masses, minimally invasive surgery to remove endometriotic implants or ovarian cysts may be considered. Decisions weigh symptom relief against surgical risks, which increase with age and comorbidities.

Fibroids

• Expectant management: Common if fibroids are stable and not causing symptoms.
• Medical therapies: In perimenopause or early postmenopause with bleeding, options include tranexamic acid for heavy episodes and progestin-containing therapies (e.g., levonorgestrel IUD). GnRH analogs are typically short-term bridges rather than long-term solutions after menopause.
• Procedures: For significant pressure symptoms or growth, uterine artery embolization, focused ultrasound, myomectomy, or hysterectomy may be options. The approach depends on symptom profile, uterine size, anatomy, and personal preference. If surgery is chosen, techniques that avoid tissue fragmentation within the abdomen are preferred in postmenopausal patients.

Proactive steps you can take

• Track symptoms: Keep a brief log of any bleeding, pain patterns, bloating, or urinary changes. Note any new medications, including hormone therapy.
• Review your hormone regimen: If you’re on HRT, discuss dose, route (transdermal vs oral), and the type of progestin. Ask how your plan accounts for prior endometriosis or fibroids.
• Support bone and cardiovascular health: Adequate calcium/vitamin D, weight-bearing exercise, and smoking cessation are beneficial, especially if therapies that affect bone density are considered.
• Schedule follow-ups: Periodic pelvic exams and ultrasound, when indicated, help confirm stability.

Key takeaways

• Many people experience relief from endometriosis and fibroid symptoms after menopause, but persistence or recurrence can occur—particularly with certain hormone therapies.
• Postmenopausal bleeding always needs evaluation; do not delay seeking care.
• HRT can be used safely by many, but regimens may need tailoring (often continuous combined therapy) and monitoring when there’s a history of endometriosis or fibroids.
• Treatment is highly individualized; decisions balance symptom relief, risks, and your quality-of-life goals.

Trusted sources and guidelines

1. National Institutes of Health (NIH) / NICHD – Endometriosis overview: https://www.nichd.nih.gov/health/topics/endometri/conditioninfo
2. American College of Obstetricians and Gynecologists (ACOG) – Endometriosis and Uterine Fibroids patient guidance: https://www.acog.org/womens-health
3. U.S. Food and Drug Administration (FDA) – Laparoscopic power morcellation safety communication: https://www.fda.gov/medical-devices/safety-communications
4. National Cancer Institute (NCI) – Endometriosis and ovarian cancer risk: https://www.cancer.gov
5. NIH MedlinePlus – Uterine fibroids and menopause-related topics: https://medlineplus.gov

This article is for educational purposes and does not replace personalized medical advice. If you have symptoms or questions about treatment, consult a qualified clinician.