Will Endometriosis Stop After Menopause and Fibroids: What to Know

Will Endometriosis Stop After Menopause and Fibroids: What to Know

Many people expect estrogen-sensitive conditions like endometriosis and uterine fibroids to fade away after menopause. While symptoms often improve, the full story is more nuanced. Here’s what to know about what typically happens to endometriosis and fibroids in the menopausal transition, how hormone therapy can influence symptoms, and when to seek care.

Endometriosis After Menopause: Does It Stop?

Endometriosis is a chronic inflammatory condition in which tissue similar to the uterine lining grows outside the uterus. Because it’s driven by estrogen, symptoms usually improve after menopause when estrogen levels decline. However, endometriosis can persist or recur in a minority of postmenopausal people. Reasons include:

  • Residual or local estrogen production: The body continues to make small amounts of estrogen after menopause, including through conversion in adipose (fat) tissue via aromatase enzymes.
  • Exogenous hormones: Certain forms of hormone therapy (HT) or phytoestrogens may stimulate residual endometriosis.
  • Prior disease burden: Extensive endometriosis before menopause may increase the chance of lingering symptoms.

In most cases, pain eases over time after the final menstrual period. Still, new or persistent pelvic pain, pain with intercourse, bowel or bladder symptoms, or unexpected bleeding after menopause should be evaluated. Rarely, endometriosis can undergo malignant transformation, so persistent or changing symptoms deserve prompt attention. Authoritative sources note symptom improvement after menopause but acknowledge the condition can continue in some people (NICHD/NIH; U.S. Office on Women’s Health).

Will Hormone Therapy Reactivate Endometriosis?

Menopausal hormone therapy can help with hot flashes, sleep, mood, and bone health, but it may reactivate endometriosis in some patients. Considerations include:

  • Use of progestin: When HT is considered in someone with a history of endometriosis, many clinicians favor regimens that include a progestin (e.g., combined estrogen-progestin therapy or a levonorgestrel intrauterine system) to counterbalance estrogen’s effects on residual lesions. Discuss individualized risks and benefits with your clinician (see ACOG).
  • Dose and route: The lowest effective dose for the shortest duration is a common principle; transdermal routes may have different risk profiles for some outcomes.

Nonhormonal options for vasomotor symptoms may be reasonable if pelvic pain recurs with HT. Decisions should be individualized based on symptom severity, cardiovascular/breast risk factors, and endometriosis history.

Fibroids After Menopause: Do They Shrink?

Uterine fibroids (leiomyomas) are benign tumors of the uterus that often grow during the reproductive years under the influence of estrogen and progesterone. After menopause, fibroids typically shrink and symptoms (heavy periods, bulk pressure) usually improve as ovarian hormones fall (U.S. Office on Women’s Health; NICHD/NIH).

However, some people continue to have fibroid-related pressure, urinary frequency, or pelvic discomfort even after periods stop. Key points:

  • Postmenopausal bleeding is never “normal”: Any bleeding warrants evaluation to rule out endometrial hyperplasia or cancer. Don’t assume fibroids are the cause.
  • Rapid uterine enlargement after menopause is uncommon: While very rare, rapid growth raises concern for uterine sarcoma and requires prompt assessment (ACOG).
  • Hormone therapy may affect fibroids: Some HT regimens can stimulate fibroid growth. If HT is needed, clinicians often use the lowest effective dose and monitor symptoms and uterine size.

Endometriosis vs. Fibroids: Related but Different

  • What they are: Endometriosis involves endometrium-like tissue outside the uterus; fibroids are benign smooth muscle tumors within or on the uterus.
  • Shared hormonal sensitivity: Both are influenced by estrogen, which is why symptoms often improve after menopause. But residual disease, exogenous hormones, and individual biology can sustain symptoms.

Diagnosis Around and After Menopause

  • Endometriosis: Diagnosis is based on symptoms, imaging (ultrasound or MRI for deep disease), and sometimes laparoscopy. Blood tests like CA-125 are not specific.
  • Fibroids: Pelvic ultrasound is first-line; MRI helps with surgical planning. In postmenopausal bleeding, endometrial sampling is essential regardless of known fibroids.

Treatment Options Near and After Menopause

Endometriosis

  • Pain management: NSAIDs and pelvic floor physical therapy may help.
  • Hormonal therapies (mostly for premenopause/perimenopause): Progestins, levonorgestrel IUD, and GnRH analogs can suppress lesions. The FDA has approved oral GnRH antagonist therapies for pain due to endometriosis (e.g., elagolix; a combination relugolix/estradiol/norethindrone is also approved for endometriosis pain FDA). These are generally indicated for premenopausal patients.
  • After menopause: If symptoms persist, options may include surgery (excision of lesions, sometimes hysterectomy and/or oophorectomy) in select cases. Aromatase inhibitors may be considered off-label with specialist guidance, often with add-back to protect bone health.

Fibroids

  • Watchful waiting: Reasonable when symptoms are mild and stable after menopause.
  • Procedures: For persistent bulk symptoms, options include uterine artery embolization (UAE), MRI-guided focused ultrasound (an FDA-approved technology for fibroids), myomectomy, or hysterectomy depending on health status and goals (ACOG).
  • Medications (mostly for heavy bleeding before menopause): Oral GnRH antagonists with add-back therapy are FDA-approved for heavy menstrual bleeding associated with fibroids (e.g., elagolix combination and relugolix combination). After menopause, these indications generally no longer apply, and any bleeding needs evaluation.

Lifestyle and Self-Care

  • Maintain a healthy weight: Reducing adipose tissue may lower peripheral estrogen production, potentially reducing endometriosis activity and fibroid stimulation.
  • Exercise and core/pelvic floor strengthening: Helps pain, posture, and overall function.
  • Anti-inflammatory strategies: Some people find symptom relief with balanced diets rich in fruits, vegetables, whole grains, and omega-3s. Evidence is evolving; use as adjuncts, not replacements, for medical care.

When to Seek Care

  • Any vaginal bleeding after 12 months without a period.
  • New, worsening, or persistent pelvic pain.
  • Rapidly enlarging abdomen, urinary retention, or bowel changes.
  • Unintended weight loss, fevers, or anemia symptoms (fatigue, shortness of breath).

Key Takeaways

  • Endometriosis: Often improves after menopause but can persist or recur, especially with exogenous estrogen or higher body fat. Consider progestin-containing HT and monitor symptoms if hormone therapy is used.
  • Fibroids: Usually shrink after menopause, but persistent symptoms or new bleeding should be evaluated; rapid growth is uncommon and warrants prompt assessment.
  • Individualized care: Work with a gynecologist to balance symptom relief, cancer screening when indicated, and the risks/benefits of hormone and nonhormonal options.

This article is for general information and does not replace personalized medical advice. If you have symptoms, consult your healthcare professional.

Sources and Further Reading

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