Endometriosis and the Menopause

For numerous women, the experience of menopause unfolds as a distressing ordeal. The well-known companions of this phase include hot flashes, mood swings and a dryness of the mucous membrane in the intimate area. However, for those enduring the trials of endometriosis, menopause can herald the long-awaited tranquility. This reprieve comes courtesy of the natural decline in hormone production within the female body as it ages. Among the casualties of this ebbing hormone tide is estrogen, the pivotal female sex hormone notorious for instigating endometriosis lesions. Regrettable, the  “hormone pause button” does not uniformly bestow the yearned-for respite for every woman. Today, I will expand upon the nuances of menopause, delineate its symptomatic landscape, and elucidate the intricate reasons why the cessation of endometriosis symptoms remains elusive for select patients both during and post-menopause.

What is Menopause?

Let us delve into the pages of medical understanding to explore the essence of menopause. Referred to as “climacteric” within medical circles, menopause signifies a remarkable phase that merits our attention. This phase demarcates the shit from a fertile era to one of infertility, orchestrating a series of changes within the female body. Typically occurring between the ages of 45 and 50, this transition heralds a time of transformation. As it unfolds, the ovaries undergo a pivotal change, gradually diminishing in their once-active role. Amidst the evolution, a significant milestone emerges – the final menstrual period, colloquially known as menopause. The average timing for this event hovers between the 51st and 52nd birthday. However, certitude is not immediate; it takes approximately a year to confirm if this was indeed the final menstrual period. Doctors vigilantly observe a span of one-year post menopause for any absence of menstrual bleeding. Once this temporal observation aligns with factors such as age, ovarian function, and the cessation of menstruation, menopause can be pinpointed. Contrary to a discrete shutdown of reproductive functions culminating in the last menstrual period, menopause unfolds as a gradual symphony. Rather than a sudden cessation, it is akin to a meticulously orchestrated series of hormone-driven steps. This symphony plays out before, during, and well beyond menopause, reshaping the hormonal landscape. This phase, spanning several years, is recognized as menopause [1].

Good to know

A study revealed not only the persistence of endometriosis among women even after menopause but also the emergence of distinct variations. Researchers directed their attention to 1100 female patients diagnosed with endometriosis, comprising 184 who were pre-menopausal and 46 who had entered the post-menopausal phase. Among these participants, those undergoing the perimenopausal phase, marking the transition from fertile years to menopause, exhibited more pronounced and aggressive endometriosis lesions. Concurrently, they frequently contended with additional implications, such as fibroid growths within the uterus. In stark contrast, study participants who had concluded their menstrual cycles were more inclined to manifest adenomyosis [10]. This intricate condition involves the growth of endometriosis lesions within the uterine wall itself.

Menopause Unveiled: Navigating Mood Swings and Hot Flashes

The prospect of menopause might not be alluring. Indeed, this phase of hormonal transformation ushers in an array of both psychological and physical challenges. As your body transitions from decades of hormonal fluctuations, the most significant change lies on the horizon. However, this transition does not pass without leaving its mark on your overall well-being. Among the hallmarks of this journey are the notorious hot flashes and perspiration episodes. Typically spanning a duration of 4–5 years, these phenomena eventually subside, but not without potentially exerting a prolonged impact on sleep quality and daily life. The intricacies of menopause extend beyond these classics. Women often grapple with discomfort in the intimate sphere. Post-menopause, the vaginal mucous membrane tends to thin, leading to reduced moisture production [2]. This shift can pose challenges, particularly during sexual intercourse. In such cases, the use of a lubricant gel can prove beneficial

Furthermore, a spectrum of other menopausal symptoms surfaces, encompassing [1]:

  • Insomnia
  • Dizziness
  • Weight gain
  • Fatigue
  • Nervousness
  • Forgetfulness
  • Headaches

Endometriosis in and Beyond Menopause: the Subsiding Waves are calming down

Imagine a tumultuous sea, waves surging and subsiding intermittently, occasionally allowing a fleeting calm to descend. Does this metaphor resonate with your perception of endometriosis? For countless women, this portrayal holds true. While quantifying the exact prevalence remains challenging, estimations provide insight. Among cases marked by painful menstrual bleeding, medical experts attribute 40-60% to endometriosis. When the quest for motherhood remains elusive, the figures stand at 20-30% [3]. Glimpsing into the statistics, it becomes evident that endometriosis predominantly intertwines its threads with women aged 35 to 44 or 40 to 45 [4]. Significantly, this period corresponds to a hormonal deluge within your body. Among the prominent players are estrogen and progesterone, both orchestrating the intricate choreography of priming your organism for potential pregnancy [2]. While progesterone wields an inhibitory influence on endometriosis, estrogen provides the nourishment that sustains the ailment’s growth. Hence, the guideline set forth by the German Society of Gynecology and Obstetrics underscores progestogens (synthetic progesterone) as the prime contenders for endometriosis treatment [5]. With declining estrogen levels, the crescendo of endometriosis symptoms often mellows, mirroring the subdued tides of the sea after a storm

Is Endometriosis Present During Menopause?

Now, my response remains a resounding “yes”. After all, the endometriosis lesions do not merely dissipate upon entering menopause, rather they enter a dormant state. However, the decline in estrogen levels can decelerate the growth of endometriosis. This sex hormone inherently orchestrates the regulation of uterine lining development. Consequently, many women experience a reduction in the hallmark symptoms of endometriosis post-menopause In fact, a considerable number even find themselves virtually devoid of symptoms after this phase. However, it is important to note that this does not translate to endometriosis completely vanishing in later years. An insightful study involving roughly 42,000 women indicated that about 2.55% continued to contend with endometriosis after their final menstrual period [6]. Another study underscores endometriosis as an estrogen-dependent condition, often ameliorating after the last menstrual period. Nevertheless, it persists in impacting up to 2.2% of individuals within this demographic [7].

Can Endometriosis Persist in Menopause?

The traverse of endometriosis extends its presence not just through menopause, but potentially beyond it. For example, there are problems that do not resolve on their own over time. Take, for instance, adhesion problems after surgical procedures or complications that have arisen as a result of such procedures. Relevant endometriosis findings, such as on the sciatic nerve, can also have far-reaching consequences. They are often accompanied by a deeply infiltrating form that can, in the worst case, destroy the largest nerve [8]. This may result in sensations that do not disappear even during menopause. Interstitial cystitis is a common concomitant of endometriosis [9].

It can still occur after menopause. Due to the decrease in estrogen during this phase, classic symptoms such as psychological issues or insomnia frequently manifest in relation to endometriosis.
Generally, individuals with endometriosis might experience similar menopausal symptoms as other women. Hormonal therapy can mitigate the accompanying menopause-related discomforts. Nonetheless, if estrogen is administered for this purpose, endometriosis lesions can reactivate, inducing symptoms.

Artificial Menopause – A Route to Address Endometriosis

If menopause holds the potential to pacify the tumult of endometriosis, could inducing artificial menopause be a viable avenue for younger women? Indeed, systemic therapeutic strategies employing progestins or GnRH analogs have emerged as possible solutions. These approaches operate through the hypothalamic-pituitary axis, orchestrating an artificial state of estrogen deficiency. The outcome?

Reduction in the size of endometriosis lesions and a shift towards dormancy [11]. When discussing artificial menopause, GnRH analogs take center stage. These agents mirror the natural gonadotropin-releasing hormones (abbreviated GnRH) present in the body, albeit with more potent and prolonged effects. Given their substantial intervention in hormonal equilibrium – exceeding even the impact of the contraceptive pill – they warrant careful application within a limited time frame. As a guideline, a six-month duration is recommended [3, 12]. However, the employment of GnRH analogs can yield unwanted side effects. It is crucial to note that these drugs curtail the production of female hormones to such an extent that symptoms characteristic of estrogen deficiency may arise. These parallels echo the manifestations observed during menopause.: disrupted sleep patterns, parched mucous membranes in intimate areas, mood fluctuations, and bouts of hot flashes. Consequently, an approach dubbed “add-back” therapy often co-prescribes some measure of estrogen alongside the medication. Another facet to consider is the potential decline in bone density associated with prolonged use of GnRH analogs. Encouragingly, select studies hint at the reversibility of this particular adverse effect [13].

Good to know!

Considering the potential side effects, your physician must thoughtfully assess the suitability of GnRH analogs treatment in your situation. If this treatment spans several months, concurrent hormone replacement therapy becomes viable. Referred to as “add back” therapy, its objective is to mitigate the adverse effects stemming from hormone deficiency. To achieve this, a minimal dose of estrogen is introduced [14].

In a Nutshell

Menopause extends over numerous years, characterized by a reduction in hormones within the female body, notable estrogen – an element known for its endorsement of endometriosis. Consequently, many individuals with endometriosis observe symptom amelioration during and post-menopause. Yet, this does not negate endometriosis’ presence in advanced age, with studies indicating that slightly over 2% still grapple with the condition. Even as traditional endometriosis symptoms wane, the aftermath might endure; instances like adhesions or interstitial cystitis, which disproportionately affects patients, underscore this reality. Perchance, you have delved into the concept of  “artificial menopause”. In this approach, compounds are administered to induce a menopausal state, albeit the stark decrease in estrogen levels could yield undesired effects – think sleep disturbances, mood fluctuations, and more. Collaborating with your physician, you can ascertain your hormonal status and explore viable treatment avenues.

References

  1. Diedrich, Klaus. Gynäkologie und Geburtshilfe (Springer-Lehrbuch) (German Edition) (S.54). Springer Berlin Heidelberg. Kindle-Version.
  2. Wechseljahrsbeschwerden | Gesundheitsinformation.de
  3. Farquhar C. Endometriosis. BMJ. 2007 Feb 3;334(7587):249-53. doi: 10.1136/bmj.39073.736829.BE. PMID: 17272567; PMCID: PMC1790744.
  4. Eisenberg VH, Weil C, Chodick G, Shalev V. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG. 2018 Jan;125(1):55-62. doi: 10.1111/1471-0528.14711. Epub 2017 Jun 14. PMID: 28444957.
  5. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe: Leitlinienprogramm. Diagnostik und Therapie der Endometriose. August 2020.
  6. Haas D, Chvatal R, Reichert B, Renner S, Shebl O, Binder H, Wurm P, Oppelt P. Endometriosis: a premenopausal disease? Age pattern in 42,079 patients with endometriosis. Arch Gynecol Obstet. 2012 Sep;286(3):667-70. doi: 10.1007/s00404-012-2361-z. Epub 2012 May 5. PMID: 22562384.
  7. Zanello M, Borghese G, Manzara F, Degli Esposti E, Moro E, Raimondo D, Abdullahi LO, Arena A, Terzano P, Meriggiola MC, Seracchioli R. Hormonal Replacement Therapy in Menopausal Women with History of Endometriosis: A Review of Literature. Medicina (Kaunas). 2019 Aug 14;55(8):477. doi: 10.3390/medicina55080477. PMID: 31416164; PMCID: PMC6723930.
  8. Prof. Dr. med. Marc Possover: Die Endometriose des Ischias-Nervs und der Sakralwurzeln
  9. S2K-Leitlinie Diagnostik und Therapie der Interstitiellen Cystitis (IC/BPS), Langfassung, Auflage 1, Version 1, Stand 30.09.2018
  10. Matalliotakis M, Matalliotaki C, Trivli A, Zervou MI, Kalogiannidis I, Tzardi M, Matalliotakis I, Arici A, Goulielmos GN. Keeping an Eye on Perimenopausal and Postmenopausal Endometriosis. Diseases. 2019 Mar 12;7(1):29. doi: 10.3390/diseases7010029. PMID: 30870972; PMCID: PMC6473414.
  11. Nagandla K, Idris N, Nalliah S, Sreeramareddy CT, George SRK, Kanagasabai S. Hormonal treatment for uterine adenomyosis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD011372. DOI: 10.1002/14651858.CD011372
  12. Hughes E, Brown J, Collins JJ, Farquhar C, Fedorkow DM, Vandekerckhove P. Ovulation suppression for endometriosis. Cochrane Database Syst Rev. 2007 Jul 18;2007(3):CD000155. doi: 10.1002/14651858.CD000155.pub2. PMID: 17636607; PMCID: PMC7045467.
  13. Sagsveen M, Farmer JE, Prentice A, Breeze A. Gonadotrophin-releasing hormone analogues for endometriosis: bone mineral density. Cochrane Database Syst Rev. 2003;2003(4):CD001297. doi: 10.1002/14651858.CD001297. PMID: 14583930; PMCID: PMC7027701.
  14. IQWIG- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen: Expertise zum Thema Endometriose. Abschlussbericht 2007

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Dipl.-Ges.oec. Jennifer Ann Steinort
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