Endometriosis and Menopause

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Endometriosis and Menopause 

Endometriosis is a painful, inflammatory condition affecting 11% of women of reproductive age globally and 6.5 million in the U.S. It takes eight to 12 years to get a diagnosis, and even so, many women are misdiagnosed. Endometriosis research is significantly underfunded.

Yet, one saving grace may be that not always, but most of the time, endometriosis symptoms improve in menopause. Those with endometriosis can’t wait for their menstrual cycle to end!

Today’s article will explore the connection between endometriosis and menopause, the hormonal connections, and answer your burning questions, including:

• What is endometriosis?
• What happens to endometriosis in perimenopause and menopause?
• What is postmenopausal endometriosis?
• Can women with endometriosis use bioidentical hormones for menopausal treatment?
• What’s different about an integrative medicine approach to endometriosis?

Let’s dive in!

What is Endometriosis?

Endometriosis occurs when endometrial (uterine lining) tissue grows outside the uterus. Where estrogen signals the growth of the endometrium and progesterone balances estrogenic growth, those with endometriosis may have a hormonal imbalance driving the disease process and inflammation.

Research suggests that changes in the genetic expression of estrogen and progesterone receptors may affect the development of endometriosis. Often, we clinically observe estrogen dominance and progesterone deficiency or resistance in women with endometriosis.

Further, endometriosis often co-occurs with autoimmune diseases, suggesting both a hormonal and immune influence. Interestingly, autoimmune disease is more likely to arise during hormonal transitions, including postpartum and perimenopause.

Symptoms of endometriosis include:

• Chronic pelvic pain
• Menstrual pain
• Abnormal bleeding
• Painful sex
• Painful urination
• Painful bowel movements
• Gastrointestinal symptoms, such as constipation
• Infertility

Because surgery is required to confirm an endometriosis diagnosis, women often suffer with unnecessary pain as diagnosis and treatments are delayed. Conventional endometriosis treatment usually involves oral contraceptives to limit endometrial growth and pain medication. These medications treat endometriosis symptoms but don’t address the root causes as an integrative approach does.

Endometriosis in Perimenopause and Menopause

Perimenopause is the transition period lasting several years to a decade before menopause, the one-year mark without a period. In perimenopause, women experience fluctuating estrogen levels, periods of high estrogen (estrogen dominance), and declining progesterone. There may be periods where menstrual cycles are shorter and more frequent, and periods can be heavier. All these changes can exacerbate endometriosis symptoms.

Women with endometriosis are also prone to perimenopausal symptoms, which may overlap with endometriosis symptoms, such as heavy, painful periods, PMS, and pelvic floor issues.

However, as perimenopause progresses, periods become further apart, and estrogen levels decline, which can be a welcome relief for endometrial symptoms. By the time women are postmenopausal and have gone over a year without a period, estrogen levels are consistently lower, which means less (or no) endometrial proliferation and less (or no) pain. For some women, scar tissue may still be present and cause pain or other issues.

Post-Menopausal Endometriosis

It’s a myth that endometriosis only affects women of reproductive age; evidence suggests that the disease process may begin even before puberty and, for some women, continue post-menopause.

Around two to five percent of women with endometriosis will continue to have symptoms after menopause. Some case reports of postmenopausal women with no prior history of the disease suggest the late development of endometriosis.

Most commonly, postmenopausal endometriosis is a side effect of improper hormone replacement therapy, high intake of dietary phytoestrogens, or exposure to endocrine-disrupting chemicals. If each individual has their own “estrogen threshold,” women with endometriosis after menopause may have a very low threshold.

Overwhelmingly, however, women with endometriosis find much-desired relief without a monthly menstrual cycle.

Bioidentical Hormone Replacement Therapy

Another common myth is that women with a history of endometriosis can’t use bioidentical hormone replacement therapy in menopause. However, in many (or most) cases, they can!

Bioidentical hormone replacement therapy is the gold standard treatment for menopausal symptoms (think: hot flashes and vaginal dryness) and may help prevent postmenopausal chronic diseases, including osteoporosis and heart disease. Women with endometriosis shouldn’t miss out on this life-improving therapy.

However, there isn’t a one-size-fits-all approach and women with a history of endometriosis need a personalized hormone plan. Keeping estrogen levels stable is often helpful, compared to the fluctuating estrogen levels during the menstrual cycle and perimenopause. Estrogen also needs to be balanced with enough progesterone to prevent endometrial proliferation.

An Integrative Approach to Endometriosis and Menopause

If you have endometriosis and are struggling in perimenopause or post-menopause (with endometriosis, menopausal symptoms, or both), TārāMD can help. We take a holistic, integrative approach, acknowledging that all body systems are connected and working to uncover and balance the root causes of symptoms and dysfunction.

Endometriosis is complex, and that complexity is still important to consider as women age. You need a knowledgeable provider with endometriosis experience and a menopause specialist (Dr. Fenske is both!) to help you navigate this life phase and find sustainable, effective solutions. Our goal is to improve your quality of life during this hormonal transition and also protect your health and prevent disease over the long term.

Some integrative strategies may include:

• Personalized bioidentical hormone replacement therapy and other medical interventions
• Achieving and sustaining a healthy weight
• Optimizing nutrition and gut health
• Supporting hormone detoxification pathways
• Building new lifestyle habits to support your goals
• Personalized supplement plan
• Pelvic floor physical therapy

Your menopausal endometriosis journey is unique to you and there is no one-size-fits-all approach. You deserve comprehensive and effective care from a provider who listens and acknowledges your experience, who’s on your team. With TārāMD you won’t get the runaround or endless referrals. We have the knowledge, tools, and experience to support you through this next phase of life.

References

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3. Chen, H., Malentacchi, F., Fambrini, M., Harrath, A. H., Huang, H., & Petraglia, F. (2020). Epigenetics of Estrogen and Progesterone Receptors in Endometriosis.Reproductive sciences (Thousand Oaks, Calif.), 27(11), 1967–1974.
4. Blanco, L. P., Salmeri, N., Temkin, S. M., Shanmugam, V. K., & Stratton, P. (2025). Endometriosis and autoimmunity.Autoimmunity reviews, 24(4), 103752.
5. Secosan, C., Balulescu, L., Brasoveanu, S., Balint, O., Pirtea, P., Dorin, G., & Pirtea, L. (2020). Endometriosis in Menopause-Renewed Attention on a Controversial Disease.Diagnostics (Basel, Switzerland), 10(3), 134.
6. Hodis, H. N., & Mack, W. J. (2022). Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing.Cancer journal (Sudbury, Mass.), 28(3), 208–223.