Managing Endometriosis After Menopause: Treatment Options and Advice

Why Does Endometriosis Persist After Menopause?

Endometriosis is largely known as a hormone-dependent condition of women, especially in their reproductive years. This period starts at menarche or in the first years of adulthood.

The decrease of follicular growth or ovulation at menopause is responsible for alleviating pain symptoms and leads to the regression of endometriosis.

The persistence of severe pain and other symptoms that occur during your menopause may be the result of some ectopic endometrial tissue that remains active in your postmenopausal period.

During the postmenopausal period, asymptomatic endometriosis lesions can be seen during the performance of pelvic imaging or surgical interventions for other conditions.

According to Ayurveda, three doshas are present in your body, and the vata dosha increases with age. Based on two symptoms, dysmenorrhea and chronic pelvic pain, Ayurveda relates endometriosis with Vataja Yonivyapada (a type of vaginal disorder), which has similar symptoms as endometriosis. 

A. Hormonal Factors

Changes in the levels of your hormones primarily cause endometriosis. Some of these are:

a) Residual Estrogen Production

Even after menopause, your body may still produce small amounts of estrogen through your fat tissue and the adrenal glands. This tends to stimulate the formation of endometrial tissue. This endometrial tissue can grow in various parts of your body.

b) Hormone Replacement Therapy (HRT)

HRT is used to manage menopause symptoms and can worsen your endometriosis. HRT contains estrogen, which is the primary hormone that increases the growth of your endometrial tissue post-menopause. Therefore, HRT can cause symptoms of endometriosis.

B. Adhesions and Scarring

Adhesions are clumps of thick scar tissue on the inside of your body. The body usually forms scar tissue in response to inflammation and injuries.

Endometriosis causes the tissue that lines your uterus to grow in other parts of your reproductive system, such as the fallopian tubes, ovaries, or bladder.

Endometriosis causes inflammation when it grows and bleeds during your menstrual cycle. This can form scar tissue during the healing process.

Adhesions can cause serious complications, mainly when they are very large and sometimes block your blood vessels.

C. Post-Menopausal Inflammation

Endometriosis is an estrogen-dependent inflammatory disease characterised by the presence of ectopic endometrial tissue. Endometriosis is more than premenopausal endometriosis.

Chronic inflammation, common in ageing, may exacerbate endometriosis symptoms.

Symptoms of Post-Menopausal Endometriosis

After menopause, there is a decline in levels of estrogen in your body. Endometriosis decreases the associated symptoms during this period. But, it may cause other distinct menopausal symptoms, like mood swings, hot flashes, and night sweats.

Some common symptoms of post-menopausal endometriosis are:

• Pelvic pain or severe cramps.
• Pain during defecation or urination.
• Bloating or other gastrointestinal issues.
• Fatigue or reduced energy levels.
• Some symptoms of intestinal obstruction can occur, but it is very rare.

Diagnosing Post-Menopausal Endometriosis

Endometriosis can be difficult to diagnose due to its similarities with other diseases. However, an experienced gynaecologist may help you in this case with the below methods:  

A. Medical History

A medical history is the primary and most vital step in diagnosing any disease. Discuss your prior diagnosis and symptom history with your healthcare provider. A detailed medical history will help better understand the causes and how your system behaves.

B. Imaging Tests

Some specific imaging tests can help rule out endometriosis:

a) Ultrasound or MRI 

TVS (Transvaginal sonography) benefits from a lack of radiation exposure. In postmenopausal women, ovarian cysts may be associated with a risk of malignancy. In addition, TVS may have a role in assessing diseases involving the bladder and rectum. It helps to identify cysts (endometriomas), malignant tumours or adhesions.

b) CT Scans

Computed tomography (CT) plays a significant role in diagnosing bowel endometriosis. It helps to get a clearer view of your affected organs.CT scan also helps to identify any genitourinary tract involvement, especially in patients with a history of chronic pelvic pain or in patients with a history of endometriosis. Radiation exposure, however, is a risk.

C. Laparoscopy

Laparoscopy is a minimally invasive surgical procedure to confirm the presence of endometrial tissue. While diagnostic laparoscopy remains the gold standard, it is often not the first line of diagnosis any more, as noninvasive testing for early diagnosis and progression of endometriosis is preferred. Yet, no imaging method can definitively confirm the diagnosis of endometriosis.

Treatment Options for Managing Post-Menopausal Endometriosis

Endometriosis can be very challenging, but there are various treatment options available that can help you manage it. They are as follows:

A. Hormonal Treatments

Endometriosis is primarily caused by an imbalance in hormones. After menopause, this can further worsen, so hormonal treatments can be a good option. 

a) Progestin Therapy

Progestin has inhibitory effects on growth factors and anti-inflammatory effects. Progestins inhibit gonadotropin-releasing hormones, suppressing follicular-stimulating hormones and luteinising hormone secretion. Endometriosis occurs in the presence of estrogen; however, when progestins are present, an estrogen-dependent proliferation of the endometrium is prevented.

Progestins can counteract estrogen’s effects, helping to shrink your endometrial tissue.

It is available as pills, injections, or intrauterine devices (e.g., Mirena IUD).

b) GnRH Agonists

Pituitary GnRH receptor down-regulation leads to a hypogonadotropic and secondary hypoestrogenic state, resulting in lesion regression and symptom improvement. There may also be an additional effect on the inflammatory processes associated with endometriosis. It suppresses residual estrogen production.

However, it may cause menopausal-like side effects, such as hot flashes or bone thinning, which can be managed with add-back therapy.

c) Aromatase Inhibitors

Aromatase activity is absent in normal human endometrium and is increased in endometriosis. Extrauterine endometrial tissue is a source of oestrogen. Moreover, estrogens stimulate the synthesis of PGE2, a potent inducer of aromatase activity in the endometrium. This underlying mechanism triggers the virtuous cycle, leading to the new growth of ectopic endometrial tissue. The use of aromatase inhibitors in the treatment of endometriosis is supposed to stop this virtuous cycle. It also blocks estrogen production in fat tissue and adrenal glands. It is often used in combination with other therapies.

d) Estrogen-Free HRT

For women experiencing menopause symptoms, estrogen-free options like progestins or non-hormonal treatments are safer without any side effects for those with endometriosis.

B. Surgical Options

Along with medical management, surgical intervention may be necessary if your symptoms don’t subside. However, it is essential to go to a registered practitioner who may help you explore your treatment options and refer to surgery only if necessary. Below are some of the surgical procedures you can expect:

Laparoscopic Surgery

A laparoscopy is a surgical procedure that may diagnose and treat various conditions, including endometriosis.

During a laparoscopy, a long, thin viewing instrument called a laparoscope is inserted into the abdomen through a small surgical incision. This allows your doctor to view tissue or take a tissue sample, called a biopsy.

They may also remove cysts, implants, and scar tissue caused by endometriosis.

A laparoscopy for endometriosis is a low-risk and minimally invasive procedure. It’s typically performed under general anaesthesia by a surgeon or gynaecologist.

Some benefits of laparoscopy are :

• It removes remaining endometrial tissue, adhesions, or cysts.
• It helps to alleviate pain and prevent complications like bowel obstruction.

Hysterectomy with Oophorectomy

Surgery for severe endometriosis is complex and associated with significant risks in the immediate operative period and longer term.

Removal of the ovaries has the benefit of reducing the risk of ovarian cancer and may be associated with reduced reoperation rates for endometriosis-related pain.

Removal of the uterus and ovaries is a definitive treatment but is typically reserved for severe or refractory cases.

C. Ayurvedic Management

Endometriosis cannot be correlated to any single disease in Ayurveda. Hence, the treatment approach is primarily symptomatic. It includes correcting your digestive fire, digestion of toxins, Vaatanulomana (removal of excessive vata), and consumption of herbs, reducing its progression.

D. Non-Hormonal Medications

Non-hormonal medications can be used to manage pain and inflammation in your body. Some of these medicines, which can be beneficial for you, are as follows:

a) Pain Management

• NSAIDs like ibuprofen or naproxen reduce inflammation and pain.
• Tricyclic antidepressants or anticonvulsants may be prescribed for chronic pain management.

b) Anti-Inflammatory Supplements

• Curcumin is a turmeric compound with anti-inflammatory properties that help reduce your pain.
• Omega-3 fatty acids reduce systemic inflammation. This is available in the form of capsules.

E. Lifestyle and Alternative Treatments

Lifestyle changes help to keep a balance in your health. Alternative treatments and lifestyle adjustments supplement your journey.

a) Dietary Adjustments

Your diet plays a vital role in shaping your health and managing diseases.

i) Anti-Inflammatory Diet: Focus on whole foods, fruits, vegetables, nuts, and fatty fish.

ii) Avoid Trigger Foods: Reduce consumption of processed foods, sugar, caffeine, and alcohol.

b) Exercise

Low-impact exercises like yoga or swimming improve circulation and reduce inflammation.

F. Stress Management

Stress exacerbates symptoms; techniques like meditation, deep breathing, or mindfulness can help.Add these techniques to your daily routine to reduce stress.

i) Acupuncture

Acupuncture is a technique by which your body is pricked at specific points. It may alleviate your pain and improve your overall well-being.

ii) Pelvic Physical Therapy

Patients suffering from endometriosis can experience dysfunction in their pelvic floor. Chronic pain can cause trauma to the muscles, ligaments, nerves, and fascia of the pelvis and abdominal wall.

This can result in pain in the pelvis, difficulty urinating, difficulty having bowel movements, painful sex, and pain with movement.

Pelvic floor therapy directly targets the pelvic floor to improve your symptoms.

Pelvic floor physical therapy combines exercises, stretches, manual techniques, and behaviour modification to improve your quality of life.

Do’s and don’ts according to Ayurveda:

• Favour warm, light and slightly oily, fresh home-cooked meals.
• Avoid alcohol, caffeine (especially coffee), carbonated drinks, red meat and refined sugar or flour. 
• Avoid red wine, chilli, coffee, and red meat.
• Avoid exercise during menstruation, and do not overexert yourself during exercise at other times of your cycle.

Preventing Endometriosis Complications Post-Menopause

Endometriosis can be difficult to manage and cause complications and significant distress in your daily life. However, this can be prevented with adequate care. Some tips which can be helpful to you are:

• Go for regular follow-ups with your healthcare provider.
• Keep a check on signs like severe abdominal pain or unusual bleeding.
• Maintain a balanced diet and active lifestyle to combat inflammation.

When to Seek Medical Attention

It is essential to seek immediate care and consult your healthcare provider if you experience the following symptoms:

• Severe pelvic pain.
• Symptoms of bowel or urinary bladder obstruction.
• Unexplained weight loss or fatigue.
• Unusual post-menopausal bleeding.

Wrapping Up

Postmenopausal endometriosis is an underestimated type of endometriosis and may develop many years after menopause in the absence of an intake of estrogen or increased systemic production. Treatment with exogenous estrogen has the potential to increase the symptoms of endometriosis. Surgery is the primary treatment. Aromatase inhibitors and HRT show promising results in patients. Endometriosis is a disease that can significantly affect your quality of life. Managing endometriosis can be challenging, especially after menopause. It requires a personalised approach which considers your body and how it acts. It includes hormonal, surgical, and lifestyle factors. Understanding endometriosis can help you handle your symptoms better. Similarly, exploring the available treatment options according to your needs can help improve your quality of life and reduce further complications.

For more information, you can contact our Nirva team of healthcare experts.