Endometriosis and menopause—management strategies based on clinical scenarios

Abstract

Endometriosis is largely considered a premenopausal disease with symptoms often improving during menopausal transition. However, 2%–4% of postmenopausal women are affected by endometriosis symptoms. At the same time, many peri‐ and postmenopausal women experience menopausal symptoms and inquire about treatment. Because of the estrogen‐dependent nature of endometriosis, treatment with menopausal hormone therapy requires careful assessment of the patient but should nevertheless be considered. Recurrence of endometriosis symptoms and risk for malignant transformation are potential risks to weigh when prescribing menopausal hormonal therapy. Choice of treatment should be guided by the presence and severity of current endometriosis symptoms, nature of menopausal symptoms, risk assessment of potential contraindications for treatment in patient history, and preferences of the woman after an informative discussion. Recurrence of endometriosis symptoms in a postmenopausal patient should always prompt rigorous evaluation, both in the presence and absence of hormonal treatment. Many recommendations on the topic are based on expert opinion and new studies are urgently needed to obtain evidence for optimal patient care.

The “Road” to Malignant Transformation from Endometriosis to Endometriosis-Associated Ovarian Cancers (EAOCs): An mTOR-Centred Review

“…High expression levels and enzyme activity have been demonstrated in cultured stromal cells from endometriotic lesions [ 154 , 155 ]. Whether endometriosis can develop de novo in this age group is unclear as there are a number of premenopausal women with asymptomatic endometriosis [ 14 ]. A case series of seven women who developed endometriosis ten years after the menopause supported the genetic and epigenetic theory of endometriosis development, i.e., endometriosis developed as a result of a cumulative series of genetic or epigenetic incidents [ 156 ].…”

“…The most widely accepted theory, Sampson’s retrograde menstruation, stipulates that endometriosis originates from a retrograde reflux of viable endometrial tissue into the peritoneal cavity during menstruation [ 9 , 10 ]. Whilst this theory may explain endometriosis in premenopausal women, it remains uncertain whether endometriosis in postmenopausal women represents a continuation of premenopausal endometriosis or arises as a “de novo” development [ 14 ]. Hormonal replacement therapy (HRT) can potentially increase the risk of endometriosis reactivation in this age group [ 15 ].…”

Rare Clinical Presentation of Postmenopausal Endometriosis: A New Perspective

“…Currently, the standard of the treatment designates ESHRE guideline: endometriosis from 2022 [3]. However, the clinical management of postmenopausal endometriosis is an insufficiently described issue and the usage of combined HRT remains unclear [33]. The diagnosis is based on imaging techniques, which are mainly used in clinical practice, including transvaginal sonography (TVS) and Magnetic resonance imaging (MRI), computed tomography (CT), rectal endoscopic sonography, and three-dimensional (3D) ultrasound [5,34].…”

“…Despite various therapeutic approaches, definitive curative therapy for endometriosis remains elusive, and a better understanding of the underlying disease is also required because it can undergo malignant transformation. There is still a lack of molecular factors that would allow us to understand the nature of DIE and indicate possible therapeutic points, especially in relation to endometriosis progressing to malignancy [1,33]. Table 2.…”