7 hours ago5 min read

Living Through Menopause: What Everyone with Endometriosis Needs to Know

Introduction:

Menopause is a natural phase of life, but for those with a history of endometriosis, it can bring unique challenges. Menopause Hormone Therapy (MHT) is often used to manage menopausal symptoms, but its impact on those with endometriosis requires careful consideration.

Definitions:

Endometriosis: A condition where tissue similar to the lining inside the uterus grows outside it, causing pain and other symptoms. During reproductive years, symptoms tend to become most difficult near the week of menstruation.
Menopause: Defined as one year without menstruation. Normally, menopause occurs between ages 45 and 54.

While often considered a premenopausal condition, endometriosis can persist or even recur after menopause.

Menopause and Endometriosis:

Endometriosis has been shown to impact the age at which menopause occurs.

Thombre Kulkarni et al. (2022):

Women with laparoscopically confirmed endometriosis have a 50% greater risk of early natural menopause (before age 45).
Early menopause is more common in those with endometriosis who never had children or who never used birth control pills, although the direction of causation is unclear.

Menopause After Hysterectomy:

Hysterectomy, with or without ovary removal, is a common surgery to treat endometriosis. Aside from obvious implications for fertility when the uterus is removed, this surgical method can impact the timing of menopause. When both ovaries are removed, the patient will undergo immediate surgical menopause. Unlike natural menopause, surgical menopause significantly impacts testosterone and estrogen levels overnight. As a result, one study found that 78.7% of women experienced a reduction in sexual desire following surgical menopause (2)

A hysterectomy without ovary removal can impact the timing of natural menopause as well. After a hysterectomy with one or both ovaries left remaining, there is double the risk of entering menopause by age 40, also known as primary ovarian insufficiency (POI), and menopause tends to occur earlier overall (3). Menopause before age 45 can have a monumental impact on one's health and quality of life.

The Effects of Menopause After Hysterectomy:

One study showed that hysterectomy increased the risk of osteoporosis regardless of ovary preservation, with the risk highest in the youngest patients (4). Hysterectomy with or without ovary removal has been associated with worse hot flashes, vaginal dryness, heart disease, and depression compared to those without hysterectomy (3-6).

Surgical menopause before age 45 has also been associated with a higher risk of heart disease, osteoporosis, and dementia (3).

In one study of sleep disturbance during the menopause transition, hysterectomy status was the only remaining predictor of increased risk for moderate sleep difficulty after adjusting for life stress, number of kids, physical symptoms, psychological symptoms, history of sleep disorders, and use of prescription medications (7).

Is Hysterectomy Even Necessary to Treat Endometriosis?

This is a complex decision that will require an in-depth conversation with your surgeon after careful consideration of your unique situation. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO: removing the cervix, uterus, fallopian tubes, and ovaries) has been shown to lead to a lower risk of endometriosis recurrence than more conservative options (8,9).

7 year reoperation-free survival rate is 91.7% for TAH-BSO.
7 year reoperation-free survival rate is 77.0% for hysterectomy with ovary preservation.
8 year reoperation-free survival rate is 64.8% for laparoscopy without hysterectomy.

Although these are averages, the skill of the endometriosis surgeon has been shown to affect both the recurrence rate and rates of fertility after laparoscopic surgery. After a surgeon has performed more than 30 laparoscopic endometriosis surgeries, recurrence rates are significantly lower (10).

Therefore, the increased risk of endometriosis recurrence with conservative surgeries must be weighed against the risks of reduced fertility and early and surgical menopause. The experience of the surgeon should be a consideration as well. There can be no one-size-fits-all approach.

Menopause Hormone Therapy (MHT) and Endometriosis:

MHT is effective in alleviating menopausal symptoms such as hot flashes, night sweats, and osteoporosis.
Normally, a progestogen (a synthetic or natural form of progesterone) is not required after a hysterectomy, and estrogen can be given on its own (unopposed). However, for those with a history of endometriosis, MHT can be a double-edged sword, as unopposed estrogen can potentially reactivate endometriosis tissue.
Zanello et al. (2019) suggest that using combined MHT with both an estrogen and a progestogen, regardless of hysterectomy status, may be a safer option for those with a history of endometriosis.

The Role of Progesterone:

Progesterone and progestins can help reduce the size of endometriotic lesions and alleviate pain by thinning the lining of the uterus.
Replacing progesterone, separately or in addition to estrogen, may help relieve sleep disruption, mood changes, and hot flashes during the menopause transition.
Progesterone plays a role in maintaining bone health, helping to prevent osteoporosis.

The Role of Testosterone:

Women with endometriosis tend to have lower testosterone levels than women without endometriosis, with one study suggesting that low testosterone may cause endometriosis (12).
After surgical menopause, testosterone replacement significantly improves sexual function (13).

Conclusion:

Managing menopause after endometriosis requires a balanced approach.
Weigh the risk of endometriosis recurrence with conservative surgeries against reduced fertility, early surgical menopause, and surgeon experience, as there is no one-size-fits-all approach.
MHT can provide relief from menopausal symptoms.
Incorporating progesterone (or a synthetic progestin) into the treatment plan can provide significant benefits, whether or not the uterus has been removed.
Testosterone replacement may improve libido after surgical menopause, and its role in the development and treatment of endometriosis requires more study.

Follow-Up Resources:

For more information, consider these resources:

References:

Thombre Kulkarni M, Shafrir A, Farland LV, Terry KL, Whitcomb BW, Eliassen AH, Bertone-Johnson ER, Missmer SA. Association Between Laparoscopically Confirmed Endometriosis and Risk of Early Natural Menopause. JAMA Netw Open. 2022 Jan 4;5(1):e2144391. doi: 10.1001/jamanetworkopen.2021.44391. PMID: 35061039; PMCID: PMC8783263.
Nappi RE, Lello S, Melis GB, Albani F, Polatti F, Genazzani AR. LEI (Lack of tEstosterone Impact) survey in a clinical sample with surgical menopause. Climacteric. 2009 Dec;12(6):533-40. doi: 10.3109/13697130902972005. PMID: 19905905.
Madueke-Laveaux OS, Elsharoud A, Al-Hendy A. What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review. J Clin Med. 2021 Nov 16;10(22):5335. doi: 10.3390/jcm10225335. PMID: 34830617; PMCID: PMC8622061.
Choi HG, Jung YJ, Lee SW. Increased risk of osteoporosis with hysterectomy: A longitudinal follow-up study using a national sample cohort. Am J Obstet Gynecol. 2019 Jun;220(6):573.e1-573.e13.
Wilson LF, Pandeya N, Byles J, Mishra GD. Hot flushes and night sweats symptom profiles over a 17-year period in mid-aged women: The role of hysterectomy with ovarian conservation. Maturitas. 2016 Apr;91:1-7.
Farquhar CM, Sadler L, Stewart AW. A prospective study of outcomes five years after hysterectomy in premenopausal women. Aust N Z J Obstet Gynaecol. 2008 Oct;48(5):510-6.
Tom SE, Kuh D, Guralnik JM, Mishra GD. Self-reported sleep difficulty during the menopausal transition: results from a prospective cohort study. Menopause. 2010 Nov-Dec;17(6):1128-35. doi: 10.1097/gme.0b013e3181dd55b0. PMID: 20551846; PMCID: PMC3151465.
Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol. 2008 Jun;111(6):1285-92. doi: 10.1097/AOG.0b013e3181758ec6. Erratum in: Obstet Gynecol. 2008 Sep;112(3):710. PMID: 18515510.
Soliman AM, Du EX, Yang H, Wu EQ, Haley JC. Retreatment Rates Among Endometriosis Patients Undergoing Hysterectomy or Laparoscopy. J Womens Health (Larchmt). 2017 Jun;26(6):644-654. doi: 10.1089/jwh.2016.6043. Epub 2017 May 4. PMID: 28472602.
Carmona F, Martínez-Zamora A, González X, Ginés A, Buñesch L, Balasch J. Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate? Fertil Steril. 2009 Sep;92(3):868-875. doi: 10.1016/j.fertnstert.2008.07.1738. Epub 2008 Oct 1. PMID: 18829016.
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.
McGrath IM; International Endometriosis Genetics Consortium; Montgomery GW, Mortlock S. Polygenic risk score phenome-wide association study reveals an association between endometriosis and testosterone. BMC Med. 2023 Dec 5;21(1):482. doi: 10.1186/s12916-023-03184-z. PMID: 38049874; PMCID: PMC10696845.
Stuursma A, Lanjouw L, Idema DL, de Bock GH, Mourits MJE. Surgical Menopause and Bilateral Oophorectomy: Effect of Estrogen-Progesterone and Testosterone Replacement Therapy on Psychological Well-being and Sexual Functioning; A Systematic Literature Review. J Sex Med. 2022 Dec;19(12):1778-1789. doi: 10.1016/j.jsxm.2022.08.191. Epub 2022 Sep 26. PMID: 36175351.