Endometriosis does not always stop at menopause. A European guide says so

Endometriosis is commonly described as an oestrogen-dependent condition of the reproductive years, with the implication that menopause resolves it. A clinical guide from the European Menopause and Andropause Society, published in Maturitas on September 2, is built on the premise that this is often wrong: problems may persist or develop after menopause, and endometriosis or its treatment before menopause may itself bring menopause forward [s1].

What the guide is

It is an evidence-based clinical guide assembled from a review of the literature and a consensus of expert opinion, aimed at clinicians managing menopausal health in women with a history of endometriosis [s1]. Like the ALEG and EMAS statements in this genre, it is consensus over existing evidence rather than new data, and its recommendations inherit the limitations of the studies behind them.

The 2022 ESHRE guideline on endometriosis — 109 recommendations spanning diagnosis, pain, infertility, recurrence, asymptomatic and extrapelvic disease, adolescents, and postmenopausal women — already covered postmenopausal endometriosis within a much broader remit [s2]. ESHRE's own assessment was that for several specific clinical issues the evidence is too scarce to make evidence-based recommendations [s2]. The EMAS guide takes the menopausal slice and treats it at length.

The substantive positions

Surgery is the preferred option for symptomatic endometriosis after menopause. The guide's reasoning is threefold: it should reduce pain, ensure an accurate diagnosis, and decrease the risk of malignancy [s1]. The diagnostic and malignancy arguments are what distinguish postmenopausal management from premenopausal — new or persisting lesions after menopause raise a question that medical management leaves unanswered.

Menopause may arrive early. Women with endometriosis may experience spontaneous early menopause or surgically induced menopause [s1]. That reframes the population: some of these women are facing decades of oestrogen deficiency starting well before the average age of menopause.

The associated risks are not confined to the pelvis. The guide records that endometriosis is associated with increased risk of cardiovascular disease, of ovarian, breast, and thyroid cancers, and of osteoporosis [s1].

On hormone therapy, the guidance is specific. Menopausal hormone therapy is indicated for managing vasomotor and genitourinary symptoms and maintaining bone health [s1]. Continuous combined therapy may be safer than other forms in both hysterectomised and non-hysterectomised women with endometriosis, because the risk of recurrence and malignant transformation of residual endometriosis may be reduced [s1]. Oestrogen-only therapy should be avoided even in women who have had a hysterectomy [s1].

That last point is the guide's most consequential departure from routine practice. Standard menopausal hormone therapy prescribing gives oestrogen alone after hysterectomy, because the progestogen exists to protect the endometrium and there is no endometrium left. The guide's position is that in endometriosis the relevant tissue may not all have been removed, so the rationale for adding a progestogen survives the operation.

For women not using hormone therapy, the guide points to alternative pharmacological options for vasomotor symptoms including neurokinin-3 receptor antagonists, and to antiresorptive and anabolic therapies with calcium and vitamin D supplementation for skeletal protection as indicated [s1].

If endometriosis recurs during hormone therapy in a symptomatic patient, the options given are altering the regimen, discontinuation, and non-hormonal strategies [s1].

Herbal preparations should be avoided, the guide says, because their efficacy is uncertain and some may contain oestrogenic compounds [s1].

How much of this is settled

Very little of it rests on randomised trials, and the guide does not claim otherwise — its stated method is literature review plus expert consensus [s1]. The hedged language in the hormone therapy recommendation is doing real work: continuous combined therapy may be safer, and recurrence and malignant transformation risk may be reduced [s1]. Those are plausible mechanistic inferences, not demonstrated outcomes.

Malignant transformation of endometriosis is rare, which is both reassuring clinically and the reason the evidence base is thin: rare outcomes require very large or very long studies to compare treatment strategies, and those studies do not exist for this question.

The cancer and cardiovascular associations the guide lists [s1] are drawn from observational literature in which surveillance bias and shared risk factors are persistent difficulties. Association is the appropriate word.

Why a menopause-specific guide was worth writing

The practical problem it addresses is a handover failure. Endometriosis care is organised around reproductive-age gynaecology; menopause care is organised around symptom management and bone and cardiovascular health. A woman with a long endometriosis history who reaches menopause — early, sometimes surgically — can fall between the two, and end up on a hormone regimen chosen by rules that were not written with her history in mind. The guide's insistence that clinicians be appropriately trained in management of endometriosis at menopause and beyond [s1] is aimed at exactly that gap.

What to watch

Whether the oestrogen-only avoidance recommendation is taken up in national menopause guidance; whether registry data quantify recurrence risk on different hormone therapy regimens; and whether neurokinin-3 receptor antagonists accumulate specific evidence in this population rather than being extrapolated from general menopause trials.

This article describes clinical guidance and is informational only. It is not medical advice and does not recommend any treatment or hormone regimen.

Sources

• [s1] Erel CT, Nigdelis MP, Ozcivit Erkan IB, Goulis DG, Chedraui P, Giannini A, Kiesel L, Phillips N, Simoncini T, Armeni E, et al., Endometriosis and menopausal health: An EMAS clinical guide, Maturitas, 2025;202:108715, published online 2025-09-02.
• [s2] Becker CM, Bokor A, Heikinheimo O, et al., ESHRE Endometriosis Guideline Group, ESHRE guideline: endometriosis, Human Reproduction Open, 2022;2022:hoac009, published 2022-02-26.