Endometriosis and menopausal symptoms
Endometriosis is a common condition affecting women of reproductive age and can be painful and debilitating. Women with endometriosis may be treated with lifestyle changes, medications or surgery to help control the symptoms and severity of the disease. Some of the medical treatments offered can cause women to feel like they are going through the menopause. Some women choose to have surgery involving removing both ovaries. In both of these situations, women can experience a sudden onset of menopause symptoms which can range in severity. There is evidence to suggest that providing women with information of what to expect can help their mental and physical wellbeing (NICE Quality Standards).
Why does inducing menopause help with the symptoms of endometriosis?
Endometriosis means that deposits of endometrium (lining of the womb) exist outside of the womb cavity and they thicken and bleed with every cycle. Inducing menopause causes suppression of the menstrual cycle and activity of the ovaries meaning that the symptoms of endometriosis may resolve. The methods of inducing a menopause are:
- Hormones by injection or nasal spray: These suppress your own hormones and stop your menstrual cycle. This means that your periods stop and you are likely to experience menopausal symptoms.
- Surgery involving removal of both ovaries. This may be with or without a removal of your womb but will permanently induce a menopause. The loss of libido (sex drive) is often felt more with a surgically induced menopause.
What is likely to happen during induced or surgical menopause?
The menopause symptoms women experience are the same as with natural menopause but they usually develop suddenly in induced or surgical menopause and can feel a bit overwhelming if they’re not expected. Women tend to experience hot flushes and night sweats, low or changing moods and loss of sexual drive. Some women experience memory loss and develop anxiety. There can be joint pains and muscle aches and some women say they lose more hair than usual. Some women experience repeated urine infections or can feel that their vagina is dry, sore or itchy.
How does Hormone Replacement Therapy help with menopause?
Hormone replacement therapy (HRT) provides hormones that can help with the symptoms of menopause and can also help to maintain bone strength and reduce the risk of heart disease.
What can I do to help these symptoms?
Increasing your exercise levels can help to reduce stress which can help manage menopause symptoms and can also help with weight loss. Managing your weight has lots of health benefits and can lessen symptoms of menopause as well. You could discuss with your GP about talking therapies, particularly cognitive behavioural therapy.
What can my health professional do to help with these symptoms?
HRT is very effective at reducing menopause symptoms so starting HRT is the first thing your medical professional will offer to do. It’s not clear from research when is the best time to start HRT for women with induced menopause. There can be a concern about the hormones keeping some areas of endometriosis active so sometimes it is not started for 3 to 6 months after induced menopause. However, if started immediately it can prevent bone loss and reduce menopause symptoms. This will be discussed with you.
The best HRT for women under the age of natural menopause with endometriosis contains at least two hormones, estrogen and progesterone, and is given continuously with no breaks. This can be given as tablets, patches or gel and sometimes alongside a hormone containing coil depending on what you would like and your situation. This combined HRT should be given for at least the first few years after removal of the ovaries but may be changed to oestrogen-only HRT later as it may have a better safety profile for women over the age of natural menopause. Ideally HRT should be continued until at least the age of 51 for all women in induced menopause.
For women with vaginal symptoms, vaginal estrogen tablets or cream are very effective and are safe to use alone or in combination with standard HRT in women with endometriosis. If your health professional is struggling to manage your situation they can refer you to a menopause specialist in your area to help you.
What can I do to help with lack of sex drive?
Lack of libido or sex drive can be due to many factors but in women with endometriosis it can relate to pain during intercourse or an induced menopause causing lack of the male hormone testosterone which plays an important role in the sex drive. Vaginal estrogen treatment can help vaginal dryness and pain and can be used along with lubricants during sex. An HRT called Tibolone can also be helpful as it has some androgen (a male hormone) in it along with estrogen and progesterone and may help with women with a reduced sex drive. In some cases, your doctor may suggest using a small amount of testosterone gel alongside your continuous combined HRT to increase libido. This may take several months to take effect.
Is there a risk of worsening endometriosis by taking HRT after having an oophorectomy or taking medications to cause menopause?
There is a theory that HRT contains just enough hormone to keep your bones healthy and to help with menopause symptoms and contains a low enough dose to not have an effect on endometriosis. This is called the estrogen threshold theory.
This means that it is rare for endometriosis to recur or get worse when on HRT but it is possible. It is more likely if there is a residual endometriosis and your HRT only contains estrogen.
Is there a risk of reactivated endometriosis transforming into cancer?
Reactivation of endometriosis by HRT is very rare and it is impossible to say how likely it is for endometriosis to turn into cancer. However, there have been a few reported cases of it occurring. This means that while on HRT, if you develop new symptoms or old symptoms start to recur, it is important to discuss this with your healthcare professional who can start any investigations that are needed. From all the evidence it seems that there is very little risk of reactivation of endometriosis or cancer for women on HRT who have had a removal of both of their ovaries and all of their endometriosis removed. For women with some endometriosis who are under 45 or who have significant menopause symptoms the evidence suggests that the benefit of taking HRT to manage the menopause symptoms outweighs the small risk of worsening of the endometriosis or risk of cancer.
- National Institute for Health and Care Excellence(NICE). Menopause Quality Standard [QS143].2017.Available from https://www.nice.org.uk/guidance/qs143/chapter/Quality-statement-5-Information-for-women-having-treatment-likely-to-cause-menopause. [Accessed on 3 March 2019]
- National Institute for Health and Care Excellence(NICE). Menopause. NG23. November 2015. Available from https://www.nice.org.uk/guidance/ng23/chapter/Recommendations. [Accessed on 3 March 2019].
- European Society of Human Reproduction and Embryology. Management of women with Endometriosis.2013. Available from https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline [Accessed 3 March 2019]
- Moen M.H.; Rees M.; Brincat M.; Erel T.; Gambacciani M.; Lambrinoudaki I.; et al. EMAS position statement: Managing the menopause in women with a past history of endometriosis. Maturitas. Sep 2010;67(1):94-97.
- Gemmell, L C; Webster, K E; Kirtley, S; Vincent, K; Zondervan, K T; Becker, C M. The management of menopause in women with a history of endometriosis: a systematic review. Human reproduction update. Jul 2017;23(4):481-500.
- Rozenberg, S; Antoine, C; Vandromme, J; Fastrez, M. Should we abstain from treating women with endometriosis using menopausal hormone therapy, for fear of an increased ovarian cancer risk? Climacteric. 2015;18(4);448-452