When endometriosis meets perimenopause - what next?
If excruciating pelvic pain holds you hostage every month, or even on a daily basis, you may have been looking forward to perimenopause more than the average person. You’ve heard, almost in disbelief, that it will fell the mighty endometriosis. All things considered, a couple of hot flushes here and there feel much more manageable than your insides trying to commit ritual suicide every few weeks.
So, does endometriosis really end with perimenopause? The short answer: probably. The long answer: there’s more to it. And it might take a while.
In a nutshell, decreasing oestrogen levels will most likely ease your endometriosis symptoms. However, oestrogen levels actually fluctuate during perimenopause (the stage leading up to menopause) meaning that symptoms can be aggravated, before they get better. In addition to this, hormone replacement therapy - a common perimenopause treatment - has the potential to reactivate endometriosis.
Ever at your service, Olivia dons the deerstalker to investigate what other options are available to ease perimenopausal symptoms. Naturally, a handy list of our best pain relief tips is included at the end so you can feel supported, no matter where you are in your journey.
1. Endometriosis: when your insides seem to hate you
First, let’s refresh on what endometriosis really is. The NHS website describes endometriosis as:
“a condition where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes”.
The cause of endometriosis is unknown, with the most common theory that of retrograde menstruation. This is where the lining of the uterus flows the wrong way, through the fallopian tubes. However, author Maisie Hill of Perimenopause Power remains unconvinced that this is the actual cause, noting that retrograde menstruation happens to the majority of menstruators. Additionally, endometriosis deposits do not have the exact same structure or behaviour as uterine lining; they are only similar.
Typical symptoms of endometriosis
Endometriosis affects 6-10% of menstruators. Regrettably, diagnosis can take up to 8-10 years, partly because severe menstrual pain is so often dismissed. Symptoms of endometriosis include:
Chronic pelvic pain
Painful periods and sex
Pain with bowel movements and urine
Fatigue and depression
Why it hurts like hell
Even for those who have no experience of this condition, endometriosis is quickly associated with excruciating pain. But where exactly does this pain come from?
The endometrial-like tissue outside your uterus is affected by hormones in the same way that the actual uterus lining is. Essentially, this means it builds and swells, in response to oestrogen levels. This inflammation can lead to bleeding and scarring and, most noticeably, a lot of pain. Scar tissue can prevent organs from moving freely, meaning that any type of movement - ovulation, sex, or bowel movement - can be agonising. This latter type of pain is not necessarily experienced in tandem with the hormonal changes in your menstrual cycle. This explains why endometriosis pain can be present both during and outside of menstruation.
2. When endometriosis meets (peri)menopause
A quick reminder. Menopause marks the point of having gone twelve months without a period. Officially, it lasts a day. Perimenopause is the hectic rollercoaster ride that gets you there, and is hallmarked by fluctuating hormonal levels. This distinction is important for understanding the endometriosis timeline.
During perimenopause, fluctuations in oestrogen and progesterone can impact your menstrual cycle, and irregular periods are a common experience during perimenopause (you read about them here). As endometriosis is an oestrogen-affected inflammation issue, fluctuations in this hormone will naturally impact the condition. Higher oestrogen levels can lead to heavier periods and more intense pain, and vice versa.
If that’s got you clutching the painkillers in panic, then fear not - at the bottom of this article, you’ll find our best tips for managing painful periods.
The good news? It is very common for endometriosis to end once you have reached menopause - aka, once your periods have been absent for 12 months. Low and stabilised oestrogen levels often lead to a reduction in tissue swelling and the associated pain.
In 2-5% of cases, however, endometriosis does continue after menopause. This is because there is still some oestrogen being produced in the body, even once you’ve hit menopause. Symptoms of postmenopausal endometriosis are similar to that of premenopause, typically including abnormal bleeding and pain.
It is always important to consider treatment of endometriosis, as leaving it unchecked can lead to further health risks down the line.
3. Endometriosis and HRT
The chances of developing endometriosis after perimenopause are slim, but it’s important to be aware that it can happen. There are some very rare cases of women without any history of endometriosis developing this condition after menopause. More commonly, postmenopausal endometriosis develops as a side effect of HRT.
Oestrogen threshold theory
It is unknown whether postmenopausal endometriosis is a continuation of pre-existing endometrial lesions, or if it develops separately by itself. Oestrogen threshold theory holds that when a certain level of oestrogen is reached in the body, undetected endometriosis is ‘activated’. It is only a theory, but it certainly seems to correlate with the fact that HRT, and in particular oestrogen-only HRT, is associated with postmenopausal endometriosis. However, as with too many areas in women’s health, more research is needed in this area before a conclusive stance can be taken.
That might put a damper on things, especially if you were ready to dive headfirst into HRT treatment once perimenopause hit. But thankfully, there are other options available that you can explore. Let’s head to the next section to find out what’s on offer.
Beyond HRT: treating perimenopause symptoms
As noted, HRT offers its own set of obstacles when it comes to navigating perimenopause from an endometriosis background, due to elevated oestrogen levels potentially ‘reactivating’ endometriosis. If this is the case, then oestrogen-progesterone HRT is possibly considered to be a safer option, as progesterone balances the effects of oestrogen. However, more research is still needed to confirm this.
That doesn’t necessarily mean that HRT isn’t the right option for you. In some cases, the benefits of HRT will outweigh the potential negatives, and all treatments come with their own level of risk. The point here is that care must be highly individual and specialised to you. This means actively consulting with your doctor and exploring every option, taking into account your age, medical history, and more. We cannot stress enough how important this is.
There are other perimenopausal treatments available if traditional HRT doesn’t feel quite right for you. These include:
Tibolone. Also a form of hormonal therapy, tibolone is used to treat menopausal symptoms such as vasomotor symptoms and bone loss. One review suggested that tibolone has the potential to be safer than traditional HRT for women with endometriosis. They noted, however, that their sample group was too small in size to give conclusive evidence. Tibolone is only suitable for women who have gone twelve months without a period.
Aromatase inhibitors. These are traditionally used to treat breast cancer in postmenopausal women. They work by preventing the enzyme aromatase from converting androgens into oestrogens.
SERMs with combined oestrogen. ‘Selective oestrogen receptor modules’ can activate oestrogen in certain areas of the body, whilst blocking it in others. This means they are potentially safer and with less side-effects than oestrogen-only treatment (specifically regarding the risk of oestrogen-related breast cancer).
Feel free to explore with a healthcare professional to see if any of these would work for you.
4. Easing endometriosis symptoms
That’s all well and good, we hear you say, but you’re in pain now. Sod waiting for menopause, you want to know how to ease those dreaded symptoms immediately. Guess what? We’ve also got you covered here.
If you’re a longtime friend of endo, you’ve no doubt collected a whole treasure trove of survival tactics. Even so, Maisie Hill might have something new to offer with her extensive list of pain-relieving treatments and tactics.
First, you can take a look at options relating to your diet:
Going gluten-free may work wonders - Hill notes that many women reported significant improvements after doing so
Avoid dairy or meat that are filled with hormones, as this can aggravate your already out-of-whack hormonal levels. Grass-fed, organic meat and dairy is best here
Supplements such as omega-3 fatty acids, curcumin, magnesium, B vitamins and zinc are all known to help with pain relief
Limit sugar, alcohol and dairy as they can increase inflammation
Nightshade vegetables such as aubergine, potatoes, peppers and tomatoes may be aggravating your pain; consider cutting them out.
Next, you can consider non-dietary options or treatments:
CBD oil. This can be great for alleviating period pain. Irregular periods during the perimenopause can make it hard to track your cycle, so regular use of CBD oil could be useful here
Low vitamin D levels have been linked to endometriosis. Confirm with a blood test before taking supplements
NSAIDs (non-steroidal anti-inflammatories) such as ibuprofen and naproxen are particularly useful in dealing with inflammatory pain
A histamine intolerance could be at fault. Histamine is produced in the body due to allergies and it causes inflammation. Some foods are rich in histamine, and your body might have trouble breaking them down, even if you are taking appropriate medication
Acupuncture, herbs and physical therapies (such as physiotherapy or reflexology) can help ease pain
Hot water bottles and baths can improve blood flow and relieve pain
Try castor oil packs on the lower abdomen
Smoking should be avoided or heavily restricted
Orgasms are well-known for aiding in pain relief
Exercise and rest during your period can be useful for alleviating pain, though it depends on what works for you.
We hope the above helps ease both your mind and your symptoms when it comes to tackling endometriosis and perimenopause together. It might take a while, with a bit of trial and error along the way, in order to find the right treatment or tactic.
But hang in there.
You’re doing an amazing job.
This article was updated 14-03-2022 to specify the use of tibolone for postmenopausal women only.
Fabian, CJ. n.d. “The what, why and how of aromatase inhibitors: hormonal agents for treatment and prevention of breast cancer.” PubMed. Accessed March 2, 2022. https://pubmed.ncbi.nlm.nih.gov/17892469/.
Gemmell, L., and et al. 2017. “The management of menopause in women with a history of endometriosis: a systematic review.” PubMed. https://pubmed.ncbi.nlm.nih.gov/28498913/.
Hill, Maisie. 2021. Perimenopause Power: Navigating Your Hormones on the Journey to Menopause. N.p.: Bloomsbury USA.
“Hormone replacement therapy (HRT) - Alternatives.” n.d. NHS. Accessed March 14, 2022. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/alternatives/.
“Overview - - - Endometriosis.” n.d. NHS. Accessed March 2, 2022. https://www.nhs.uk/conditions/endometriosis/.
Royo, Pedro. 2009. “Endometriosis in a postmenopausal woman without previous hormonal therapy: a case report - Journal of Medical Case Reports.” Journal of Medical Case Reports. https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-3-135.
S, Secosan, and et al. 2020. “Endometriosis in Menopause—Renewed Attention on a Controversial Disease.” Diagnostics 10(3): 134 (March).
“Tibolone as menopausal hormone therapy.” n.d. Australasian Menopause Society. Accessed March 2, 2022. https://www.menopause.org.au/hp/information-sheets/tibolone-as-menopausal-hormone-therapy.