Endometriosis at midlife and beyond

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Endometriosis at midlife and beyond

Endometriosis symptoms usually subside after menopause, but not always. And they are sometimes related to other health problems.

Crippling menstrual cramps, gastrointestinal problems, and pain during sex are among the most common and distressing symptoms of endometriosis, a gynecological disorder that affects as many as 1 in 10 women. The disease occurs when tissue similar to the lining of the uterus (the endometrium) shows up on the walls of the abdominal cavity and the outer surfaces of the uterus, ovaries, fallopian tubes, bowel, bladder, and nearby organs. Rarely, endometriosis appears in the heart, lungs, and brain.

Like the endometrium, this wayward tissue builds up and sheds monthly in response to the menstrual cycle. But unlike menstrual fluid, which exits through the vagina, the blood and tissue from endometriosis lesions remain trapped, triggering inflammation and adhesions (weblike scar tissue that binds organs together). Endometriosis can also distort the large intestine, ovaries, and fallopian tubes, causing bowel problems and infertility. Experts estimate that among women with pelvic pain, infertility, or both, 35%–50% have endometriosis.

Traditional treatments include surgery to remove the misplaced tissue and drugs that suppress or regulate menstruation. Many women say that they get some relief from dietary changes (avoiding red meat, caffeine, alcohol, and refined flour and sugar), acupuncture, massage, and relaxation techniques such as yoga or meditation. However, these are unproven approaches to treating endometriosis.

Although endometriosis symptoms are most troublesome during the reproductive years, they don’t necessarily disappear once a woman stops menstruating. “I think of endometriosis as a chronic disease that often—but not always—improves after natural or surgical menopause,” says Harvard Women’s Health Watch editorial board member Dr. Martha K. Richardson.

Anatomy of endometriosis Tissue similar to the uterine lining appears on the outer surfaces of organs in the abdominal cavity. Adhesions (weblike scar tissue) may also be present.

Perimenopause and menopause

Fluctuating hormone levels during perimenopause (the years leading up to menopause) can cause erratic periods and heavier-than-usual flow. Some women with endometriosis who suffer gut-wrenching pain during menstruation may benefit from eliminating their periods altogether through the use of continuous low-dose birth control pills. Others take birth control pills for three months followed by a week off, so they have a period only four times a year.

Another option is an intrauterine device called Mirena that releases levonorgestrel (a progestin) and has been shown in a few small studies to ease menstrual cramps. The Mirena device can be left in place for up to five years. Periods eventually become lighter and may disappear completely after one year.

Estrogen fuels the growth of endometriosis lesions, so in theory, dwindling estrogen levels at menopause should lessen the symptoms. But even after periods have ceased, the ovaries continue to produce small amounts of the hormone, so endometriosis may continue to cause trouble.

Women bothered by menopausal symptoms such as hot flashes and night sweats are often concerned that taking hormone therapy to quell them could reactivate any previous endometriosis. To reduce this possibility, many clinicians recommend using hormone preparations such as Estrace, Vivelle, Climara, or Estraderm patches and micronized progesterone (Prometrium and Crinone vaginal gel) rather than synthetic or animal-derived hormones (such as Premarin and Provera).

Surgical menopause

Women with severe endometriosis who’ve gotten no relief from various medical and surgical treatments often resort to hysterectomy—sometimes in their 30s or 40s, or even earlier. Most also have their ovaries removed, which results in “surgical menopause.” Even then, endometriosis may persist if remnants of ovarian tissue remain in the pelvis. Hysterectomy and ovariectomy do reduce the risk of ovarian cancer, but evidence suggests that removing the ovaries before age 65 has a downside. Ovariectomy may increase the risk of heart disease and osteoporosis, which are far more common than ovarian cancer. This is one reason why doctors say that ovary removal should be decided on a case-by-case basis.

Most experts agree that women with endometriosis who undergo surgical menopause should probably take hormone therapy until natural menopause (around age 51) to avoid the risks of osteoporosis and heart disease. Some recommend waiting three to nine months after surgery before starting hormone replacement, to give the endometriosis a chance to die out.

Osteoporosis concerns

Women may be at increased risk for osteoporosis if they’ve been taking medications that lower estrogen levels in order to reduce endometriosis growth. These medications, called GnRH agonists (Lupron, Synarel, Zoladex, and others), induce a temporary “pseudomenopause” that eases endometriosis symptoms but may also weaken bones. Women who take GnRH agonists may be given small amounts of hormones or bisphosphonate drugs to prevent bone loss. They also should be diligent about bone density testing, bone-healthy habits, and follow-up with their clinicians.

Autoimmune and related disorders

According to a 2002 study in the journal Human Reproduction, women with endometriosis have a higher-than-average risk of autoimmune and related disorders. Researchers found that, compared with American women in general, women who had endometriosis were 100 times more likely to have chronic fatigue syndrome, 7 times more likely to have hypothyroidism, and twice as likely to have fibromyalgia. Multiple sclerosis, rheumatoid arthritis, lupus, Sjögren’s syndrome, allergies, and asthma were also more common. These findings support the theory that the immune system plays a role in endometriosis. They also suggest that women who have endometriosis should be alert to new symptoms that could signal the onset of one of these conditions.

The cancer connection

Women with endometriosis are more likely to develop ovarian cancer (although their lifetime risk is still low, about 2%). The reasons are unclear. On the plus side, taking birth control pills—one of the most widely used treatments for endometriosis—for five years or more can cut ovarian cancer risk by as much as 40%.

Ovarian cancer can mimic endometriosis, with symptoms including abdominal pain, swelling, fatigue, back pain, and a frequent need to urinate. Women who have had endometriosis should be alert to this possibility, especially if symptoms recur after menopause, when most ovarian cancers develop. Several reports also suggest an association between endometriosis and an increased risk for breast cancer, non-Hodgkin’s lymphoma, and melanoma.

If you have endometriosis, be sure to have annual checkups and any tests recommended by your clinician. Be aware that abdominal adhesions—a common result of repeated surgeries for endometriosis—can make colon cancer screening with sigmoidoscopy or colonoscopy more painful or difficult. Alert the physician performing the procedure; you may also want additional sedation and pain medication.

Future generations

Some studies suggest that genes play a role in the development of endometriosis. Researchers have identified several gene variants that appear to be involved, some of which code for enzymes that detoxify unwanted substances. This discovery is consistent with research suggesting that endometriosis is associated with exposure to dioxin and estrogen-like compounds in the environment, although a connection has not been proved.

Young women with endometriosis whose mothers also have the disease are fortunate in having someone close to them who understands their pain. Too often it has not been taken seriously enough. Endometriosis was once characterized as a disease of “career women” (meaning women who chose career over childbearing), and it’s still sometimes dismissed as “bad cramps.” Sometimes it’s difficult to diagnose because the symptoms can be vague. But today greater awareness is leading to earlier diagnosis and treatment, and research holds the promise of a better understanding of the disease.

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Last updated:	August 21, 2006