The Menopause
Does menopause mean an end to endometriosis symptoms?
Naomi Lake shares her experience of living with endometriosis and consults with the experts who explain how menopause affects this condition.
Packing for a few nights away is no unusual task. But it’s important that I’m prepared.
Living with endometriosis, it really does sneak up on you when you menstruate for 10 days. I always have a ‘period bag’ at the ready. I instinctively go through the motions to stow each item. Period tracker – check. Peppermint tea and paracetamol – check, check. Tranexamic acid, mefenamic acid, tramadol… check, check and check again.
What is endometriosis?
According to Endometriosis UK, the condition affects 1 in 10 people assigned female at birth and is the second most common gynaecological condition in the UK.
Despite these stats, endometriosis is still relatively unknown, with few treatment options available.
So what actually is it? Put simply, the endometrial lining of the womb is made up of cells that react to the monthly rhythm of hormonal changes, acting to shed and bleed with each new cycle. However, for those living with endometriosis, these cells can migrate and attach to other areas of the body, like the ovaries, intestines, lungs or even the skin. There have even been three reported cases of cerebral endometriosis, whereby these ‘alien’ cells have been found on the brain tissue.
This migration can lead to inflammation, localised and referred pain, and permanent scarring to the tissues. Why this happens, however, is still unknown.
How does menopause impact endometriosis?
The average age of menopause is 51 in the UK. But, with periods starting at an average age of 12, it’s a long stretch for a condition like endometriosis to take hold.
Unlike dysmenorrhea (painful periods) and menorrhagia (heavy bleeding), the scarring to tissues often caused by endometriosis won’t become a distant memory as the monthly cycle wanes. I wonder what this might mean for my future.
To find out more, I catch up with Oliver O’Donovan, an NHS consultant at University Hospitals Bristol and Weston.
As Oliver explains, the change in hormones during menopause may bring a shift in endometriosis symptoms.
“Endometriosis is driven by oestrogen, and menopause is when your ovaries stop producing, or stop producing a significant amount of oestrogen,” he says. “So, what normally happens is that the drive is removed and its symptoms improve dramatically.
“With pain symptoms, specifically when you’ve got heavy bleeding, that’s going to get better as your periods stop.
“It’s unusual for me to see somebody over 50 in the endometriosis clinic. Most women get significantly better and it’s very rare for us to have an endometriosis referral after menopause.”
The lasting effects of endometriosis
Endometriosis is categorised into different stages, using a scale that categorises patients with abnormal tissue growth. This ranges from endometriosis and endometrioma (painful, fluid-filled cysts), to scarring and adhesions. Adhesions can cause a web-like scar tissue, joining other tissues that shouldn’t be attached. How might menopause affect these often permanent changes?
“You can think about the pain from endometriosis as being caused by two things,” explains Oliver. “Firstly, with endometriosis itself. Those cells shouldn’t be sitting outside of the womb, growing and bleeding every month.
“But secondly, if you have significant scarring in your pelvis caused by years and years of this happening, this related pain may not change [at menopause].
“We can’t say whether it’s the traces of endometriosis outside the womb, or scarring causing pain, and that too may vary from person to person.”
Dr Nicky Keay, endocrinologist and author of Hormones, Health and Human Potential, echoes Oliver’s thoughts.
“Scarring and any adhesions are permanent, including after any sort of pelvic operation – especially for an inflammatory condition like endometriosis,” she says. “Unfortunately, any scarring will remain, as will potential gut issues. Hopefully, symptoms are not as severe as during the menstrual cycles.”
This rang true for me. IBS-like symptoms began not long after my first period and was later explained by scarring found on my bowels.
“In terms of gut adhesions and their effects, although they won’t be ‘stirred up’ by menstrual periods after menopause, menopause itself can be associated with gut issues,” says Nicky. “This could potentially be compounded if you already have adhesions.”
Can those with a history of endometriosis take HRT?
With menopause bringing along a number of unwelcome and challenging symptoms, HRT is often recommended as first-line treatment. But, I worry that adding more hormones back will encourage painful endometriosis symptoms to flare up again.
“The oestrogen drive for endometriosis removed by menopause can be replaced again by HRT,” says Oliver. “However, any HRT that we give is a lower level of oestrogen [than what is naturally in the body pre-menopause].
“The idea is to give the minimum amount that achieves the desired effect [and reduce menopause symptoms].”
As Oliver goes on to explain, it can take some trial and error to find the right dosage of HRT.
“The hope is that, for most women, it’s enough to relieve their symptoms from menopause, but not enough to drive their endometriosis.
“We ask ‘try this, how do you get on with that? Does that relieve your symptoms? Does that bring your pain back?’ Overall, it might just be that we can relieve the worst of the menopausal symptoms, but not all of them, and hopefully the endometriosis-related pain will improve.”
Are some forms of HRT better than others for endometriosis?
Much like the contraceptive pill, there are a plethora of different forms of HRT. This needs careful selection for those living with endometriosis.
“A low-dose HRT in a form that does not give a withdrawal bleed would be best to work alongside endometriosis,” says Nicky. “But of course, the main indication for taking HRT is quality of life.
“If you have a uterus, you’ll need to take progesterone alongside oestrogen. There is the option to take progesterone in blocks of time, either with a withdrawal bleed or continuously to avoid a bleed, which can be better alongside endometriosis.”
Oliver shared some insight on prescriptions here too.
“There are certain forms of HRT that we think, through research, are better with endometriosis,” he says. “The typical HRT we often try first is tibolone. It contains no actual oestrogen but has a chemical with oestrogen-like properties, so hopefully, it relieves the symptoms of menopause, but without oestrogen.
“There is a theoretical benefit here because of the lessened risk of reactivation. It’s not the best HRT in terms of relieving menopause-type symptoms, however.
“We are driven by the patient’s symptoms. The same is true of menopause. It’s just a question of getting that balance right.”
Talking to Oliver and Nicky goes a long way to reassuring me that there may be a time when the symptoms that terrorise me each month are absolute.
Words: Naomi Lake
