Clinical Management of Endometriosis in Menopause: A Narrative Review

Abstract

Endometriosis, an inflammatory disease primarily affecting the pelvis and peritoneum, manifests with pelvic pain, dysmenorrhea, dyschezia, dyspareunia, and infertility. Despite its ubiquity, the management of endometriosis is challenging due to its heterogeneous presentation, limitations in diagnostic methods, variable therapeutic responses, and personal and socio-cultural impact on quality of life. This review attempts to consolidate the current literature on endometriosis occurring during and beyond menopause, and to present details regarding management strategies that take into account individual outcomes and goals when managing this condition. The topics included in this review are the clinical features and differential diagnosis of pelvic pain in postmenopausal patients, imaging considerations, serum and laboratory biomarkers, indications for surgery, the principles of hormone replacement therapy, the de novo development of endometriosis after menopause, and malignant transformation. Each topic includes a summary of the current literature, utilizing clinical research, case reports, and expert opinion. Despite a better understanding of the impact of endometriosis beyond menopause, there are many limitations to this condition, specifically with regard to cancer risk and indications for surgery. The existing evidence supports the use of shared decision making and the incorporation of patient preferences in guiding clinical management. Future research endeavors must shed light on the natural history of postmenopausal endometriosis through longitudinal studies in order to foster a deeper understanding of its complicated disease course across women's lifespans.

Keywords: de novo endometriosis; endometriosis; endometriosis-associated ovarian cancer; hormone replacement therapy; menopause.

Figure 1

(a): O-RADS 2 lesion; 4.7 cm right ovarian endometrioma (orange arrow) with no enhancement, nodularity, or suspicious features. (b): Laparoscopic image (orange arrow indicating lesion); pathology consistent with endometriosis. (c): O-RADS 3 lesion; increasing size and complexity of a right adnexal mass measuring 13.5 cm (orange arrow indicating the areas of septations). (d): Laparoscopic image; pathology consistent with the grade 1 endometrioid adenocarcinoma of the ovary.