There is little evidence on how endometriosis and pelvic pain should be managed in perimenopause and post-menopause. But this advice can help.
Endometriosis and pelvic pain are incredibly common conditions, yet there is limited evidence on how endometriosis should be managed around the time of perimenopause and after the menopause.
While menopause results in regression of endometrial deposits which could therefore “cure” endometriosis, it does not necessarily follow that those with persistent pelvic pain will also be “cured”.
Information about the prevalence of persistent pelvic pain post-menopause is limited (1), but this article outlines three major factors to consider when treating these patients.
Fortunately, there is a growing awareness of the importance of timely treatment, with the National Women’s Health Strategy 2020- 2030 identifying menopause, endometriosis and pelvic pain as areas of focus, among other issues.
Endometriosis is a common cause of persistent pelvic pain and is estimated to affect around 11% of women (2), with 830,000 Australians estimated to be living with endometriosis (3). Persistent pelvic pain due to endometriosis can be seen as its own disease entity, with its own significant personal and societal costs.
Endometriosis is an oestrogen-driven disease. Much of the treatment involves reducing systemic oestrogen via hormonal therapies. Treatment involves stopping uterine bleeding, suppressing oestrogen, treating associated bladder, bowel, vulval and pelvic floor pain and dysfunction and reducing pain sensitisation. Surgery is utilised for endometriosis refractory to conservative management. The treatment can be expensive, time consuming and can involve significant side effects for many patients. There is often a psychological burden, so multidisciplinary care is especially important.
Persistent pelvic pain is estimated to affect 15-25% of women and people assigned female at birth (AFAB) (4). The underlying primary or instigating cause can vary, and includes endometriosis, inflammatory bowel disease, bladder pain syndromes, irritable bowel syndrome, pudendal neuralgia and post-surgical pain syndromes. Despite there being a variety of triggering causes, persistent pelvic pain consists of a group of symptoms that can occur together and overlap as part of a pain syndrome. It is defined as greater than six months of noncyclical pain with functional disability (5). This includes a combination of the symptoms of the primary diagnosis, musculoskeletal pain, viscero-visceral pain, sensitisation and often an overlap of social and psychological implications.
The symptoms vary between people with the condition and may impact on their lives in different ways.
Management should be aimed at addressing the primary cause and the distressing symptoms. It is likely that pelvic pain will need ongoing management after menopause.
Menopause Hormone Therapy
There are several things to consider when diagnosing menopause and managing menopausal symptoms in this population. One of the first is the age at which menopause occurs, although researchers are still investigating how endometriosis may affect the age of menopause (3). There is some evidence endometriosis is associated with earlier menopause, either due to surgery (including surgical treatment of endometriomas, and hysterectomy and oophorectomy) or possibly the impact of agents within endometriomas on ovarian reserve. (3)
We should be looking for and treating premature ovarian insufficiency in this cohort, bearing in mind many will have treatment-induced amenorrhoea.
A history of endometriosis requires extra thought when helping someone manage symptoms of perimenopause and menopause. It also requires us to consider endometriosis and its treatment as additional risk factors for cardiovascular disease and osteoporosis.
The next consideration is how to treat symptoms of menopause in this patient cohort. There is a theoretical risk of disease recurrence and malignant transformation of endometriosis deposits, and for this reason it is suggested that combined MHT be used in this cohort even with past history of a hysterectomy. The information around malignant transformation is limited, “the current evidence is available from case reports and case series” (6). While the evidence is limited, the implications of both recurrence and malignant transformation are significant. It is recommended that the lowest effective dose of oestrogen should be used in combination with a progestogen, despite the history of hysterectomy.
Cardiovascular Disease
The perimenopause and menopause consultation is a great launching pad for a discussion of midlife health and chronic disease prevention. We know that oestrogen is cardioprotective, and that menopause is a time of accelerated cardiovascular disease (CVD) risk. People who have a history of endometriosis have a higher risk of CVD than other people AFAB. Endometriosis is a chronic inflammatory condition, with endothelial dysfunction, and is associated with increased oxidative stress. Some studies have shown a more atherogenic lipid profile with endometriosis (7,8). This results in premature atherosclerosis and a higher risk of CVD, although this gap is most evident in younger women. There are also potential genetic factors linking endometriosis and CVD.
In addition to this, surgically induced menopause, as well as treatment with GnRH agonists may further increase the risk of CVD. Physical inactivity among those suffering from persistent pelvic pain due to endometriosis is an additional CVD risk factor. It is important to consider looking for modifiable risk factors early in this cohort, perhaps before perimenopause, and continuing to review thereafter.
Osteoporosis
The presence of long-standing physical inactivity requires consideration with regard to bone health. The combination of hormonal suppression in young women with endometriosis, reduced physical activity and the potential for increased risks associated with earlier natural or surgical menopause should highlight the need to target strategies to minimise osteoporosis, across the lifetime but especially at perimenopause and post-menopause.
Dr Carmel Reynolds MBBS DCH FRACGP (Cert Family Planning and Sexual Health) is a GP with a strong interest in women’s health and feels strongly about giving women a voice. She works in an inner-city GP Clinic, is the current Chair of the Adelaide Pelvic Pain Network, occasional clinical lecturer for medical students and Pelvic Pain Foundation Australia educators and the SA/NT Board director for the Australasian Menopause Society. Dr Reynolds spends three mornings each month surgical assisting for an obstetrician and gynaecologist and a breast cancer surgeon.
References
Alio, L., Angioni, S., Arena, S., Bartiromo, L., Bergamini, V., Berlanda, N., Bonanni, V., Bonin, C., Buggio, L., Candiani, M. and Centini, G., 2019. Endometriosis: seeking optimal management in women approaching menopause. Climacteric, 22(4), pp.329-338
Australian Institute of Health and Welfare, Australian Government (2019). Endometriosis in Australia: prevalence and hospitalisations. https://www.aihw.gov.au/getmedia/a4ba101d-cd6d-4567-a44f-f825047187b8/aihw-phe-247.pdf.aspx?inline=true
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Australian clinical practice guideline for the diagnosis and management of endometriosis (2021). https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Endometriosis-clinical-practice-guideline.pdf?ext=.pdf
Evans, S., 2015. Management of persistent pelvic pain in girls and women. Australian family physician,?44(7), pp.454-459.
Saha, S. and MRepMed, F.R.A.N.Z.C.O.G., What else could it be? Causes of pelvic pain.
Tanmahasamut, P., Rattanachaiyanont, M., Techatraisak, K., Indhavivadhana, S., Wongwananuruk, T. and Chantrapanichkul, P., 2021. Menopausal hormonal therapy in surgically menopausal women with underlying endometriosis. Climacteric, pp.1-7.
Mu, F., Rich-Edwards, J., Rimm, E.B., Spiegelman, D. and Missmer, S.A., 2016. Endometriosis and risk of coronary heart disease. Circulation: Cardiovascular Quality and Outcomes, 9(3), pp.257-264.
Okoth, K., Wang, J., Zemedikun, D., Thomas, G.N., Nirantharakumar, K. and Adderley, N.J., 2021. Risk of cardiovascular outcomes among women with endometriosis in the United Kingdom: a retrospective matched cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 128(10), pp.1598-1609.
