Endometriosis and menopausal health: An EMAS clinical guide

Introduction: Endometriosis is a common gynecological condition, and problems may persist or develop after the menopause. Endometriosis or its treatment in premenopausal women may lead to premature or early menopause. Thus, it is imperative that healthcare providers are appropriately trained in management of endometriosis at the menopause and beyond. Aim: To provide an evidence-based clinical guide for the assessment and management of menopausal health in women with a history of endometriosis. Materials and methods: Review of the literature and consensus of expert opinion. Summary recommendations: Surgery is the preferred option for managing symptomatic endometriosis after the menopause, as it should reduce pain, ensure an accurate diagnosis, and decrease risk of malignancy. Women with endometriosis may experience a spontaneous early menopause or surgically induced menopause. Endometriosis is also associated with an increased risk of cardiovascular disease, ovarian, breast, and thyroid cancers, as well as osteoporosis. Menopausal hormone therapy (MHT) is indicated for managing vasomotor and genitourinary symptoms and maintaining bone health. Continuous combined MHT may be safer than other forms in both hysterectomized and non-hysterectomized women with endometriosis as the risk of recurrence and malignant transformation of residual endometriosis may be reduced. Estrogen-only MHT should be avoided, even for women who have had a hysterectomy. For women not using MHT, alternative pharmacological treatments, such as neurokinin-3 receptor antagonists, should be considered for managing vasomotor symptoms. Additionally, antiresorptive and anabolic therapies, along with calcium and vitamin D supplementation, should be provided as indicated to ensure skeletal protection. If endometriosis recurs during MHT use and the patient is symptomatic, several management strategies may be employed: altering the regimen, discontinuation, and use of non-hormonal strategies. Herbal preparations should be avoided as their efficacy is uncertain and some may contain estrogenic compounds.