Dr. Steve Vasilev, MD, Gynecologist, Endometriosis Surgeon*:

True hormonal menopause (not just when periods stop but when ovarian-produced estrogen levels decrease to low levels) may slow the growth of endometriomas but will not result in them resolving. The old blood within (chocolate cyst) may or may not be absorbed very slowly or, worse, the endometrioma may rupture causing severe pain and more fibrosis, which can result in more pain.

Also, as one gets older, it is important to ask some questions and consider other factors and risks:
1/ do you have a family history of ovarian or breast cancer (or prostate)?
2/ does this really look like an endometrioma on MRI (the best imaging test) or not?
3/ how large are the endometriomas?
4/ do you have pelvic pain or intestinal symptoms?

The smaller the endometrioma(s) and the more it is pretty certain on MRI to be an endometrioma (not possible to be 100% because it is just “pictures”, but is a pretty good test), along with a negative family history or personal history of cancer and no really bothersome symptoms, it is possible to observe with some repeat imaging and not do surgery. However, no medication or natural treatment will make these go away.

The more any of the factors above are a concern and symptoms are an issue, the more surgery may be a good idea. It requires an individualized risk/benefit discussion with an expert, after reviewing all of the information and imaging.

It is crucial to understand that ovaries are not the only source of estrogen. Your fat cells convert hormones into a weaker estrogen and store estrogen for continued release. There is local estrogen production around endometriosis and if you take any estrogen as a hormonal replacement, the endometriomas and/or associated endometriosis will not go away. Endo is only partly driven by estrogen on a molecular level. Lastly, many toxins act as estrogen and are called xeno-estrogens. Excess estrogen from all sources can be partly metabolized and excreted if your intestinal microbiome is optimized. So, as you can see, there are a lot of factors and they do not disappear after menopause.

It is also crucial to understand that the scarring that endometriosis produces as part of your body’s normal healing can cause pain as well. So, while some of the endometriosis can regress after menopause this is not guaranteed and by not removing significant endo during this time, the ongoing fibrosis can cause continued problems into menopause.

Keep in mind that endometriosis does increase the risk of ovarian cancer in a small percentage of patients and the endo itself can undergo malignant change. While this is truly a small percentage, your personal family history and risk factors may be higher or lower. Especially if the endometriomas look atypical, something more than endo may be going on.

The last thing to consider is that uterine adenomyosis, closely related, does not go away after menopause either. While this is not often recognized as being a problem it can explain persistent pelvic pain in menopause.

So, it’s important not to try to “wait out” endometriosis into menopause, hoping that it will disappear, without expert guidance.

*This is not medical advice and is aimed for informational use only. Please contact the doctor’s office or consult with your doctor for any medical questions.