Endometriosis, HRT and Menopause: How Are They Connected?

For many women with endometriosis, menopause brings mixed emotions. You may hope that pain and heavy periods will finally improve. At the same time, you may worry about hot flashes, night sweats, sleep problems, and mood changes. You might also hear different opinions about the safety of hormonal replacement therapy hrt if you have endometriosis.

This article explains the relationship between endometriosis, HRT and menopause. It reviews research that looks at the benefits and risks and why combined hrt is often preferred.

It also shows how to work with your care team to improve the quality of life in a safe way. This information is educational and cannot replace personalized medical advice. Always discuss your specific situation with your clinician.

You may also see terms like only hrt in some papers when they refer to estrogen-only therapy. We will explain what this means and why it matters.

What is endometriosis and why does it matter at menopause?

Endometriosis occurs when endometriotic tissue grows outside the womb. This tissue is similar to the uterine lining. It can appear on the ovaries, pelvic ligaments, bowel, or bladder.

These endometriotic lesions respond to hormones much like the uterine lining. Estrogen often drives them.

Because endometriosis is estrogen-dependent, many people assume it disappears completely after menopause. In reality, studies show that people can experience endometriosis after menopause, either as persistent disease or as new lesions. This is more likely if they continue to be exposed to estrogen from their own bodies or from medication.

Women with a history of endometriosis may also go through menopause earlier than average. This can happen after repeated ovarian surgery or removal of both ovaries.

Natural, surgical and medically induced menopause in endometriosis

Natural and early menopause

Natural menopause usually occurs between ages 45 and 55. For women with endometriosis, this transition may or may not improve pain. Some symptoms fade as estrogen levels decline. Others, such as pelvic pain from scarring or deep lesions, can persist.

A large international study found that women with endometriosis have a higher chance of early menopause. They are also more likely to need surgery that causes menopause. This type of surgical menopause can affect long-term bone and heart health.

Medically induced menopause

Some treatments for endometriosis, such as GnRH analogues, create a temporary or “chemical” menopause. Guidelines say that doctors often use these therapies with low-dose “add-back” HRT. This helps control symptoms and protect bone health while lowering the chance of disease returning.

Why consider HRT at menopause if you have endometriosis?

Menopause symptoms can have a major impact on daily life. The benefits of hrt are well documented. HRT is one of the most effective treatments for:

• Vasomotor symptoms (hot flashes, night sweats)
• Sleep problems, fatigue and low mood
• Urogenital symptoms such as vaginal dryness and pain with sex
• Long-term bone loss and fracture risk
• Cardiovascular and metabolic health when started near the time of menopause in appropriate candidates

For women with endometriosis, the question is not whether HRT works for menopause symptoms. It does help menopausal symptoms. The key issue is whether it can trigger recurrence of endometriotic lesions or, more rarely, malignant transformation of long-standing disease.

What does the research say about HRT in women with a history of endometriosis?

Evidence from reviews and case reports

Several systematic reviews and narrative overviews have evaluated HRT in women with a history of endometriosis. Overall, the evidence base is limited. Most data come from observational studies and case reports, not from large randomized clinical trials.

Key points from this literature include:

• HRT can be used to relieve menopausal symptoms and improve the quality of life in symptomatic women with past endometriosis, particularly those who experienced premature or surgical menopause.
• Some reports describe recurrence of endometriosis or rare cancers arising from endometriotic tissue in women on HRT. This is seen more often when they received unopposed estrogen (estrogen-only HRT).
• Larger studies show that hormone replacement therapy may not greatly raise cancer risk in women with endometriosis. However, the data are still limited, so any increased risk is hard to measure.

Because of these uncertainties, experts emphasize personalized risk assessment rather than a one-size-fits-all approach.

Estrogen-only versus combined HRT

Across multiple reviews and guidelines, a consistent message appears:

Estrogen-only HRT (sometimes referred to in studies as “only hrt”) is more often linked to recurrence or growth of endometriosis lesions, especially in women with residual disease.

Doctors generally recommend combined hrt (estrogen plus a progestogen) or tibolone for women with current or past endometriosis. This advice usually applies even after hysterectomy and bilateral salpingo oophorectomy, to reduce the chance of stimulating any remaining endometriotic tissue.

Researchers believe that the progestogen component helps counterbalance estrogen’s growth-promoting effects on lesions. However, adding a progestogen can slightly change other risks (for example, breast cancer risk). For this reason, the benefits and risks must be weighed carefully for each person.

Malignant transformation and “increased risk”

A small number of case reports and reviews describe malignant transformation of long-standing endometriosis in postmenopausal women. Some of these women were taking estrogen-only HRT.

Important context:

• This appears to be rare, and the true increased risk is difficult to quantify.
• Larger cohort studies do not show a clear overall rise in ovarian cancer among women with endometriosis who use well-prescribed HRT.
• Because the risk, although small, seems more associated with unopposed estrogen, experts pay special attention to estrogen-only regimens.

For many women, especially those who are young at surgical menopause, the potential harms of leaving severe menopausal symptoms untreated are high. These harms include bone loss, cardiovascular changes, and reduced daily functioning. In these cases, the benefits of carefully chosen HRT may outweigh the uncertain risk of recurrence.

How HRT can improve the quality of life in endometriosis and menopause

When used thoughtfully, HRT may:

• Ease severe menopausal symptoms such as hot flashes and night sweats that interrupt sleep.
• Support bone mineral density, which is especially important after early or surgical menopause.
• Help maintain muscle mass, metabolism and cardiovascular health when started near the time of menopause in appropriate candidates.
• Reduce vaginal dryness and pain with intercourse, which can be particularly distressing for women with endometriosis who already live with chronic pelvic pain.

These benefits of hrt explain why major menopause and endometriosis societies, including EMAS and national menopause organizations, now emphasize individualized decision-making. They no longer recommend automatically denying HRT to anyone with a history of endometriosis.

Practical considerations to discuss with your clinician

Because the evidence is nuanced, it helps to go into your consultation prepared. Here are key points to explore with your provider or menopause specialist:

1. Your personal endometriosis history

• Where were your endometriotic lesions located (ovaries, bowel, deep pelvic sites)?
• Have you had complete excision or is residual disease likely?
• Did you have hysterectomy and bilateral salpingo oophorectomy, or do you still have your uterus and/or ovaries?

This context helps your clinician consider the safest regimen.

2. Type and route of HRT

Ask about:

• Combined hrt vs estrogen-only, and why combined options are usually preferred in women with a history of endometriosis.
• Transdermal (patch, gel, spray) vs oral estrogen and how each affects clotting and metabolic risk.
• The choice of progestogen (micronized progesterone vs synthetic progestins) and how it may influence breast, cardiovascular and mood outcomes.

3. Monitoring plan

Safe care does not end with a prescription. A good plan may include:

• Regular follow-up to review symptom relief and side effects.
• Surveillance for new or recurrent pelvic pain, bleeding or masses that could signal recurrent endometriosis.
• Routine screening for cardiovascular risk factors, bone health and breast cancer according to national guidelines.

4. Non-hormonal and local options

If systemic HRT is not appropriate for you, ask about:

• Non-hormonal options for hot flashes and night sweats (certain antidepressants, CBT, lifestyle strategies).
• Local vaginal estrogen or moisturizers for dryness, which have minimal systemic absorption.

FAQs: Endometriosis, HRT and Menopause

Does endometriosis always go away after menopause?

No. While many people notice improvement as estrogen levels fall, endometriosis after menopause can persist or present with new symptoms. This is more likely in those exposed to external estrogen or with residual deep disease.

Why is estrogen-only HRT a concern?

Estrogen-only therapy may stimulate any remaining endometriotic tissue. It has been linked with more reports of recurrence and rare malignant change in long-standing lesions. For this reason, most experts advise against estrogen-only HRT in women with significant past endometriosis, even after hysterectomy and bilateral salpingo oophorectomy.

Can endometriosis turn into cancer after menopause?

There are documented cases of cancers arising in endometriosis lesions. However, these events are rare and the absolute risk appears low. Some reviews suggest a possible link with long-standing disease and unopposed estrogen. However, larger cohort data do not show a clear large increased risk in overall cancer with appropriately used HRT.

Conclusion

For many women with endometriosis, menopause is not the simple end of a painful chapter. It is a new stage with its own challenges. It is also an opportunity to reassess health goals and improve the quality of life.

The current evidence suggests that:

• HRT can be an important tool for controlling menopausal symptoms, protecting bones and supporting long-term health.
• The main concern is not HRT itself, but how doctors use it, especially by avoiding estrogen-only regimens in women with a history of significant disease.
• Combined hrt or tibolone, tailored dosing, close monitoring and shared decision-making are central to balancing benefits and risks.

If you have endometriosis and are nearing or going through menopause, you do not have to suffer in silence. You can feel safer and more informed about your treatment options.

Work with a knowledgeable clinician or menopause specialist to review your history, values and risk profile. Together, you can create a plan. This plan can be hormonal, non-hormonal, or a mix of both. It will help you feel comfortable now and stay healthy in the future.

References

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2. Cassani, C., Rees, M., & Erel, C. T. (2024). Menopause and endometriosis. Maturitas, 180, 1–8.
3. Erel, C. T., Rees, M., & EMAS Writing Group. (2025). Endometriosis and menopausal health: An EMAS clinical guide. Maturitas, 202, 108715.
4. Gemmell, L. C., Webster, K. E., Kirtley, S., Vincent, K., Zondervan, K. T., & Becker, C. M. (2017). The management of menopause in women with a history of endometriosis: A systematic review. Human Reproduction Update, 23(4), 481–500.
5. Giannella, L., La Marca, A., & Ternelli, G. (2021). Malignant transformation of postmenopausal endometriosis: A systematic review of the literature. Cancers, 13(16), 4026.
6. National Institute for Health and Care Excellence (NICE). (2024). Menopause: Identification and management (NG23 update).
7. National Institute for Health and Care Excellence (NICE). (2017, reviewed 2025). Endometriosis: Diagnosis and management (NG73).
8. Zanello, M., Borghese, G., Manzara, F., Degli Esposti, E., Moro, E., Raimondo, D., et al. (2019). Hormonal replacement therapy in menopausal women with history of endometriosis: A review of literature. Medicina, 55(8), 477.