Endometriosis and perimenopause: symptoms and HRT

Q: Will my endometriosis symptoms get better when I reach menopause?

For most people, symptoms do ease once oestrogen levels settle after menopause. The lead-up to it can be bumpier though, as swinging oestrogen levels can flare symptoms for a while. An estimated 2 to 5% of people keep having symptoms after menopause, particularly with severe disease or significant scarring. Your GP or specialist can give you a clearer picture based on your history.

Q: Can I take HRT if I have endometriosis?

HRT is an option for many people with endometriosis, and the type matters. The oestrogen in HRT can reactivate dormant endometriosis tissue, so continuous combined HRT (oestrogen and progestogen taken together each day) is usually the approach guidance points to when endometriosis is in your history. This holds true even after a hysterectomy, which differs from the usual oestrogen-only HRT given afterwards. Talk through your history with your GP or gynaecologist to work out what is right for you.

Q: How do I know if new symptoms are endometriosis or perimenopause?

A lot of symptoms overlap, including pelvic pain, bladder changes, and pain during sex. A detailed symptom diary noting timing, location, severity, and any patterns can help your doctor tell the two apart. Some of these symptoms also overlap with other conditions, so it helps to have them assessed properly rather than working it out yourself. Bring your diary to your next GP appointment.

Q: What should I do if my endometriosis symptoms return while I am on HRT?

Call your GP for an assessment. Symptoms like pelvic pain coming back can be a sign your HRT needs reviewing or adjusting. You do not need A&E for this unless your pain is severe and sudden, though it is best not to sit on it until a routine review either. Call NHS 111 if you are unsure how urgently you need to be seen.

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If you live with endometriosis, you may have been told that menopause will bring relief. For many people, it does. The years leading up to it can feel less predictable though, with pain that flares, symptoms you have not had before, and questions about whether Hormone Replacement Therapy (HRT) is the right move for you. The hormonal swings of perimenopause, particularly oestrogen spikes, can make endometriosis symptoms worse before they settle. Understanding what is happening, and what your options are around HRT, puts you in a stronger position to make decisions alongside your doctor.

How endometriosis symptoms can shift in perimenopause

If your symptoms had felt manageable for a while, perimenopause can catch you off guard. Oestrogen does not simply taper off in a smooth line. It swings, sometimes climbing higher than before, then dropping again. Those spikes can stir up any remaining endometriosis tissue and bring flare-ups back.²

The pain itself can change shape. Instead of arriving and leaving with your period, you may notice it sticking around, less tied to your cycle and spread across more of the month. Because this kind of pain overlaps with other conditions, any new or shifting pattern is worth raising with your GP rather than working out on your own.³

Because oestrogen levels fall during menopause, many women experience relief from endometriosis symptoms. In some cases, however, new symptoms can show up or existing ones can feel different. You may notice painful bowel movements, a sudden urge to urinate, or pain during sex, either for the first time or more strongly than before. Because these symptoms overlap with conditions like irritable bowel syndrome and urinary tract infections, it helps to discuss them with your GP to identify the cause rather than managing them alone.¹⁴

HRT and endometriosis: what the interaction means for you

HRT does a lot to ease perimenopausal and menopausal symptoms, and it carries longer-term benefits too, like supporting your bone density, with possible benefits for your heart in the right circumstances. These matter especially if you have had an early or surgical menopause. With a history of endometriosis, there is one thing to weigh up: the oestrogen in HRT can wake up dormant endometriosis tissue and bring symptoms back. That shapes how HRT is usually prescribed for you.⁶

Why progestogen is included

A combination of oestrogen and progestogen is standard for women with a womb, as progestogen helps prevent an unwanted buildup of the womb lining. For those who have had a hysterectomy, HRT is generally oestrogen-only. However, if you have a history of endometriosis, it is worth discussing with your doctor whether adding a progestogen is still recommended, as it can help reduce the risk of remaining endometriosis tissue reactivating.⁷

Continuous combined HRT means taking oestrogen and progestogen together every day, without a break. Clinical guidance points to this approach when you have endometriosis, and that holds true even after a hysterectomy. Standard HRT after a hysterectomy is usually oestrogen-only. Where endometriosis is part of your history, the combined approach helps keep any remaining tissue from reactivating. It is a specific point worth raising with your clinician, since the right path depends on your history and how endometriosis has affected you.⁸

The levonorgestrel IUS as a progestogen option

A levonorgestrel intrauterine system (IUS), a small device placed in your womb that releases progestogen, such as the Mirena, may be worth discussing with your doctor. This is something for you and your doctor to work through together, weighing up your symptoms, your history, and what fits your life.⁹

Monitoring after menopause

There is a very small chance that endometriosis tissue can turn cancerous. Because of this, any new lump in your pelvis or symptoms that linger after menopause need looking into rather than a wait-and-see approach. This is rare, and it is the reason to stay in touch with your healthcare team and to take any new symptoms seriously rather than brushing them off as routine.¹¹

What to discuss with your GP

Endometriosis and perimenopause share a lot of symptoms, and telling them apart is hard to do on your own. Keeping a detailed symptom diary, noting where the pain is, when it comes, how strong it feels, and anything new, gives your GP a clearer picture. It can help separate perimenopausal changes from an endometriosis flare-up. Bring this diary to your appointments along with your full gynaecological history.¹²

A few specific things are worth raising: whether HRT is right for you and, if so, which type; how your endometriosis history shapes the choice between oestrogen-only and continuous combined HRT; whether your current pain relief is still doing enough; and whether any new symptoms need looking into.

If you have not yet had a proper conversation with your GP about how endometriosis affects your perimenopause care, including your HRT options, booking that in is a practical next step. Your full gynaecological history feeds directly into the decisions your clinician makes, so it is worth making sure it is part of the conversation.

Frequently Asked Questions

Will my endometriosis symptoms get better when I reach menopause?

Can I take HRT if I have endometriosis?

How do I know if new symptoms are endometriosis or perimenopause?

What should I do if my endometriosis symptoms return while I am on HRT?

Sources

[1] NICE NG73: Endometriosis: diagnosis and management

oestrogen levels fall in menopause, endometriosis symptoms usually improve or resolve, though symptoms like deep pelvic pain, bowel dysfunction, or urinary urgency can persist or present in a subset of individuals and require GP evaluation
[2] Jo's Hot Topics: Endometriosis and Menopause

During perimenopause, endometriosis symptoms can unexpectedly worsen due to erratic hormonal fluctuations, particularly oestrogen spikes.
[3] Menopause: A Guide for People With Endometriosis

Pain patterns may change, becoming more persistent and less tied to the menstrual cycle, reflecting chronic inflammation and the presence of scar tissue.
[4] Jo's Hot Topics: Endometriosis and Menopause

New symptoms such as painful bowel movements (dyschezia), bladder urgency, and pain during sex (dyspareunia) can develop during perimenopause.
[5] BMS Tools for Clinicians: Induced Menopause in women with endometriosis

Symptoms persist in an estimated 2 to 5% of postmenopausal women, particularly in cases of severe disease or extensive scarring.
[6] Jo's Hot Topics: Endometriosis and Menopause

The oestrogen in HRT can potentially reactivate dormant endometriosis tissue, causing symptoms to recur.
[7] BMS Tools for Clinicians: Induced Menopause in women with endometriosis

To reduce the risk of reactivating endometriosis tissue, a progestogen is typically prescribed alongside oestrogen to suppress the growth of any remaining deposits.
[8] Jo's Hot Topics: Endometriosis and Menopause

Continuous combined HRT (daily oestrogen and progestogen) is the recommended approach for people with endometriosis, even after a hysterectomy.
[9] Endometriosis & Perimenopause

A levonorgestrel IUS (such as Mirena) may serve as the progestogen component of combined HRT and can help manage endometriosis symptoms directly.
[10] Jo's Hot Topics: Endometriosis and Menopause

Any return of endometriosis symptoms such as pelvic pain while on HRT should be reported to a doctor for assessment.
[11] BMS Tools for Clinicians: Induced Menopause in women with endometriosis

There is a very small risk of malignant transformation in endometriosis tissue; any new pelvic mass or persistent symptoms after menopause require investigation.
[12] Menopause: A Guide for People With Endometriosis

Keeping a detailed symptom diary can help distinguish between perimenopausal symptoms and endometriosis flare-ups.