L26/P-368 A systematic comparative appraisal of endometriosis clinical guidance documents for menopausal transition management

Abstract Study question To what extent do national and international endometriosis-related clinical guidance documents address the management of menopausal health in women with a history of the disease? Summary answer Clinical guidance on managing menopause in women with endometriosis is limited. Disease recurrence and malignant transformation are the main concerns regarding menopausal hormone therapy (MHT). What is known already Although symptoms of endometriosis typically regress after natural or surgical menopause, the disease has been reported to affect several postmenopausal women. Managing symptoms of the menopausal transition in this patient population presents unique clinical challenges, particularly regarding the safe use of MHT because of the risk of disease reactivation or malignant transformation. Study design, size, duration A systematic methodological analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. Literature searches were performed in the MEDLINE, Web of Science, and Scopus databases and the Guideline International Network (GIN) library for national and international endometriosis-related clinical guidance documents. In addition, targeted searches were conducted on professional society websites and governmental bodies to capture eligible documents that might not be indexed in electronic databases. Participants/materials, setting, methods Eligibility criteria included clinical guidance documents published in English, between 2000 and 2025, available in full-text electronic format with recommendations on endometriosis management. Extracted data included document characteristics, recommendations on MHT, phytoestrogens, and alternative therapies, and information on recurrence and malignancy risk. The quality of clinical practice guidelines (CPGs) and consensus statements was assessed using the AGREE-II tool, while other documents were appraised using the Joanna Briggs Institute (JBI) Critical Appraisal for Text and Opinion. Main results and the role of chance A total of 48 clinical guidance documents published between 2002 and 2025 were included: 31 CPGs, eight consensus documents, one position statement, and eight expert opinions. Of these, 45.8% (22/48) addressed the menopausal transition in women with endometriosis, primarily focusing on MHT use after surgical menopause (19/48, 39.6%), with less emphasis placed on natural menopause (6/48, 12.5%). The documents recommended the use of continuous combined estrogen-progesterone therapy or tibolone. An association between MHT, especially unopposed estrogen regimens, and disease reactivation or malignant transformation was reported in 33.3% (16/48) and 22.9% (11/48) of the documents, respectively. Additional concerns regarding increased breast cancer risk with combined estrogen-progesterone MHT or tibolone were reported in five documents (5/48, 10.4%). A minority of documents incorporated information on phytoestrogens (3/48, 6.3%) and alternative therapies (2/48, 4.2%). Only two guidelines issued by the National Institute for Health and Care Excellence (NICE) exhibited high quality across all six AGREE-II domains. While most guidelines and consensus statements demonstrated high methodological quality in the domains of “Scope and Purpose” and “Clarity of Presentation”, they were of moderate to low quality in the remaining domains. Documents evaluated using the JBI Text and Opinion Checklist met all six quality criteria. Limitations, reasons for caution The identification of relevant documents may have been constrained as only records published in English were included, and some society repositories restrict access to members only. Quality assessment with the AGREE II tool was omitted for three documents to avoid assigning a falsely low score because of insufficient methodological data. Wider implications of the findings Despite the prevalence of endometriosis, recommendations addressing menopausal transition are limited and primarily focus on the use of MHT after surgical menopause. The increasing volume of relevant literature underscores the need for high-quality, evidence-based guidelines to optimize the management of this specific patient population. Trial registration number No