Menopause and Endometriosis: Tracing the Entanglements of Hormones, Ageing and Gendered Chronic Illness

The article explores menopause as a feminist question through a chronic gynaecological illness: endometriosis. As endometriosis is an oestrogen-associated condition, menopause is expected to alleviate endometriosis symptoms, yet its unfolding effects are unknown. Drawing on interviews with clinicians and people with endometriosis in Finland, as well as ethnographic observation at an endometriosis clinic, we show that endometriosis sheds crucial light on menopause as an embodied process. First, the anticipation of menopause in endometriosis involves uncertainties concerning unique bodily responses and narrowing treatment options that affect how people with endometriosis orientate towards a post-menopausal future. Menopause thus extends in time, becoming entangled with the practices of managing gynaecological illness years before the actual onset of menopause symptoms. Second, radical endometriosis surgery that involves removal of the uterus and ovaries produces an early menopause that raises questions about what constitutes menopause. Post-operative care involves delicate tinkering with hormonal medications to achieve a postponement of menopause symptoms while also responding to slowly unfolding processes of gendered ageing that extend beyond hormonal health. At the same time, ideas about “natural menopause” structure radical surgery and postoperative care as a reference point in relation to which post-operative embodied processes are managed.

Menopause is often described in cultural discourse as a mid-life event that marks a move from a reproductive female body to a post-reproductive one. It is portrayed as a series of hormonal changes whose effects are felt across the body and mind as hot flashes, sleeplessness, difficulty to concentrate, muscle and joint pain, and changes in body weight (De Graeve & De Vuyst, Citation2022; Orgad et al., Citation2024). Public discourses have increasingly framed the years following the initial menopause symptoms—the so-called perimenopause –– as a critical period that requires medical and personal management (e.g. Bergstein, Citation2024; see Krajewski, Citation2018; Orgad & Rottenberg, Citation2024). However, for those living with oestrogen-associated health conditions such as endometriosis, menopause may bring much awaited relief. Endometriosis is described as an illness of reproductive years bookended by the onset of menstruation and the completion of menopause (WHO, Citation2023). In the context of endometriosis, menopausal hormonal changes—especially decreasing oestrogen production—often alleviate endometriosis symptoms. The prospect of menopause carries the hope of finally calming a body in pain (Harper et al., Citation2022, p. 10). However, the impact of menopause on endometriosis is not a straightforward process of waning symptoms. While menopause offers hope, uncertainties about its effects shape experiences of living with endometriosis (Denny, Citation2009, pp. 991–992). Little is known about how the hormonal fluctuations during perimenopause affect endometriosis, with health blogs cautioning that endometriosis symptoms may get worse before they get better (e.g. Forbes, Citation2023). Furthermore, biomedical literature has documented cases of post-menopausal endometriosis, either as a continuation of existing disease or, in rare cases, new disease (Cassani et al., Citation2024; de Almeida Asencio et al., Citation2019). While menopausal hormone therapies can potentially activate remaining endometriosis tissue (Gemmell et al., Citation2017; Secosan et al., Citation2020), endometriosis has also been described as “a self-perpetuating condition” in that the production of hormones in tissue could sometimes keep the illness active (Bendon & Becker, Citation2012, p. 217). Indeed, research has suggested that endometriosis could be considered a systemic disease that involves complex hormonal, inflammatory and neurological dynamics not directly linked to menstruation (Taylor et al., Citation2021). Furthermore, if endometriosis-associated pain becomes chronic, it may continue after menopause. Scarring from endometriosis surgeries may result in persistent pain (Krämer et al., Citation2021), while sensitization to pain in chronic illness can engender pain symptoms “long after the initiating pathophysiology resolves” (Stratton & Berkley, Citation2011, p. 336). In this article, we draw on interview and ethnographic data collected among patients and clinicians in Finland to explore the entanglements of endometriosis and menopause and to rethink menopause as a feminist, embodied issue. Focusing on endometriosis, we suggest, unsettles common assumptions of what menopause is by rendering visible the temporal and material connections between gender, ageing and chronic illness. The article also expands the existing feminist discussion of hormonal pharmaceuticals in menopause by foregrounding the instability of concepts such as natural and medically moulded processes of ageing. Our analysis also fills a gap in the endometriosis literature, which has focused on the so-called reproductive years. Our findings complicate the image of endometriosis as a reproduction-related illness by highlighting the ambiguities that structure the anticipation of menopause in endometriosis. We take the gendered, hormonally changing body as a lens through which we explore the entanglement of endometriosis and menopause. We first introduce feminist scholarship on menopause and endometriosis as well as our qualitative data. We then discuss our results in two sections. The first one explores the tension between hopeful anticipation of menopause as an end to endometriosis and the worry that hormonal fluctuations during perimenopause—or hormone therapy addressing those fluctuations—may fuel endometriosis symptoms. The second one looks at radical surgery—the removal of the uterus and ovaries in difficult cases of endometriosis—focusing on the intricate tinkering with hormonal medications in the post-operative years. We show that radical surgery takes place in relation to assumptions about a naturally occurring menopause, resulting in a simultaneous presence of menopause as a surgically produced and pharmaceutically moulded process and as a norm against which medically induced processes are evaluated. Feminist Research on Menopause The medicalization of menopause has generated debate in feminist research and health activism (for an overview, see De Graeve & De Vuyst, Citation2022). We focus on two aspects of the feminist menopause literature: the anticipatory reconfiguration of menopause and the pharmaceutical modification of menopause. A growing repertoire of anticipatory technologies addressing reproductive ageing are being marketed to women. These include ovarian reserve testing and perimenopausal self-tracking (Roberts & Waldby, Citation2021), social egg freezing (van de Wiel Citation2020), and ovarian tissue freezing (Kroløkke & Bach, Citation2020). Such technologies extend the temporality of menopause. Roberts and Waldby (Citation2021) use the term “incipient infertility” to capture the underlying assumption that women’s bodies are always already failing and that women have a responsibility to prolong their reproductive potential. At the same time, menopause-related anticipatory technologies extend to the postmenopausal years. Kroløkke and Bach (Citation2020) demonstrate that the freezing and re-implantation of ovarian tissue is seen as a potential source of rejuvenation that addresses wider concerns about ageing. Drawing on these studies of the anticipatory management of menopause, we approach the years leading to menopause in endometriosis as characterized by an evolving tension between hopes and concerns. Such conflicted expectations engender an ambivalent sense of anticipation that keeps the pre-menopausal present under the hold of a future (see Adams et al., Citation2009). The second strand of feminist research centres on the pharmaceutical management of menopause, especially menopausal hormone therapies, typically oestrogen and progesterone. Menopausal hormone therapies have been promoted variedly as a way of maintaining youthfulness, of restoring purportedly natural hormonal balance, of preventing long-term health issues such as osteoporosis, and managing difficult menopause symptoms (Fishman et al., Citation2015; Fugh-Berman, Citation2015). Critical analyses have argued that the marketization of menopausal hormone therapies posits them as neoliberal solutions that sideline structural social inequalities (Orgad & Rottenberg, Citation2024). Feminist discussion has foregrounded the question of risk. The debate has a long history (see, e.g. Lupton, Citation1996) reflecting changing understanding of risks associated with hormonal products (such as breast cancer) and risks associated with menopause (such as osteoporosis). Changing ideas of risk engender uncertainty. Niland and Lyons point out that there is a contradiction in how “the medicalization of women’s bodies at midlife renders them as ‘patients’ in need of treatment, yet the uncertainty of medical ‘facts’ means that in practice menopause must be managed as an individual risk assessment” (Niland & Lyons, Citation2011, p. 1243). At the same time, what counts as risk is negotiated between clinicians and patients. Fishman et al. (Citation2015) show how the safety of so-called bioidentical hormone therapies is enacted in clinical practices in relation to ideas of naturalness. Flore et al. (Citation2024) note that in the treatment of early menopause, what constitutes a risk, and what risk is acceptable, is assessed in relation to a person’s unique health situation. Meanwhile, routinization of clinical practices has been shown to maintain the idea of menopause as hormone deficiency, even when clinicians and patients recognize the equation as simplistic (Guillemin, Citation2000). We draw on this literature as we trace how risks and benefits of pharmaceutical interventions are negotiated when managing endometriosis and menopause. Feminist Research on Endometriosis Feminist research has shown how the association of endometriosis with reproduction has shaped endometriosis treatment. Endometriosis is often described as an oestrogen-dependent disease as endometriosis lesions, meaning tissue similar to that found in the uterine wall but occurring outside of the uterus, react to hormonal changes and bleed during menstruation “into places where [the blood] cannot escape” (Denny, Citation2009, p. 985). One prominent biomedical theory suggests that endometriosis lesions are formed when menstrual blood travels in a wrong direction in the body (Horne & Missmer, Citation2022, p. 6). Feminist scholars have noted that the association with menstruation led to the perception that a typical endometriosis patient is someone who has failed to fulfil their reproductive role by delaying their pregnancy. Gender, race, class and age intersected in this image, as white, middle-class, educated women were considered as the main patient group (Griffith, Citation2019; Jones, Citation2015, Citation2021). This logic has also impacted the treatment of endometriosis in that pregnancy has, at least historically, been recommended to alleviate endometriosis symptoms (Jones, Citation2015), and emphasis is often placed on enabling pregnancies for patients whose fertility is affected by endometriosis (Jones, Citation2016). Furthermore, as Hudson (Citation2022) notes, endometriosis research continues to be shaped by its historical links to reproduction, which places it among “women’s illnesses” that have received less medical and social attention than conditions affecting men. Feminist researchers also emphasize that knowledge of the development of endometriosis is filled with uncertainty as biomedical research and clinical practice struggle to address the differences between endometriosis cases (Seear, Citation2014). Currently, biomedical research on endometriosis is shifting from considering it a gynaecological disease towards examining its impact on neurological and immunological systems (Ford, Citation2024). As Ford (Citation2024) argues, these conceptualizations are central to understanding how endometriosis could be best traced and treated in clinical practice. Our analysis shows that the practices of endometriosis treatment have been shaped by the idea of endometriosis as an illness of reproductive years, which causes uncertainty among people with endometriosis when they approach menopause. We also draw on feminist research on how “epistemic injustices” hinder recognition in endometriosis (Hallström, Citation2024) and make it difficult to gain medical interventions such as post-menopausal endometriosis treatment (Langmann et al., Citation2025). By asking how menopause is enacted in clinical practices and lived experiences, we trace situated expectations and potential tensions.

The article draws on in-depth interviews with 27 people living with endometriosis and 20 clinicians treating endometriosis across Finland, as well as ethnographic observation at a public endometriosis clinic in Finland. The data was collected in 2021–2023 in a social science research project on gendered chronic illness in Finland. The interviews covered different aspects of managing endometriosis; menopause was one of the topics that came up in many interviews. The data collection followed the ethical guidelines of the Finnish National Board on Research Integrity for social scientific research. The ethnographic work at the endometriosis clinic received a research permit from the hospital following ethical approval by the Ethics Committee of the Tampere Region, which oversees non-medical research in the field of human sciences. All participants gave written informed consent and were able to withdraw their consent. The interviews have been anonymized. The analysis was conducted jointly by the authors drawing on critical qualitative textual methods and close reading. Through comparison of descriptions of menopause across the data, we identified tensions and uncertainties that structure the role of menopause in endometriosis. This initial reading led us to formulate two research questions: How does the nearness of menopause shape embodied experiences of living with endometriosis? How does the medical treatment of endometriosis reconfigure menopause? In the following two sections, we address these questions through examples from our data. Anticipating Menopause The idea that menopause constitutes an endpoint to endometriosis structures both patients’ and clinicians’ expectations about endometriosis treatment. During ethnographic fieldwork at a public endometriosis clinic, Temmes was present in a clinical encounter during which the link between menopause and endometriosis was discussed. A patient (mid-50s) had arrived at the clinic for consultation. The doctor and the patient discussed whether a hormonal intra uterine device (IUD) would alleviate the patient’s endometriosis pain. The doctor suggested the use of a transdermal oestrogen product to help with possible menopause symptoms. Instead of being concerned about the approaching menopause, the patient exclaimed that “I am really looking forward to menopause.” Later in the meeting, the doctor returned to the topic of IUD and the discussion turned to the question of when to remove it. The patient asked whether taking the IUD out would help to induce menopause, clearly hoping to speed up the process. The doctor responded that it should be kept until all bleeding stops and that “menopause comes when it comes.” This clinical encounter illustrates that the planning of endometriosis care takes place in relation to the understanding that menopause will ease endometriosis symptoms. The hope that menopause will bring an end to endometriosis engenders a sense of anticipation across our interview data. The prospect of menopause offers consolation while shaping temporal orientation in chronic illness. This sense of consolation in the middle of seemingly endless endometriosis symptoms is described by one interlocutor, who is in her mid-40s, actively seeks information and reads scientific publications on endometriosis: I always remember that I found it comforting that the illness will wane with age. I was thinking that this is much better than … I will not die of this, it’s just pain and suffering, I can handle that. […] While many illnesses get worse with age, I always knew that it will get better with age, it will get easier. The interlocutor contrasts endometriosis with chronic conditions that get progressively worse with age. Implicit in this framing is the understanding that menopause constitutes a crucial step in ageing that carries the possibility of an endometriosis-free future. The anticipation of menopause interrupts the sense of chronicity that this interlocutor, among many others, has lived with for years. Yet, the consolation that the prospect of menopause offers is ambiguous. This is especially the case with those who are involuntarily childless because of endometriosis. In the following interview, an interlocutor reflects on the approaching menopause in terms of illness trajectories. She is in her early 40s and undergoing fertility treatment and unsure whether she and her partner will ever have a child: I got my [endometriosis] diagnosis a few years ago. I’m on the better side now. If I were 23, I would be scared to read all those stories of how people are doing and how [endometriosis] has affected reproductive health and careers and social relations and all aspects of life. In that respect I feel that I’m doing okay. I have coped with living with it and there’s not much time left now. Of course, menopause might not remove all symptoms. But I probably have about ten years [of endometriosis] left. A piece of cake compared to the previous thirty years. It will be okay. A distinct sense of illness trajectory arises here from the understanding of endometriosis as an illness that is linked to the so-called reproductive years. At the same time, questions of infertility cast a shadow on the anticipation of menopause as an end of illness. The interlocutor notes that “at this age, the end of [reproductive years] is almost here in the sense of how long it will be possible to continue the [fertility] treatments.” The interview shows poignantly how menopause is charged with relief as well as dwindling hope in the context of infertility. Relief and disheartenment are both structured by the sense that the passage of time and processes of ageing are inevitable. Anticipation of menopause is complicated by the concern that the end of illness may not be straightforward. Several interlocutors with endometriosis reflect on the possibility that their endometriosis symptoms may get worse before menopause. Such uncertainty engenders illness trajectories that are not linear or predictable. In the following interview, one interlocutor, who is in her late 40s, describes how her endometriosis symptoms have worsened in the years preceding menopause: The doctor said that, well, the endometriosis did a last trick right before the final stretch, it started getting worse a couple of years before [menopause]. I didn’t reach the point where menopause would have started. But yes, my understanding is that when menopause begins, it will gradually quench the endometriosis. Sudden health concerns unsettle hope about an illness-free future, as the “final stretch” of an oestrogen-associated illness turns into an unexpected uphill battle. Perimenopause appears as a potentially chaotic phase that may result in complicated health outcomes, including long-term effects such as new scar tissue or adhesions. Despite menopause promising eventual relief, the complex entanglements of endometriosis and perimenopause in the chronically ill body engender unforeseen twists in how illness and ageing materialize. Worries about how endometriosis will react to menopausal hormone therapies also shape anticipation. This is discussed by an interlocutor who is in her mid-30s, has a complicated history of difficult endometriosis, and has been offered the option of radical surgery in the future: I was very young when my period started, and I know my mother had an early menopause at the age of 42. In fact, I’m hopeful that my menopause will begin early so it would quench the endometriosis. But early menopause may become an issue. If you take estrogen, there’s a risk of a relapse. The effects of [the offered] hysterectomy are not really talked about. The idea is that my ovaries would also be removed, which will end the body’s hormone production. The implications are not discussed much. The bones will get brittle and can you handle the menopause symptoms. I don’t know but I kind of wish that the menopause would start naturally, and I also hope that I won’t necessarily have to use hormone therapy. The possibility of spontaneously occurring early menopause appears here as preferable to early menopause resulting from radical surgery. Yet, the use of menopausal hormone therapy to prevent osteoporosis and alleviate menopause symptoms raises concerns for our interlocutor in both scenarios. At the same time, both spontaneously occurring and surgically induced menopause appear as steps that will help to suppress endometriosis. Such tensions render anticipation ambivalent in that the object of anticipation—the end of illness—is unknown in its timing, as are the embodied effects of the hormone treatments that early menopause may necessitate. The interlocutor’s personal and family history brings further uncertainty to anticipation, as it suggests that her body’s processes of ageing may differ significantly from the medical expectation of how women’s bodies age. For several interlocutors living with endometriosis, anticipation of menopause appears as something that requires action. This highlights patients’ agency in seeking a steady trajectory towards the end of an illness. The question of agency is elaborated on by an interlocutor with endometriosis, who is in her early 40s, has a hormonal IUD to alleviate endometriosis symptoms, and is looking for “a gynaecologist who is also specialized in menopause so that I can see them also in the future, that there would be a care relationship.” Her concerns about menopause rise from her endometriosis history. She wants to minimize the use of hormonal products because of past side effects and because her body appears to respond strongly to all medications: It’s time to replace the IUD so I need to search for a doctor. Find out information because menopause … one gynecologist said recently that it’s not until around fifty, but I’d like to know more because I expect that hormone treatment will be discussed. What should I think about it based on my background [with endometriosis]. Who do I trust, whose advice, will they hear my view that if this is a normal dose that the average person is given, could I get a smaller dose because I have this [sensitivity to hormones]. To start mentally preparing how to handle it all and where I can get the right help. Anticipation of menopause is structured by the interlocutor’s personal history of being treated for endometriosis, which includes experiences of doctors dismissing her symptoms as well as unique bodily responses to hormonal medications. This history underscores her need to actively seek perimenopausal care. For this interlocutor, menopause begins as a form of preparation years before the physical menopause. Importantly, the preparation does not directly reflect marketization of perimenopause—a phenomenon explored and critiqued in feminist menopause literature (e.g. Orgad & Rottenberg, Citation2024; Roberts & Waldby, Citation2021)—but stems from the perceived need to navigate the material entanglement of endometriosis and menopause. In the process, the pharmaceutical treatment of endometriosis becomes intertwined with the anticipatory management of menopause symptoms. Other interlocutors with endometriosis express concerns that their current course of endometriosis treatment may be jeopardized if menopause symptoms turn out to be so severe that menopausal hormone therapy is needed. These concerns are discussed by an interlocutor who is in her early 40s and has finally found an endometriosis treatment that she is happy with: I’d like to think that this [current medication] will work for me until menopause. When you consider that I’ve had endometriosis practically all my life and now there’s maybe, I don’t know, five, six, I don’t know how many years I’ll still need these hormones before menopause. Perhaps my next concern is what will happen with menopause and possible hormone replacement therapy. I don’t want to really think about it yet, but yes, what kind of treatment options will be available for me compared to others because of my endometriosis background. As I don’t have pain and feel good now, endometriosis is mostly just a diagnosis that I know I can manage with the [current] medication, but what might affect my quality of life are the treatment options in the future. This excerpt makes visible the limits of agency. Even when a person is actively negotiating medication options and has achieved a satisfactory treatment plan, they may discover that their choices are limited when navigating two hormone-associated phenomena, endometriosis and menopause. As the hormonal mechanisms of endometriosis and menopause are mutually entangled, hormone treatment offered for one may limit how the other one can be managed. Likewise, possible future medications’ unknown effects may compromise a person’s “quality of life.” As the space for action is curtailed, agency becomes mixed with a sense of helplessness. These difficulties in treating endometriosis and menopause symptoms simultaneously are recognized by specialized clinicians. A clinician we interviewed describes how menopausal hormone medications are used in endometriosis: As long as the ovaries produce estrogen, the estrogen is like gasoline for the disease and [endometriosis tissue] can grow. With menopause, if a woman has mild menopause symptoms and doesn’t need menopausal hormone therapy, the illness will gradually fade […] Then there are different situations, for example, the woman has difficult menopause symptoms and needs hormone therapy because her hot flashes are so difficult. […] Estrogen alleviates menopause symptoms in all women, but if she has her uterus left, a progesterone needs to be added. We try to find a combination of the lowest possible dose of estrogen that will alleviate symptoms and progesterone that will prevent the estrogen from making the endometriosis worse. This quotation reflects the medical literature that discusses combining oestrogen and progesterone when treating menopause symptoms in endometriosis patients (Gemmell et al., Citation2017; Secosan et al., Citation2020). However, the interview excerpt suggests that this is not simply a matter of prescribing standard products. Rather, pharmaceutical treatment of menopause symptoms in endometriosis involves what STS scholars call “tinkering” (Mol et al., Citation2010)—in this case, finding, through trial and error, the combination of hormonal compounds that is effective enough with the least possible risk of endometriosis recurrence. While menopause and endometriosis become intertwined in such tinkering, the different ways in which they respond to oestrogen posits them as separate entities. Yet, as examples throughout this section have demonstrated, for those living with endometriosis, endometriosis and menopause, as well as their hormonal treatment repertoires, appear as entangled. Clinicians we interviewed acknowledge that despite the decrease in the body’s oestrogen production, menopause may not always end endometriosis-related pain. Some highlight that this is the case if pain is no longer caused by endometriosis lesions. One doctor notes that “with some patients the pain may become chronic. The disease has faded but the pain is left, chronic pain continues even though there’s no disease.” Furthermore, a physiotherapist specialized in endometriosis reflects on how a chronic illness that has moulded the body for years may continue to shape how the body responds after menopause: Patients that may have had all their gynecological organs removed and have gone through menopause, they may notice familiar pains that were active during endometriosis. The body remembers. It can be other things as well, leaks and contractions that used to happen, but it can also appear as awakened sensations of pain. Endometriosis lives on in the body as an embodied memory. Postmenopausal endometriosis symptoms are addressed here beyond the question of endometriosis cells responding to menopausal hormone therapy. Instead, endometriosis manifests through the working of nerve pathways, muscles and other tissues affected by years of illness. This resonates with several accounts by interlocutors with endometriosis who describe how, even after radical surgery, their bodies continue to respond as if they still carried active endometriosis tissue. For example, one interlocutor told us how she still instinctively sleeps in a position that was the least painful for her when she had severe endometriosis pain. This extended temporality of endometriosis challenges the conception of endometriosis as an illness of reproductive years. While the prospect of menopause may require anticipatory action in the present, the embodied memory of endometriosis pain extends to the future beyond the signpost of menopause. To sum up, our data shed light on the complex ways in which menopause extends in time beyond its biomedical frame. The hope of ending endometriosis brings the issue of menopause to the planning of endometriosis care years before it becomes a practical clinical question. For our interlocutors living with endometriosis, anticipation appears as a material necessity and a call for agency. Awareness that menopause may fail to bring relief, and that pain may linger, renders the end of endometriosis elusive. Knowledge about narrowing treatment options brings a sense of uncertainty to the present, orientating embodied experiences of waiting. In these experiences, menopause emerges as a medically moulded phenomenon and yet as an inevitable, naturally occurring process. In the next section, we look into this multiplicity of menopause in endometriosis by exploring how menopause appears as properly or wrongly timed, and how these temporal frameworks affect medical interventions. Menopause After Radical Surgery For people with severe endometriosis pain, menopause is also present as a potentiality that can be induced through radical surgery. Analysis on assisted reproductive technologies (ARTs) has shown how ideas of nature and naturalness are strategically used in medical practices to legitimize biomedical interventions to biological processes (Thompson, Citation2005). While “nature” is defined in biomedical interventions in ways that are fluid and situated, it nevertheless works as a point of reference (Mäkelin et al., Citation2024). Indeed, feminist scholars have emphasized that the moulding of biological processes in ARTs reveals the profound entanglement of “nature” and “culture” (Franklin, Citation2013; Franklin & McKinnon, Citation2001; Strathern, Citation1992). In comparison, the case of endometriosis and menopause not only highlights the entanglement of “nature” and “culture” but also makes visible the many unknowns that underlie menopause as an embodied process. In our study, gynaecological surgeries as medical interventions reveal the ambiguity of menopause as a process of gendered ageing. Surgical procedures in which the uterus and both ovaries are removed are considered as the last surgical option in endometriosis treatment. One surgeon describes the circumstances in which radical surgery is considered: Usually in a situation where we cannot control the pain with usual treatments: hormone treatments do not help, pain killers are not enough, and the patient continues to have severe pain. Another situation is that the patient is already nearing menopause age and has no wish for pregnancy. In those situations, we often aim to remove all endometriosis with radical surgery. The decision to do radical surgery is not an easy decision for the clinicians. Rather, radical surgery is conducted only if the patient’s symptoms are intolerable and do not respond to conventional treatment, or if the patient is considered to be close to the age associated with spontaneously occurring menopause. The decision to opt for radical surgery engendered a range of feelings in the people who underwent the procedure. One interlocutor, who is in her late 30s, describes her concerns before the surgery: We had already agreed that the uterus and both ovaries would be removed. I had considered keeping one ovary so that my body’s hormone production would not shut down. It was perhaps the most difficult decision – not so much not being able to have children, but what will happen if I become an old woman because my menopause starts when I’m 35. It felt hard to process. Surgically induced menopause is interpreted through a notion of a naturally occurring menopause, which for the interlocutor indicates a start of the later stages in life. The two appear similar but are juxtaposed through what the interlocutor considers, respectively, as premature and correct timing. Her hesitancy towards undergoing a menopausal transition at 35 shows that while the surgery might be needed to treat the endometriosis, it challenges the normative expectations of what menopause should mean. This example echoes Pearce et al.’s (Citation2014) observation that menopause symptoms induced by surgery might clash with people’s expectations of what a body should be like at their age. For some endometriosis patients, radical surgery is a preferable option even when doctors hesitate. One interlocutor, who is in her mid-40s, states: Some doctors have been doubtful whether it’s wise because I’m quite young. My ovaries are apparently in such condition that I might not get menopause for ten years, so they’d rather not remove them. But my view is that I’d rather take the risk that menopause will begin, whatever it will be like. The interlocutor wishes to have radical surgery despite knowing that the surgery will bring forth menopause symptoms in some form. These symptoms are conceptualized as similar to the menopause that would, in her case, likely occur spontaneously in her mid-50s. She deems the risks she associates with menopause preferrable to her endometriosis symptoms. Yet, surgically induced menopause does not carry similar hopeful anticipation as age-related menopause discussed in the previous section. Rather, surgically induced menopause is perceived by several interlocutors to embody both biological and social risks associated with premature gendered ageing. Such risks are compared to the severity of endometriosis symptoms. Surgically induced menopause challenges the common conceptualization of menopause, as people who are considered to be in their reproductive years can undergo the procedure. Clinicians we interviewed stress that if surgery is seen as necessary, the hormone treatment that follows must be planned carefully. One gynaecologist explains: If a 35-year-old’s uterus and ovaries are removed, she can’t be just told to endure the menopause symptoms. Normally, if the uterus has been removed, the patient is given estrogen replacement therapy to remove menopause symptoms. It’s standard practice. But if she has endometriosis, even if it is radical surgery, there are always some endometriosis cells left. In that situation, estrogen therapy may trigger new endometriosis growth. That’s why we always tell the patients that they need a combination treatment that includes also progesterone. Menopause symptoms after radical surgery are treated similarly to the symptoms following spontaneously occurring menopause in endometriosis patients—that is, with a hormone treatment that includes both oestrogen and progesterone. However, the perceived necessity of these treatments differs based on whether the menopause is induced by surgery or occurs through processes of ageing. As we showed in the previous section, for endometriosis patients undergoing age-related menopause, combined hormone treatment is recommended if severe menopause symptoms arise. In contrast, the imagined 35-year-old surgery patient in this quotation is understood to inevitably need hormone therapy to cope with menopause symptoms. At the same time, our interviews suggest that the necessity of hormone therapy after radical surgery has more to do with the age of the patient than with the surgical or spontaneous causation of menopause. One interlocutor describes her experiences after being asked in the interview whether she has a hormone treatment plan following radical surgery: No, I don’t. I would have been close to the age of menopause anyway, I’m 49. I was told that if I get difficult symptoms, I should call the endometriosis nurse, and we’ll take a look at medication together. I’ve been certainly worried because hormone therapy may trigger endometriosis, so what would happen. If I get symptoms, I may have to consider hormone therapy. When I asked the doctor whether the symptoms will come immediately or within a couple of months, they said that it depends on the person, you never know. The quotation indicates that only in cases where menopause is considered to happen prematurely, hormone therapy is viewed as essential for the operation of the body. In medical practice addressing menopause before the age of 40, hormone therapy is seen as a key means of supporting cardiovascular health and bone density (Flore et al., Citation2024, p. 1196), as well as coping socially with bodily changes that would otherwise distinguish a patient with early menopause from their age group (Flore et al., Citation2024, p. 1194). For patients in their late-40s, the interview excerpt suggests, the possibility for hormone therapy is kept open if menopause symptoms appear. However, recognizing symptoms caused by menopause can be tricky when coping with post-operative rehabilitation. For example, one interlocutor mentions that she does not know whether increased nightly sweating is due to menopause or post-operative dressings. The quotation also suggests that the particular embodied manifestations of menopause are unpredictable and unknowable in advance: “you never know.” This underlines the blurriness of what counts as “natural” or “premature” in menopause. Hormone treatment after radical surgery is characterized by uncertainty for both doctors and patients. Doctors treating early menopause are advised to consider each patients’ needs individually and balance the risks of treatment with the need to alleviate menopause symptoms (Flore et al., Citation2024). An additional uncertainty occurs when a patient who has undergone radical surgery and has been treated with hormone therapy reaches the age when spontaneous menopause typically occurs. Both clinicians and people with endometriosis mention that it is difficult to predict what will happen when hormone therapy is discontinued. One gynaecologist notes: If it’s decided that it will be discontinued around the age of 50, and if symptoms appear then, it can be started again. Or if the patient is motivated and willing and the overall assessment is that benefits outweigh potential harm and the woman wants to continue it, there is no reason not to continue it after menopause if there are no contraindications. It’s very different for different people. The age of 50 is set up here as a timepoint when menopause could have occurred spontaneously if the patient had not undergone radical surgery. This means that people undergoing radical surgery in their 30s or early 40s go through menopause in two stages: first by medically controlling the body’s reaction to ceased ovarian hormone production and then by stopping the said medication when the body is deemed ready to experience menopause symptoms. In some cases, the elapsed time between the two stages may be 20 years. The quotation indicates that the decision to stop medication, or its later continuation, is considered on a case-by-case basis, and that it involves a range of factors whose relevance is situated and difficult to predict. In general, patients undergoing radical surgery are expected to have bodily reactions to the decline of ovarian oestrogen that are similar to the symptoms among those undergoing age-related menopause. However, it does not appear clear whether and how the time between surgically induced menopause and the time of age-related menopause shapes menopause symptoms. One gynaecologist elaborates: Overall, about a third of Finnish women need treatment for menopause symptoms, and I assume that this group [people with endometriosis undergoing radical surgery] is no exception. It’s likely that a large number of them will continue to need hormone treatment. Yet, if they were young when the reproductive organs were removed and time has passed, it might be … I don’t know if it has been studied whether a larger number of them could manage without hormone therapy. I don’t know if there’s even any data. But the starting point is probably that a roughly equal proportion of them will need hormone treatment. Patients who have undergone radical surgery and taken menopausal hormone therapy are grouped together with other Finnish women in terms of the likelihood of needing menopause treatment. However, the gynaecologist hints towards the possibility that in the years following radical surgery, the body might get somewhat used to the underlying menopausal state, and thus these patients might be less likely to need further hormone treatment. While the clinician then discards this speculation as there is no data, it shows the difficulty in drawing a clear line between what constitutes pre-menopausal, menopausal and postmenopausal bodies after radical surgery and during post-operative hormone therapy. The difficulty in predicting menopause symptoms is experienced also by patients. One interlocutor describes her feelings about a forthcoming change in her treatment: I’m waiting with uncertainty. I don’t know what will happen in a few years’ time – now my hormones come from a pill bottle because I no longer have ovaries, but doctors have said that when I turn 50, they will be discontinued. […] Probably we’ll have to try and see how I feel, and when I stop the hormones if I get menopause symptoms. That will be in two or three years from now. It seems to me that the doctors I have seen after the operation know quite little about it all. The only certain thing for our interlocutor is that her hormone medication will cease when she turns 50. However, as described by one of the gynaecologists we interviewed, the line for discontinuing the hormone medication is “flexible and negotiable, we consider it individually in each case”. The unknowns related to what will happen after reaching the hypothetical menopausal age of 50 create ambiguity as to how a body moulded by surgery and years of hormone treatment will react to processes of ageing. This may result in uncertainty among patients as to how their bodies will be treated. In these circumstances, the categories of surgically induced and naturally occurring menopause provide a structure for making sense of gendered ageing.

This article has asked what we can learn about menopause as a gendered embodied phenomenon by exploring the common chronic gynaecological illness, endometriosis. In endometriosis, menopause appears as an anticipated end to illness, yet its closeness may impact the options of treating endometriosis, while a history of endometriosis may limit available menopause treatments. Those with difficult endometriosis symptoms may also face the choice of premature menopause produced through medical interventions such as radical surgery. The case of endometriosis provides a contrast to feminist critiques that approach the medicalization of menopause as capitalizing on healthy ageing. When a person with endometriosis approaches menopause, the hormonal processes of endometriosis, and the complicated histories of a person’s endometriosis treatments, become entangled with the hormonal dynamics of menopause and its treatments. In such cases, hormonal processes appear as multiple and situated, evading the categories of “natural” and “artificial” through which gendered ageing is often approached in society. We have used the case of endometriosis to address the temporal underpinnings of menopause. While menopause is commonly understood as a naturally occurring process related to gendered ageing, its temporality appears as ambiguous in endometriosis. Menopause is enacted in the shape of expectations and preparedness regarding the trajectory of gendered ailing years before the typical menopausal age is reached. This observation contributes to the feminist menopause scholarship by showing that the feminist critique of marketization and medicalization of perimenopause may enshroud the ways in which anticipation is profoundly intertwined with the aims of alleviating suffering in endometriosis. For our interlocutors, menopause provides a horizon leading towards a likely end of an illness. However, the history of living with endometriosis may linger to the post-menopausal years as embodied memory of pain. We propose that the expansive temporality of menopause in endometriosis needs to be seen as a lens through which the effects of chronic hormone-associated illness on embodied experiences of gendered ageing become visible. The ambivalences and uncertainties present in such experiences complicate the idea of menopause as a clear-cut moment of hormonal transition. In endometriosis, menopausal hormone therapy emerges as an object of tinkering, through which the complex hormonal dynamics at play at the intersection of endometriosis and menopause are navigated. Our analysis of the concerns and hopes around the pharmaceutical management of the entangled hormonal phenomena of endometriosis and menopause contributes an important perspective to the long-standing feminist debate about the testing, marketing and prescription of menopausal hormone therapies. Although there is much to critique in the pharmaceutical marketing for healthy ageing bodies, how to live with hormonal pharmaceuticals is a complicated question in endometriosis. While in menopause discourse the notion of a “natural body” is often mobilized to criticize medicalization of gendered ageing, in endometriosis the absence of medical monitoring and management carry a risk of re-emerging illness. This draws attention to the situatedness of risk and benefit in medical practices that attend to hormonally complicated bodies such as those affected by endometriosis and other oestrogen-associated illnesses. As such, menopause is a relatively uncontested biological process. Although negotiations of how and whether menopause should be medically treated include tension and controversy, menopause itself is understood to be inevitable and evident. However, the case of radical surgery demonstrates that when observed from the perspective of endometriosis, menopause emerges as peculiarly unknown, unclear, and uncertain in its timing. Nevertheless, the notion of a naturally occurring menopause appears as a reference point against which surgical interventions to endometriosis and post-operative hormone treatment are conceptualized. Radical surgery appears as an intervention that prematurely moulds the reproductive body into a post-reproductive one. At the same time, radical surgery makes visible the blurriness of the distinction between premenopausal, menopausal and postmenopausal bodily processes. How long hormone therapy should be continued after radical surgery, or how the timing of radical surgery shapes menopause symptoms, are among questions that our interlocutors contemplate—with few affirmative answers. These unknowns bring uncertainty to experiences and expectations about radical surgery and post-operative hormone treatment. They also make visible norms and assumptions that structure clinical approaches to gender and ageing. The case of radical surgery and associated hormone treatments adds an important angle to feminist debate about menopause by showing that medical interventions not only seek to avoid the effects of menopause but may aim to imitate the notion of naturally occurring gendered ageing. In endometriosis, the rationale for tinkering with pharmaceutical treatment, taking or avoiding risks of worsening endometriosis or menopause symptoms, and tracking the reproductive age of bodies is often to achieve a version of menopause that is as liveable as possible for a body moulded by decades of pain. These complexities of pharmaceutical treatment and radical surgery highlight the multiplicity and situatedness of ageing as a material, embodied process. Crucially, endometriosis is only one among many hormone-associated long-term illnesses that shape experiences of menopause. Examining menopause in the context of hormone-associated illnesses shows clearly that clinical practices around menopause foreground reproduction as a framework through which gendered ageing is approached. We have shown that this can hamper understanding of diversity of menopause experiences. Further feminist research as well as careful clinical reflection is needed to understand not only how chronic illnesses complicate menopause but also how they expand the conceptualization of menopause to better account for individual differences. Acknowledgments We thank our interlocutors for generously sharing their experiences and views of managing endometriosis and menopause. Disclosure Statement No potential conflict of interest was reported by the author(s). Additional information Funding Notes on contributors Venla Oikkonen Venla Oikkonen is an Associate Professor at Tampere Centre for Science, Technology and Innovation Studies (TaSTI), Tampere University. She is the author of two books, Population Genetics and Belonging (2018) and Gender, Sexuality and Reproduction in Evolutionary Narratives (2013). Her current research focuses on experiences of pharmaceuticals and self-tracking in endometriosis. Maria Temmes Maria Temmes is a postdoctoral researcher in the project Gendered Chronic Disease, Embodied Differences and Biomedical Knowledge (GenDis) at Tampere University. Her current research focuses on patient activism and biomedical management of endometriosis and hormonal migraine. Elina Helosvuori Elina Helosvuori is a Postdoctoral Researcher and Core Fellow at the Helsinki Collegium for Advanced Studies, University of Helsinki. Her current research focuses on intersections of medical practices and experiences of chronic pain, as well as climate activism and reproductive imaginaries.

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