Postmenopausal endometriosis: current evidence and clinical challenges in diagnosis and treatment

Postmenopausal endometriosis: current evidence and clinical challenges in diagnosis and treatment - Amber Trujillo Lalla - Jaden R Kohn - Dave Pasternak - Xiaoming Guan Purpose of review Endometriosis was once thought to affect only reproductive-aged women. However, 2–5% of postmenopausal individuals remain affected. Guidance for this group is limited. This review outlines an updated approach to postmenopausal endometriosis, addressing pathophysiology, diagnostic challenges, and management in both natural and surgical menopause. Recent findings Postmenopausal endometriosis is underrecognized and has many diagnostic challenges. MRI is the preferred imaging modality for detecting lesions and assessing malignancy risk, while surgery with excision remains the diagnostic and treatment gold standard. Medical treatment options are limited, with aromatase inhibitors showing the most promise by targeting main sources of estrogen production; however, research is limited. Hormonal replacement therapy is recommended after surgical or premature menopause (<age 45), and hormone therapy may be considered for symptomatic natural menopause, though optimal regimens and duration remain unclear. Combined estrogen–progestogen therapy or tibolone is preferred due to the possible risk of recurrence or malignancy. Ovarian-sparing surgery may be considered in select younger patients to reduce the need for hormonal replacement therapy given the lack of data. Summary Evidence on postmenopausal endometriosis remains limited. Further research is needed to guide treatment, refine hormone therapy strategies, and improve long-term outcomes and quality of life.