What Happens to Endometriomas After Menopause? A Non-Invasive Follow-Up Focusing on Ultrasound Features and Clinical Changes

Consuelo Russo, Ambra Pisante, Francesca Fabrizi, Aikaterini Selntigia, Giulia Monaco, Elvira Nocita, Veronica Yacoub, Giorgia Soreca, Alfredo Ercoli, Caterina Exacoustos
Journal of clinical ultrasound : JCU · 2026 · doi:10.1002/jcu.70266 · PMID:42121389
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This study describes the ultrasound features and clinical course of ovarian endometriomas in postmenopausal women, finding early dimensional reduction and later structural remodeling without malignant changes.

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This retrospective observational study followed postmenopausal women with at least one ovarian endometrioma identified by transvaginal ultrasound, using baseline and 12- and 24-month clinical and ultrasound assessments (2018–2023, University of Rome Tor Vergata), with endometrioma size classified by the #Enzian system. Among 41 women (45 endometriomas), most lesions were unilocular with “ground glass” echogenicity and were predominantly #Enzian O1 at the first postmenopausal scan, and the key findings were significant early size regression from pre- to postmenopause with continued decline at 12 and 24 months. Later, morpho-structural changes emerged, particularly an increase in wall irregularities, while vascularization stayed minimal and serum epithelial tumor markers remained normal, with no suspicious or malignant transformations observed and pain symptoms stable. The paper’s major limitation is its retrospective design and the relatively small, single-center cohort. This paper is centrally about endometriosis — it longitudinally characterizes how ovarian endometriomas evolve after menopause using ultrasound and clinical follow-up.

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Abstract

OBJECTIVES: To describe the longitudinal ultrasound features and clinical course of ovarian endometriomas in postmenopausal women, aiming to improve diagnostic accuracy and guide follow-up strategies. METHODS: This retrospective observational study included postmenopausal women with at least one ovarian endometrioma identified by transvaginal ultrasound (TVUS) and monitored for a minimum of 24 months at the University of Rome Tor Vergata (2018-2023). All had a known premenopausal endometriosis detected by TVUS at our Unit. Clinical and ultrasound assessments were conducted at baseline and at 12 and 24 months, recording changes in TVUS characteristics and symptoms. Endometrioma size was classified using the #Enzian classification. RESULTS: Forty-one postmenopausal patients (mean age 53.5 ± 6.4 years) were included. A total of 45 endometriomas were analyzed, mostly unilocular (100%), with a typical "ground glass" echogenicity (75.6%) and classified as #Enzian O1 (82.2%) at the first postmenopausal scan. A significant early dimensional reduction occurred between pre- and postmenopause: the mean maximum diameter decreased from 29.0 ± 15.2 to 20.6 ± 9.7 mm (p = 0.002), and the mean diameter from 24.5 ± 13.1 to 17.9 ± 8.9 mm (p = 0.006), with continued decline at 12 and 24 months (p < 0.05). In contrast, morpho-structural changes emerged later during follow-up, with the proportion of cysts showing wall irregularities rising from 11.1% in premenopause to 38.6% at 24 months (p = 0.003). Vascularization remained minimal throughout. All serum epithelial tumor markers stayed within normal ranges, no suspicious or malignant transformations were observed, and pain symptoms remained stable during follow-up. CONCLUSIONS: Ovarian endometriomas in postmenopausal women exhibit a benign evolution, characterized by early dimensional regression and later structural remodeling without malignant features. Regular ultrasound surveillance remains essential to recognize benign morphologic changes, avoid unnecessary surgery, and promptly identify lesions requiring further evaluation.
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Abstract

Objectives To describe the longitudinal ultrasound features and clinical course of ovarian endometriomas in postmenopausal women, aiming to improve diagnostic accuracy and guide follow-up strategies.

Methods

This retrospective observational study included postmenopausal women with at least one ovarian endometrioma identified by transvaginal ultrasound (TVUS) and monitored for a minimum of 24 months at the University of Rome Tor Vergata (2018–2023). All had a known premenopausal endometriosis detected by TVUS at our Unit. Clinical and ultrasound assessments were conducted at baseline and at 12 and 24 months, recording changes in TVUS characteristics and symptoms. Endometrioma size was classified using the #Enzian classification.

Results

Forty-one postmenopausal patients (mean age 53.5 ± 6.4 years) were included. A total of 45 endometriomas were analyzed, mostly unilocular (100%), with a typical “ground glass” echogenicity (75.6%) and classified as #Enzian O1 (82.2%) at the first postmenopausal scan. A significant early dimensional reduction occurred between pre- and postmenopause: the mean maximum diameter decreased from 29.0 ± 15.2 to 20.6 ± 9.7 mm (p = 0.002), and the mean diameter from 24.5 ± 13.1 to 17.9 ± 8.9 mm (p = 0.006), with continued decline at 12 and 24 months (p < 0.05). In contrast, morpho-structural changes emerged later during follow-up, with the proportion of cysts showing wall irregularities rising from 11.1% in premenopause to 38.6% at 24 months (p = 0.003). Vascularization remained minimal throughout. All serum epithelial tumor markers stayed within normal ranges, no suspicious or malignant transformations were observed, and pain symptoms remained stable during follow-up.

Conclusions

Ovarian endometriomas in postmenopausal women exhibit a benign evolution, characterized by early dimensional regression and later structural remodeling without malignant features. Regular ultrasound surveillance remains essential to recognize benign morphologic changes, avoid unnecessary surgery, and promptly identify lesions requiring further evaluation. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Enzian

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endometriosisendometrioma

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