Managing Fibroids and Endometriosis After Menopause

As hormones that trigger fibroids and endometriosis decrease, it would make sense that the conditions themselves would have less prominent symptoms after menopause, and while that is usually the case, that does not mean that fibroids or the scarring from endometriosis disappear. Although uncommon, women who have suffered from abnormal vaginal bleeding or pelvic pain for an extended period of time can still experience these symptoms well into menopause. Surgical treatment for these conditions may be necessary.

In the perimenopause, estrogen and progesterone decrease to very low levels. When egg production stops and the monthly cycle ceases, that usually means the end to monthly cramps and bleeding. Women who experience hot flashes, weight gain, night sweats, and vaginal dryness, may find some relief in taking hormone replacement therapy. However, it’s important to know that using HRT to lessen the symptoms of menopause can inadvertently trigger endometriosis symptoms or encourage existing fibroids to continue growing.

Depending on your experience with these conditions prior to menopause, monitoring changes, including abnormal bleeding after your period stops, or continued pain is important.

Removing endometriosis can be an intensely difficult procedure for many surgeons, because it requires removal of lesions, ranging from small to large, which may extensively involve the ovaries, bladder, ureters, bowel and other pelvic structures. Since the lesions may not be exclusive to the uterus, hysterectomy is not always the answer. Extensive endometriosis, previous surgeries or trauma to the pelvis can cause significant adhesions between structures that can also cause severe pain. With all of these potential concerns, women with endometriosis who are past menopause will require a GYN surgical specialist to ensure that each condition is addressed with an expert hand. In order to eliminate pain, the scar tissue from severe endometriosis may need to be removed.

Hearing from your doctor that a fibroid is too large to remove, or that you don’t need your uterus any longer can be emotionally difficult. After menopause, that can feel like insult to injury, though before menopause it can be even harder to hear. Realize that menopause results from the cessation of estrogen and progesterone production from the ovaries which results in well documented symptoms: hot flashes, night sweats, mood swings, anxiety, depression, vaginal dryness and painful intercourse, as well as osteoporosis.

The lack of estrogen and progesterone also results in no more periods for most women, with some shrinkage of fibroids.  Unfortunately for some women, fibroids may often not shrink enough to alleviate symptoms such as frequency of urination, back pain, pelvic pressure, abdominal dissension and bloating, leg pain, and others.  Still other women may have degeneration or “calcification” of their fibroids, leading to worsening or persistent symptoms of pain and in some cases bleeding and discharge.  For these women, removal of the uterus may be a helpful procedure that can eliminate years of suffering from fibroids, even into menopause.

It’s important to find a specialist who will listen to your concerns and who will help you weigh the pros and cons.

Many surgeons are skilled at laparoscopic procedures. For menopausal patients, it’s even more important to find minimally invasive surgeon with advanced training.

Menopausal patients with calcified fibroids, for example, can be especially difficult to treat with hysterectomy.  Fibroids in these cases are similar to “stones” or “rocks”, and can be very difficult to remove.  Many menopausal patients have decreased pliability of the vaginal and pelvic tissues.  In this situation, a surgeon who understands the changes menopause can cause will be better able to address surgical treatment of fibroids and endometriosis without damage to more susceptible pelvic organs.

Open procedures are usually never required for menopausal patients needing surgery for fibroids or the scarring and pain from endometriosis.  Menopausal patients have a higher incidence of health problems such as high blood pressure, diabetes, lung or kidney problems that may result in complications from open surgery requiring a long hospital stay or ICU care.  Further, there are much better options for menopausal women with these conditions than a robotic procedure performed by your OBGYN.  Always get a second opinion to ensure you are getting the best possible surgery from a minimally invasive surgical specialist.

It is important to note that the doctor recommending the procedure may not be the right person to perform your surgery. Whether or not laparoscopic surgery is offered most likely has nothing to do with you or your condition. No matter how complex your condition, or the size of your fibroids or uterus, it is highly likely that you are still a candidate for minimally invasive GYN surgery.

Dr. Paul J. MacKoul, MD, The Center for Innovative GYN Care, innovativegyn.com