Perimenopause and Endometriosis: Relief, Complexity, and What to Expect

When Perimenopause Meets a Long-Standing Condition

If you have spent years managing endometriosis, you have learned a particular kind of patience. You have tracked pain cycles, negotiated with providers, and built strategies around your own unpredictable body. When perimenopause begins, many women with endometriosis feel a complicated mix of emotions: cautious hope that the estrogen decline might finally bring relief, alongside real worry about what the hormonal turbulence of the transition might stir up before it settles down.

Both feelings are well-founded. Endometriosis is an estrogen-dependent condition, meaning the lesions that cause pain and inflammation thrive in a high-estrogen environment. As estrogen declines during and after perimenopause, many women do eventually experience significant reduction in endometriosis symptoms. But the path there is not always smooth, and the perimenopausal years, with their fluctuating hormone levels, can bring unpredictable pain patterns before the relief arrives.

Understanding what is happening in your body during this transition, and knowing what questions to ask your provider, can make a real difference in how you navigate this chapter.

How Declining Estrogen Affects Endometriosis Lesions

Endometriosis lesions respond to estrogen the same way the uterine lining does. They grow, thicken, and bleed with the hormonal cycle. When estrogen production becomes erratic during perimenopause, some women notice that their symptoms become harder to predict. A month with higher estrogen might bring a painful flare. A month with lower levels might offer more relief than usual. This unpredictability can be disorienting when you have worked so hard to understand your own patterns.

As perimenopause progresses and estrogen levels trend lower overall, most women with endometriosis find that pain gradually decreases. After menopause, when the ovaries have largely stopped producing estrogen, many women experience significant and lasting relief. This is the biological basis for the old advice that menopause would cure endometriosis, advice that was oversimplified but not entirely without basis.

However, it is important to know that endometriosis lesions do not always disappear completely after menopause. In some women, especially those who take systemic hormone therapy after menopause, lesions can remain active. Postmenopausal recurrence is less common but real, and it is worth discussing your specific situation with a provider who is familiar with endometriosis, not just menopause in general.

Pain Pattern Changes During the Transition

One of the confusing things about having endometriosis during perimenopause is that your pain patterns may shift in ways that do not follow the old logic. You may have pain during weeks when you are not expecting a period. You may have cycles that are unexpectedly heavy and painful after months of relative quiet. Some women with endometriosis also experience pelvic pain that becomes harder to attribute clearly to endo versus other perimenopausal changes, like pelvic floor tension, bladder changes, or musculoskeletal shifts.

New or changing pain is always worth reporting to your provider rather than assuming it is just the transition. While endometriosis is a common source of pelvic pain during perimenopause, other conditions, including fibroids (which are also estrogen-sensitive and may behave differently as hormones shift), adenomyosis, and pelvic floor dysfunction, can cause overlapping symptoms. Getting a clear picture requires a provider who will take your history seriously and not dismiss new symptoms as generic perimenopause.

Keeping a detailed symptom log becomes even more valuable during this time. Noting when pain occurs in relation to your cycle, what it feels like, how long it lasts, and what helps or hurts gives your provider usable information rather than a blurry description of vague discomfort.

Is Hormone Therapy Safe If You Have Endometriosis?

This is one of the most common and important questions women with endometriosis ask about perimenopause. The traditional medical caution was that hormone therapy after menopause could reactivate endometriosis, since the lesions are estrogen-sensitive. For many years, women with endometriosis were advised to avoid hormone therapy entirely or to use it only briefly.

Current thinking is more nuanced. For many women with endometriosis, the benefits of hormone therapy, including relief from hot flashes, sleep disruption, cognitive changes, and bone protection, genuinely outweigh the risks. The key is in the specifics of how hormone therapy is prescribed. Unopposed estrogen (estrogen without progesterone) carries a higher risk of reactivating endometriosis, which is why most providers will recommend combined estrogen-plus-progesterone therapy, or in some cases, add-back progesterone specifically to protect against endo reactivation.

Women who have had a hysterectomy for endometriosis sometimes assume they can skip progesterone in their hormone therapy, since they no longer have a uterus. But if endometriosis lesions remain outside the uterus, estrogen without progesterone can still stimulate them. This is an area where the standard advice about hormone therapy after hysterectomy does not apply cleanly to women with endo, and your provider needs to know your history in detail before making a recommendation.

Surgical History and the Perimenopausal Transition

Many women with endometriosis have had one or more surgeries, whether laparoscopy to remove lesions, procedures for cysts, or in some cases hysterectomy with or without removal of the ovaries. Your surgical history shapes your perimenopausal experience in significant ways.

If you had your ovaries removed (oophorectomy) as part of your endometriosis treatment, you experienced surgical menopause, which is abrupt and complete rather than gradual. Surgical menopause at a younger age is associated with different health considerations than natural perimenopause, including higher cardiovascular risk and accelerated bone loss. If this is your situation, hormone therapy is typically recommended at least until the average age of natural menopause, unless there is a specific reason to avoid it.

If you had lesion removal surgeries but kept your ovaries, your perimenopausal transition will follow a more natural timeline, though your hormonal environment may be somewhat affected by scar tissue, adhesions, or any remaining lesions. Discussing your full surgical history with any new provider is important, not just mentioning that you had endometriosis but specifying what was done and what remains.

Overlapping Symptoms That Can Be Hard to Separate

Endometriosis already affects multiple systems in the body, including digestion, bladder function, and mood. Perimenopause brings its own set of symptoms that overlap significantly. Bloating, bowel changes, urinary urgency, fatigue, anxiety, and sleep disruption are common in both conditions, which means it can be genuinely difficult to know what is driving what during the transition.

Gastrointestinal symptoms deserve particular attention. Endometriosis that affects the bowel can cause bloating, constipation, diarrhea, and pain with bowel movements, especially around the time of your period. Perimenopause also changes gut motility for many women, as estrogen and progesterone affect the digestive system. If your GI symptoms are shifting or worsening, it is worth flagging this specifically rather than lumping it into a general complaint about perimenopause.

Bladder-related symptoms are similarly layered. Interstitial cystitis is more common in women with endometriosis, and pelvic floor changes during perimenopause can affect bladder control and urgency. A pelvic floor physical therapist who is experienced with endometriosis can be genuinely helpful here, both for pain management and for bladder and bowel symptoms that are influenced by pelvic floor function.

Managing the Transition Practically

Managing endometriosis during perimenopause works best when you have a team rather than a single provider. Your gynecologist, ideally one with endometriosis expertise, is central. But depending on your symptom picture, you might also benefit from a pelvic floor physical therapist, a pain specialist, a gastroenterologist familiar with endo-related bowel symptoms, or a menopause specialist who knows your history.

Non-hormonal symptom management remains relevant and often underused during this transition. Anti-inflammatory dietary approaches, pelvic floor therapy, gentle but consistent movement, and stress regulation all matter for endometriosis, and they also support the perimenopausal transition more broadly. These are not alternatives to medical care but complements to it.

Pain management plans may need revision during perimenopause. What worked in your thirties may not be the right fit now. Some women find that the dose or type of pain medication they relied on earlier is less effective during hormonal fluctuations. Others find that hormonal medications they used to manage endo cycles need to be reconsidered as they approach menopause. Approaching this as an active, evolving conversation with your provider rather than a fixed protocol will serve you better.

What the Research Is Still Working Out

Endometriosis research has long been underfunded relative to the burden the condition places on women's lives, and the intersection of endometriosis with perimenopause is an area where the evidence base is still thin. Most clinical guidance is based on expert opinion and smaller studies rather than large randomized trials. This means your provider may not have a clean protocol to follow and may need to make judgment calls based on your individual situation.

This is frustrating, but it also means you have real power in shaping your care. Asking your provider what the evidence says, what they are less certain about, and what they would watch for gives you a more honest picture than simply being handed a recommendation. Seeking care from providers who acknowledge uncertainty and stay current with emerging research tends to produce better outcomes than those who apply outdated one-size-fits-all advice.

Advocacy organizations focused on endometriosis, such as the Endometriosis Foundation of America and the World Endometriosis Society, publish patient-facing resources that can help you stay informed about evolving guidance. Being an informed participant in your care is not the same as second-guessing your doctor. It is how you get the best from the partnership.

Medical Disclaimer

This article is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. If you have endometriosis and are experiencing perimenopause symptoms, please consult a qualified healthcare provider who can evaluate your specific history and circumstances. Do not change or stop any medication or treatment without professional guidance.