Endometriosis after 40 symptoms vs menopause

Endometriosis After 40: When Symptoms Are Not ‘Just Menopause’

Introduction

Endometriosis after 40 is not uncommon. Symptoms can persist or return during perimenopause and after menopause, and are often mistaken for “just menopause.” Understanding why this happens and how to recognise endometriosis-related symptoms is essential for protecting your long-term health.

1. What Changes with endometriosis After 40?

What happens in Perimenopause

During perimenopause, hormone levels fluctuate from month to month. Ovulation becomes irregular and progesterone levels may be lower (a hormone that helps counterbalance endometriosis activity). At the same time, oestrogen levels can be unpredictable, and sometimes relatively high, which may contribute to symptom reactivation.

What Happens After Menopause

After menopause, overall oestrogen and progesterone levels are low. However, symptoms may persist because of existing scarring, fibrosis, or nerve involvement from earlier disease. In these cases, pain is driven by structural and nerve changes rather than active hormone cycling.

In women using menopause hormone therapy (MHT), added oestrogen may stimulate residual endometriosis tissue in some cases. This does not mean MHT is unsafe, but ongoing follow-up is important.

 Publication by Dr. Maria Zalazar at the International Menopause Society

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Medical Disclaimer

This questionnaire collects perspectives on endometriosis for research and service development. It does not provide medical advice, diagnosis or treatment, and completing it does not establish a doctor–patient relationship. For medical concerns, consult a qualified healthcare professional. In an emergency, contact local emergency services.

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2. Why Symptoms May Flare in Perimenopause

Hormonal Fluctuations

In perimenopause, oestrogen levels can spike unpredictably while ovulation becomes irregular, meaning progesterone is often lower or inconsistent. Because oestrogen can stimulate endometriosis tissue and progesterone helps keep it under control, this hormonal pattern can allow symptoms to persist or return.

Inflammation, Fibrosis, and Nerve Sensitivity

Endometriosis is not only hormonal; it is also an inflammatory condition. Inflammation can lead to fibrosis (scar tissue), which can cause tissues and organs to stick together. This can contribute to pain, tightness, painful bowel movements, constipation, bladder discomfort, and pain with intercourse.

Inflammation can also irritate nerves and make the nervous system more sensitive to pain. This can mean pain becomes persistent, may spread into the lower back, pelvis, hips, or legs, and may continue even when periods are lighter.

Read about the real impact of endometriosis.

3. When Symptoms Are Not “Just Menopause”

Pain with Intercourse

Pain mainly at the vaginal opening or with dryness often relates to genitourinary syndrome of menopause. Deep pain during penetration or certain positions may suggest endometriosis.

Bowel or Bladder Symptoms

Painful bowel movements, constipation with pelvic pain, a sensation of incomplete emptying, pain when the bladder fills, or urinary urgency without infection may suggest endometriosis.

In contrast, urine leakage with coughing, laughing, or sneezing is more commonly related to changes seen in peri- and post-menopause.

Lower Back or Leg Pain

Persistent lower back, pelvic, hip, or leg pain (sometimes described as sciatica) is not a typical menopause symptom. This may reflect irritation of pelvic nerves by endometriosis.

Fatigue, Mood Changes, Poor sleep

Unusual fatigue, low mood, or poor sleep can be part of both peri- and post-menopause and endometriosis. When these symptoms occur alongside pelvic, bowel, bladder, or deep pain, they warrant further evaluation and should not be attributed to menopause alone.

Conclusion

Endometriosis is not limited by age. Pelvic, bowel or bladder pain, deep lower back pain ,painful intercourse, fatigue or low mood are not always “just menopause.”

A normal ultrasound, MRI, or even past surgery does not always exclude endometriosis. Diagnosis can be challenging, and in some countries emerging non-invasive assessment tools may help.

Early diagnosis — and most importantly, ongoing follow-up — help protect your long-term health.

Some symptoms attributed to perimenopause may also reflect underlying endometriosis.

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About the author

Dr María Zalazar — Founder & Medical director MZ-Medical

Dr Maria Zalazar is a medical doctor and the Founder and CEO of MZ Medical. She has nearly two decades of clinical experience in hospitals and private practice. She graduated in medicine from the University of Buenos Aires and undertook postgraduate training in gynaecology. She leads MZ Medical’s research initiative, which focuses on unmet needs in endometriosis care.

Can endometriosis after 40 still exist?

Yes. Symptoms can persist or return in perimenopause and may continue in post-menopause due to scarring, fibrosis, and nerve involvement

Are new symptoms after 40 always caused by perimenopause?

No. Perimenopause may occur at the same time as endometriosis or another condition. New or worsening symptoms deserve an assessment rather than an assumption about their cause

Can endometriosis cause pain between periods?

Yes. Pelvic pain may follow a menstrual pattern, but it can also be constant. Pain on days without bleeding should still be taken seriously.

Can endometriosis continue after menopause?

Yes, although some symptoms can improve or stop. Some people continue to have symptoms after menopause, and new pelvic symptoms at that stage need careful assessment.

Can endometriosis remain after a hysterectomy?

Yes. Removing the womb does not necessarily remove endometriosis elsewhere in the body. A hysterectomy does not guarantee that the disease or its symptoms will disappear.

Can someone have endometriosis without severe period pain?

  Yes. Symptoms vary widely. Some people have little or no period pain but experience pelvic, bowel or bladder symptoms.

What bowel symptoms can occur with endometriosis?

Bloating, abdominal pain, constipation, diarrhoea and pain when opening the bowels can occur. These symptoms have several possible causes, so their pattern and any accompanying pelvic symptoms matter.

Can endometriosis cause bloating after 40?

Yes. Bloating is reported by people with endometriosis, sometimes alongside abdominal pain or changes in bowel habits. Bloating alone cannot establish its cause.

Can endometriosis cause pain when opening the bowels?

Yes. Pain during a bowel movement is a recognised symptom, particularly when the bowel or nearby pelvic tissues are affected

Can nausea be part of endometriosis?

Yes. Nausea has been reported alongside endometriosis and bowel symptoms. Persistent nausea also has many other possible causes and needs assessment on its own terms.

References

 

  1. Deep infiltrating endometriosis of the sciatic nerve
    Read the case report and literature review    ⁠
  2. Bowel endometriosis: symptoms, diagnosis and treatment
    Read the clinical review    ⁠
  3. Endometriosis diagnosis, hysterectomy and menopause
    Read the ESHRE guideline (2022)    ⁠
  4. Endometriosis symptoms after menopause
    Read the review of postmenopausal endometriosis    ⁠
  5. Menopausal care for women with a history of endometriosis
    Read the EMAS clinical guide    ⁠
  6. Pelvic pain and symptoms that overlap with bowel or bladder conditions
    Read the Leeds Teaching Hospitals patient information    ⁠
  7. Bowel and bladder symptoms in severe endometriosis
    Read the University Hospitals Sussex information    ⁠.
  8. Endometriosis and sleep problems
    Read the Chelsea and Westminster Hospital information    ⁠.
  9. Endometriosis diagnosis when an ultrasound is normal
    Read the NICE recommendations    ⁠.
  10. Clinical diagnosis of endometriosis without immediate surgery
    Read the ACOG clinical guideline (2026)    ⁠.
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