It is not clear how the disease evolves with time. In its deep form (DIE), it is likely that endometriosis is a progressive disease (getting progressively worse over time¹). This only makes sense, if we accept that large lesions must have developed over a period of time. The rate of progress is unlikely to be fast², but may vary between patients. However, in mild cases, spontaneous resolution has been described³.

Radical excision of endometriosis lesions reduces the risk of recurrence^4,5. However, it does not fully eliminate the risk of recurrence⁶. This is likely secondary to a number of factors, such as the surgical technique⁷, patients age at the time of surgery⁴, as well as the severity of the disease⁸. What is more, non-visible lesions exist in up to 12% of cases⁹.

It appears that amenorrhea (lack of periods) by means of post-operative hormonal contraception, reduces the risk of post-operative recurrence¹⁰. We, therefore, recommend the use of hormonal contraception post-operatively, except in cases where the woman wishes to get pregnant post-operatively. This sounds reasonable, if we accept that Sampson’s theory of retrograde menstruation plays a role in the pathogenesis of endometriosis¹¹.

Endometriosis is a hormone-sensitive disease of the reproductive age- sensitive to hormones¹². It, therefore, makes sense that menopause (with its associated rapid drop in the levels of hormones) causes an improvement in the symptoms¹³. Despite this being the general rule, cases of disease progression post-menopause have been described, usually as a result of hormone replacement therapy (HRT)¹⁴, and rarely in women with no previous history of endometriosis before the menopause¹⁵.

References :

1. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril. 1991 Apr;55(4):759-65.
2. Koninckx PR, Ussia A, Keckstein J, Wattiez A, Adamyan L. Epidemiology of subtle, typical, cystic, and deep endometriosis: a systematic review. Gynaecol Surg 2016;13:457–67.
3. Evers JL. Is adolescent endometriosis a progressive disease that needs to be diagnosed and treated? Hum Reprod 2013; 28:2023.
4. Busacca M, Chiaffarino F, Candiani M, Vignali M, Bertulessi C, Oggioni G, et al. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol. 2006;195:426–32.
5. Vignali M, Bianchi S, Candiani M, Spadaccini G, Oggioni G, Busacca M. Surgical treatment of deep endometriosis and risk of recurrence. J Minim Invasive Gynecol. 2005.
6. Cea Soriano L., López-Garcia E., Schulze-Rath R., Garcia Rodríguez L.A. Incidence, treatment and recurrence of endometriosis in a UK-based population analysis using data from The Health Improvement Network and the Hospital Episode Statistics database. Eur. J. Contracept. Reprod. Health Care. 2017;22:334–343.
7. Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N, Carmignani L. Long-term follow-up after conservative surgery for bladder endometriosis. Fertil Steril. 2005.
8. Parazzini F, Bertulessi C, Pasini A, Rosati M, Di Stefano F, Shonauer S, et al. Determinants of short term recurrence rate of endometriosis. Eur J Obstet Gynecol Reprod Biol. 2005
9. Nisolle, M.; Paindaveine, B.; Bourdon, A.; Berlière, M.; Casanas-Roux, F.; Donnez J, Histologic study of peritoneal endometriosis in infertile women. Fertil. Steril. 1990, 53, 984–988.
10. Liu Y, Gong H, Gou J, Liu X, Li Z. Dienogest as a Maintenance Treatment for Endometriosis Following Surgery: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2021 Apr 7;8:652505.
11. Sampson JA. Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol 1927; 14:422–69.
12. Chantalat E, Valera MC, Vaysse C, Noirrit E, Rusidze M, Weyl A, Vergriete K, Buscail E, Lluel P, Fontaine C, Arnal JF, Lenfant F. Estrogen Receptors and Endometriosis. Int J Mol Sci. 2020 Apr 17;21(8):2815.
13. Cumiskey J., Whyte P., Kelehan P., Kelehan P., Gibbons D. A detailed morphologic and immunohistochemical comparison of pre- and postmenopausal endometriosis. J. Clin. Pathol. 2008;61:455–459.
14. Dong-Su J., Tae-Hee K. Endometriosis in a Postmenopausal Woman on Hormonal Replacement Therapy. J. Menopausal Med. 2013;19:151–153.
15. Benjamin M. Snyder Postmenopausal Deep Infiltrating Endometriosis of the Colon: Rare Location and Novel Medical Therapy. Hindawi Case Rep. Gastrointest. Med. 2018;2018:5.