Multiple recurrences of postmenopausal endometriosis associated with estrogen pellet therapy: clinical implications for hormone therapy and surgical management

OBJECTIVES: To challenge the perception that endometriosis uniformly regresses after menopause by presenting the case of repeated, pathology-confirmed symptomatic recurrences spanning two decades after menopause, and to emphasize key considerations for hormone therapy use and surgical management in postmenopausal endometriosis. METHODS: We report the case of a 70-year-old postmenopausal patient with prior hysterectomy, bilateral salpingo-oophorectomy, appendectomy, and pathology-confirmed endometriosis who presented with pelvic pain while receiving subcutaneous estrogen pellet therapy. Preoperative imaging was suggestive of recurrent endometriosis. The patient underwent laparoscopic excision for diagnostic and therapeutic purposes, with final pathology confirming recurrent disease. Written informed consent was obtained for publication of this case report and use of de-identified clinical images. A focused narrative literature review was performed to contextualize this case within existing data on postmenopausal endometriosis. RESULTS: Laparoscopy revealed a cystic mass arising from the right round ligament with associated retroperitoneal fibrosis and multiple peritoneal implants consistent with endometriosis. Surgical management included resection of the round ligament mass, excision of peritoneal implants, lysis of adhesions, and right ureterolysis. Histopathologic examination confirmed a round ligament adenomyoma and peritoneal endometriosis. Postoperatively, the patient experienced symptomatic improvement and was transitioned to low-dose transdermal estradiol combined with progestogen therapy. CONCLUSIONS: Endometriosis can develop, persist, or recur after menopause, particularly in the setting of unopposed and potentially supraphysiologic exogenous estrogen. This case highlights the importance of appropriate menopausal hormone therapy selection, including consideration of progestogen use regardless of uterine status, and reinforces the role of surgical excision in postmenopausal patients with suspected disease.