Endometriosis and Fibroids Don't Stop at Menopause with Dr. Karen Tang

Karen Tang explains that many well-meaning clinicians prescribe only micronized progesterone (Prometrium) for perimenopausal symptoms, but this is 'a drop in the bucket' for endometriosis or adenomyosis. She often 'stacks' progesterone: micronized for sleep and hot flashes, plus a synthetic progestin or IUD for bleeding control. She emphasizes that the goal is to counteract the estrogen stimulation that can flare these conditions. She uses the analogy of playing chess: anticipate that adding estrogen may require a stronger progestin move.

Karen Tang stresses that the common belief that women with endometriosis cannot take HRT is false. The key is to anticipate the need for stronger progestin. She advises having a 'game plan' and thinking several steps ahead, like chess. If a woman has had a hysterectomy and oophorectomy for endo, she must still receive progesterone with estrogen to prevent microscopic disease from flaring. She warns that giving estrogen alone is 'the worst thing you could do.' She reassures that with proper planning, women do very well on HRT.

Karen Tang notes that she diagnoses new fibroids and adenomyosis frequently in perimenopause, often after HRT initiation 'wakes up' previously asymptomatic lesions. She has a very low threshold for ordering an ultrasound because these conditions are so common and treatable. She also points out that many women have had these conditions silently and only discover them when estrogen is introduced.

Karen Tang describes this as one of the few recent breakthroughs in gynecologic surgery. She has followed the technology for 15 years. The procedure is done either through the vagina (Sonata) or abdomen (Acessa). It doesn't remove the fibroid but shrinks it, making it softer and less symptomatic. It's a middle ground between medication and major surgery. She emphasizes that because the uterus is left in place, fibroids can return, so it may not be definitive.

Karen Tang explains that even when ovaries are left, hysterectomy is associated with an earlier age of menopause—about 4 years earlier. She notes that this was not taught in her training, and many clinicians still don't counsel patients. She also mentions that some women experience temporary hot flashes or mood swings right after surgery due to disrupted ovarian function. She emphasizes the importance of awareness so that women can seek HRT or other management when symptoms arise, rather than being dismissed.

Karen Tang explains that while lower estrogen levels (as in menopause or with hormonal suppression) often reduce symptoms, the disease does not vanish. She sees postmenopausal patients with severe endometriosis, including large cysts. She also notes that transgender men on testosterone, who have no periods, can still have endometriosis pain. The myth that pregnancy cures it is also pervasive; pregnancy temporarily suppresses symptoms via high progesterone and no ovulation, but it is not a long-term solution. She emphasizes that even after hysterectomy, microscopic disease can remain and flare if estrogen is given without adequate progesterone.

Karen Tang describes adenomyosis as a 'cousin' to endometriosis, occurring when endometrial tissue invades the muscular wall of the uterus. It causes severe bleeding, pain, and bulk symptoms. She notes a classic story: a woman who had manageable periods until after a C-section or D&C, then experiences a dramatic worsening. The disruption of the border between the endometrium and myometrium is thought to allow tissue to grow into the muscle. Adenomyosis is easier to see on ultrasound or MRI than endometriosis, appearing as a blotchy, heterogeneous myometrium with indistinct borders. It often coexists with fibroids and can be triggered by HRT if estrogen is unopposed.

Karen Tang explains that radiofrequency ablation involves inserting needles into the fibroid under ultrasound or laparoscopic guidance and passing electricity to heat and destroy the tissue. It shrinks the fibroid, making it softer and less symptomatic, though it doesn't remove it entirely. She has followed this technology for 15 years and notes it is now more widely available, though still limited to certain centers. It is ideal for women who want to avoid major surgery or preserve the uterus, but fibroids can recur because the uterus is left in place.

Karen Tang explains that during her fellowship in 2009-10, aggressive ovary removal was common. Now, because of the known dangers of surgical menopause—cardiovascular disease, bone thinning, diabetes, quality of life—they try to preserve ovaries. Exceptions include strong family history of ovarian cancer or recurrent, aggressive endometriosis despite optimal excision. If ovaries must be removed, she emphasizes the need for HRT with a progestin component to prevent microscopic endo from flaring. She warns that giving estrogen alone after hysterectomy and oophorectomy is 'the worst thing you could do' because it can reactivate disease.

Karen Tang cites specific figures: in 2022, smallpox received $37 million, endometriosis $27 million, and fibroids $15 million. She points out that smallpox is considered a national defense priority, while women's quality of life is given almost no consideration. This lack of funding means we don't know the basic biology—what causes these diseases, how to prevent them, or how to develop targeted therapies. She ties this to the long diagnostic delays and the perpetuation of myths.