What Happens to Endometriomas After Menopause? A Non‐Invasive Follow‐Up Focusing on Ultrasound Features and Clinical Changes

OBJECTIVES: To describe the longitudinal ultrasound features and clinical course of ovarian endometriomas in postmenopausal women, aiming to improve diagnostic accuracy and guide follow-up strategies. METHODS: This retrospective observational study included postmenopausal women with at least one ovarian endometrioma identified by transvaginal ultrasound (TVUS) and monitored for a minimum of 24 months at the University of Rome Tor Vergata (2018-2023). All had a known premenopausal endometriosis detected by TVUS at our Unit. Clinical and ultrasound assessments were conducted at baseline and at 12 and 24 months, recording changes in TVUS characteristics and symptoms. Endometrioma size was classified using the #Enzian classification. RESULTS: Forty-one postmenopausal patients (mean age 53.5 ± 6.4 years) were included. A total of 45 endometriomas were analyzed, mostly unilocular (100%), with a typical "ground glass" echogenicity (75.6%) and classified as #Enzian O1 (82.2%) at the first postmenopausal scan. A significant early dimensional reduction occurred between pre- and postmenopause: the mean maximum diameter decreased from 29.0 ± 15.2 to 20.6 ± 9.7 mm (p = 0.002), and the mean diameter from 24.5 ± 13.1 to 17.9 ± 8.9 mm (p = 0.006), with continued decline at 12 and 24 months (p < 0.05). In contrast, morpho-structural changes emerged later during follow-up, with the proportion of cysts showing wall irregularities rising from 11.1% in premenopause to 38.6% at 24 months (p = 0.003). Vascularization remained minimal throughout. All serum epithelial tumor markers stayed within normal ranges, no suspicious or malignant transformations were observed, and pain symptoms remained stable during follow-up. CONCLUSIONS: Ovarian endometriomas in postmenopausal women exhibit a benign evolution, characterized by early dimensional regression and later structural remodeling without malignant features. Regular ultrasound surveillance remains essential to recognize benign morphologic changes, avoid unnecessary surgery, and promptly identify lesions requiring further evaluation.