Hormone Replacement Therapy in Women with Endometriosis After Hysterectomy

Introduction to HRT

The American College of Obstetricians and Gynecologists recommends that unopposed estrogen therapy is safe and appropriate for women after total hysterectomy with bilateral salpingo-oophorectomy, and should be initiated immediately to prevent cardiovascular disease, osteoporosis, cognitive dysfunction, and early mortality 1, 2

Estrogen-only hormone replacement therapy is appropriate and eliminates the need for progestogen, which is only required to protect the endometrium in women with an intact uterus, according to the Human Reproduction Update 3, 4, 5
The North American Menopause Society suggests that estrogen-only therapy has demonstrated better safety outcomes compared to combined estrogen-progestogen preparations in women without a uterus 1

The European Menopause and Andropause Society recommends that HRT must be initiated immediately after surgery and continued until at least age 51 to maximize benefits and prevent long-term health consequences 1, 2
At age 40, this patient faces 11 years of premature estrogen deprivation, which significantly increases risks of cardiovascular disease, accelerated bone loss, cognitive dysfunction, and increased all-cause mortality, as stated by the American Heart Association 1, 2

The Endocrine Society recommends 17-beta estradiol via transdermal delivery as the preferred formulation for estrogen replacement 3, 4, 5
17-beta estradiol is preferred to ethinylestradiol or conjugated equine estrogens for estrogen replacement, according to the Human Reproduction Update 3, 4, 5

Initiate unopposed transdermal 17-beta estradiol immediately post-operatively, as recommended by the Human Reproduction Update and Praxis Medical Insights 3, 1, 2
Continue therapy until at least age 51, as suggested by Praxis Medical Insights 1, 2

HRT is contraindicated only in women with personal history of breast cancer or venous thromboembolism, according to the American College of Obstetricians and Gynecologists 1