Should a 57-year-old female with a history of total hysterectomy due to endometriosis receive estrogen and progesterone for hormone replacement therapy (HRT)?

From the Guidelines

A 57-year-old female with a history of total hysterectomy due to endometriosis should receive estrogen-only hormone replacement therapy (HRT), not combined estrogen and progesterone. Since the patient has had her uterus removed, progesterone is unnecessary as its primary purpose in HRT is to protect the uterine lining from estrogen-stimulated overgrowth. Estrogen-only therapy would be appropriate to manage menopausal symptoms like hot flashes, vaginal dryness, and to help prevent osteoporosis. Some key points to consider when prescribing estrogen-only HRT include:

• The use of estrogen without progestin has generally been restricted to women who have had a hysterectomy because unopposed estrogen use increases the risk for endometrial cancer in women with an intact uterus 1.
• The USPSTF found convincing evidence that estrogen (specifically, oral conjugated equine estrogen, 0.625 mg/d) is of moderate benefit in reducing the incidence of fractures 1.
• There is adequate evidence that the use of estrogen alone results in a small reduction in the risk for developing or dying of invasive breast cancer 1.
• However, the USPSTF found adequate evidence that its use is also associated with moderate harms, including the risk for stroke, gallbladder disease, and urinary incontinence, as well as a small increase in the risk for DVT 1. A typical regimen might include oral estradiol 0.5-1mg daily, estradiol transdermal patch 0.025-0.05mg/day changed twice weekly, or estradiol vaginal ring 2mg released over 90 days. The lowest effective dose should be used for the shortest duration needed to control symptoms. Regular follow-up appointments every 6-12 months are important to assess benefits, side effects, and to determine if continued therapy is necessary. While estrogen therapy carries some risks including increased chance of blood clots and stroke, these risks are generally lower in women who have had a hysterectomy and are using estrogen-only therapy compared to combined hormone therapy 1.

From the FDA Drug Label

When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. A woman without a uterus does not need progestin

• The patient in question is a 57-year-old female with a history of total hysterectomy, meaning she does not have a uterus.
• According to the drug label, a woman without a uterus does not need progestin.
• Therefore, for HRT, this patient would likely receive estrogen alone, without the need for progesterone 2.

From the Research

Hormone Replacement Therapy for a 57-year-old Female with a History of Total Hysterectomy due to Endometriosis

• The patient has a history of total hysterectomy due to endometriosis, which is a hormone-dependent disease 3.
• Estrogen replacement can be associated with a risk of recurrence or malignant transformation of endometriosis, especially in known severe cases and in obese patients 3.
• Unopposed estrogen appears to carry a higher risk than combined preparations 3, 4.
• Since the patient has undergone a total hysterectomy, the risk of endometrial cancer is not a concern, and estrogen-only therapy may be considered 5.
• However, the decision to use hormone replacement therapy should involve an individualized risk/benefit analysis, taking into account the patient's medical history and current symptoms 5, 6.
• Estrogen-only therapy may be beneficial for relieving menopausal symptoms, preventing urogenital atrophy, and protecting against bone loss 3, 5.
• The use of combined estrogen and progesterone therapy may not be necessary in this case, as the patient has undergone a hysterectomy, and the risk of endometrial cancer is not a concern 5.
• Current guidelines recommend that hormone therapy in postmenopausal women with a uterus include a progestin to protect against endometrial hyperplasia, but this may not be necessary for women who have undergone a hysterectomy 7, 5.