Does a patient with a history of endometriosis who undergoes a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) require both progesterone and estrogen replacement therapy?

From the Guidelines

Patients who have had endometriosis and undergo a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) typically require estrogen-only hormone therapy rather than combined estrogen and progesterone. Since the uterus has been removed during the TAH, progesterone (which is primarily used to protect the uterine lining) is not necessary 1. Estrogen-only therapy can help manage menopausal symptoms that occur after ovary removal, such as hot flashes, vaginal dryness, and bone density loss. Some key points to consider in the management of these patients include:

• The decision to start hormone therapy should be individualized based on the patient's symptom severity, age, endometriosis history, and risk factors 1.
• Estrogen replacement therapy is a reasonable option for patients who are at low risk for tumor recurrence, and it should be discussed in detail with the patient 1.
• Hormone therapy should begin soon after surgery if indicated and continue until the typical age of natural menopause (around 51 years) unless contraindications develop.
• Common estrogen options include oral estradiol (0.5-1mg daily), transdermal estrogen patches (0.025-0.05mg/day), or vaginal estrogen for localized symptoms.
• Some clinicians may still consider combined therapy in certain cases of severe endometriosis, as there's a theoretical risk that microscopic endometriosis implants might respond to estrogen alone 1. However, the most recent and highest quality study suggests that estrogen-only therapy is sufficient for most patients 1.

From the FDA Drug Label

When estrogen therapy is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer. A woman without a uterus does not need progestin 8. Exacerbation of endometriosis A few cases of malignant transformation of residual endometrial implants have been reported in women treated post-hysterectomy with estrogen-alone therapy For women known to have residual endometriosis post-hysterectomy, the addition of progestin should be considered.

A patient with a history of endometriosis who undergoes a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) may require estrogen replacement therapy.

• The patient may also require progesterone replacement therapy if there is residual endometriosis, as the addition of progestin should be considered in these cases to prevent exacerbation of endometriosis 2. However, if there is no residual endometriosis, progesterone replacement therapy may not be necessary, as the patient no longer has a uterus 2.

From the Research

Hormone Replacement Therapy for Endometriosis Patients

• Patients with a history of endometriosis who undergo a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) may require hormone replacement therapy (HRT) to alleviate menopausal symptoms 3, 4, 5, 6, 7.
• The use of HRT in these patients is a topic of debate due to the potential risk of reactivating endometriotic foci or malignant transformation 3, 4, 5, 6, 7.

Types of Hormone Replacement Therapy

• Combined HRT preparations, which include both estrogen and progesterone, are recommended for patients with a history of endometriosis 3, 5, 6.
• Estrogen-only HRT should be avoided in these patients, as it may increase the risk of malignant transformation or recurrence of endometriosis symptoms 5, 6.
• Tibolone, a synthetic hormone that has estrogenic, progestogenic, and androgenic properties, may be a suitable alternative for some patients 3, 6, 7.

Considerations for Hormone Replacement Therapy

• The decision to prescribe HRT to a patient with a history of endometriosis should be made on a case-by-case basis, taking into account the severity of menopausal symptoms, the risk of recurrence or malignant transformation, and the patient's individual preferences and medical history 4, 5, 6.
• Patients should be closely monitored for any signs of recurrence or exacerbation of endometriosis symptoms while on HRT 4, 7.
• The benefits of HRT, including relief of menopausal symptoms, prevention of urogenital atrophy, and protection against osteoporosis, should be weighed against the potential risks 3, 6.