Can progesterone be prescribed with a transdermal estrogen (estrogen replacement therapy) patch in a female who has had a hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries)?

Progesterone Use with Transdermal Estrogen in Women After Hysterectomy and Oophorectomy

Progesterone is not required with transdermal estrogen therapy in women who have had both their uterus and ovaries removed. 1, 2

Rationale for Estrogen-Only Therapy

The primary purpose of adding progesterone to estrogen therapy is for endometrial protection. When the uterus has been removed (hysterectomy), this protection is unnecessary:

• Women without a uterus require only estrogen replacement therapy 1
• After hysterectomy, current literature favors not including a progestogen 2
• The addition of progesterone to estrogen therapy in women without a uterus may increase certain health risks without providing additional benefits 2

Benefits of Estrogen-Only Therapy After Hysterectomy

Estrogen-only therapy offers several advantages over combined estrogen-progesterone therapy in women who have had a hysterectomy:

• Lower risk of breast cancer compared to combined therapy 2
• Equivalent relief of menopausal symptoms 2
• Similar protection against bone fractures 2
• Potential cardiovascular benefits that might be attenuated by adding progesterone 2

Recommended Approach

For women who have had both hysterectomy and oophorectomy:

1. Transdermal estrogen alone is the preferred treatment 1, 2

   • Standard adult dose: 50-100 μg/24 hours of transdermal estradiol 1
   • Maximum dose for menopausal symptoms: 100-200 μg/24 hours 1

2. Transdermal administration is preferred over oral due to:

   • Lower risk of venous thromboembolism 1, 3, 4
   • Lower risk of stroke 1, 3
   • Avoidance of first-pass hepatic metabolism 3, 4

Special Considerations

Rare Exceptions for Adding Progesterone

There are limited circumstances where progesterone might be considered even after hysterectomy:

• History of endometriosis (to prevent stimulation of potential residual endometriotic implants) 2
• History of endometrial neoplasia with potential residual disease 2

Monitoring and Follow-up

• Clinical review every 3-6 months initially, then annually 1
• Assessment of symptom control, side effects, and compliance 1

Common Pitfalls to Avoid

1. Adding unnecessary progesterone: Adding progesterone when not needed may increase breast cancer risk without additional symptom relief 2

2. Using oral estrogen instead of transdermal: Oral estrogen carries higher risks of thromboembolism and stroke compared to transdermal formulations 1, 3, 4

3. Inadequate dosing: Women who have had surgical menopause due to oophorectomy often experience more severe symptoms and may require adequate dosing for symptom relief 2

4. Overlooking contraindications: Estrogen therapy is contraindicated in women with history of breast cancer, estrogen-dependent neoplasia, active thromboembolic disorders, and certain other conditions 1

In summary, for women who have undergone both hysterectomy and oophorectomy, transdermal estrogen alone is the recommended therapy, with no need for progesterone supplementation unless specific risk factors for residual endometriosis or endometrial neoplasia are present.