Hormone Replacement Therapy After Total Hysterectomy
For women after total hysterectomy without a history of endometrial cancer, estrogen-only therapy is recommended without the addition of progestogen, as there is no uterus to protect from endometrial hyperplasia. 1, 2
Clinical Approach Based on Indication and Patient History
For Benign Indications (No Cancer History)
Estrogen-only therapy is the standard approach:
Transdermal 17β-estradiol 50-100 mcg daily is preferred over oral formulations as it avoids hepatic first-pass metabolism, provides better safety regarding thrombotic risk, and has more favorable effects on lipids and blood pressure 3
Oral alternatives include 1-2 mg daily of 17β-estradiol or 0.625-1.25 mg conjugated equine estrogens if transdermal route is not feasible 3, 1
Start at the lowest effective dose and titrate based on symptom control; cyclic administration (3 weeks on, 1 week off) may be used 1
Progestogen should NOT be added after hysterectomy for benign indications, as adding progestogen increases breast cancer risk without providing additional benefit for vasomotor symptoms or bone protection 2
Special Consideration: History of Endometriosis
If hysterectomy was performed for endometriosis with residual intra-peritoneal disease:
Consider adding continuous progestogen to estrogen therapy to reduce risk of endometriosis reactivation 3, 4
Evidence shows recurrence rates are low (2%) even with estrogen-only therapy, but combined estrogen/progestogen regimens provide additional protection 4
After Hysterectomy for Endometrial Cancer
The approach differs significantly and requires careful risk stratification:
For low-risk endometrial cancer (Stage I-II, low grade):
Estrogen replacement therapy is a reasonable option as randomized trials show no increased recurrence rates 3
Wait 6-12 months after completion of adjuvant treatment before initiating hormone therapy 3
Individualized discussion is mandatory given the increased breast cancer risk from estrogen therapy in general populations, even though endometrial cancer recurrence risk is not increased 3
Contraindications to estrogen therapy after hysterectomy:
Smokers, history of breast cancer, history of multiple strokes should receive non-hormonal alternatives for menopausal symptoms 3
Selective estrogen receptor modulators (SERMs) may be considered as alternatives, though they don't relieve vasomotor symptoms 3
Age-Specific Considerations
For younger women (age <60 years) after hysterectomy:
Long-term follow-up from the Women's Health Initiative suggests lower cardiovascular and breast cancer risks with estrogen-alone therapy in this age group compared to older women 3
Surgical menopause before natural menopause causes more severe and rapid-onset symptoms, necessitating earlier treatment decisions 2
Duration and Monitoring
Treatment duration should be:
The shortest duration consistent with treatment goals, with re-evaluation every 3-6 months to determine ongoing necessity 1
Attempts to taper or discontinue should be made at 3-6 month intervals 1
Common Pitfalls to Avoid
Do not routinely add progestogen after hysterectomy for benign disease - this increases breast cancer risk without benefit 2
Do not deny estrogen therapy to all women with prior endometrial cancer - evidence shows safety in low-risk cases 3
Do not use oral estrogen when transdermal is available - transdermal has superior safety profile regarding thrombosis 3
Do not forget to assess ovarian function in women with conserved ovaries - up to 22% may have premature ovarian failure requiring treatment 5