Progesterone After Hysterectomy: Not Indicated
After hysterectomy, progesterone is not needed and should not be routinely prescribed—estrogen-only therapy is the appropriate hormonal treatment for menopausal symptoms in women without a uterus. 1, 2
Why Progesterone Is Unnecessary Post-Hysterectomy
The sole purpose of adding progestin to estrogen therapy is to protect the endometrium from unopposed estrogen stimulation, which increases endometrial cancer risk 10-30 fold in women with an intact uterus 3. Once the uterus is removed, this risk no longer exists, making progestin unnecessary 1.
Adding progestin when it's not needed introduces avoidable harms:
- Increased breast cancer risk compared to estrogen-alone therapy 1, 4
- No additional benefit for vasomotor symptoms or vaginal atrophy 4
- Potential attenuation of cardiovascular benefits seen with estrogen-alone 4
Specific Exceptions Requiring Progestin After Hysterectomy
Progestin should only be added in these rare circumstances:
- Residual endometriosis: If endometrial tissue remains outside the uterus after hysterectomy, unopposed estrogen could stimulate this tissue 4
- History of endometrial cancer with supracervical hysterectomy: If the cervical stump remains and contained endometrial tissue 1
Optimal Estrogen-Only Regimen Post-Hysterectomy
Transdermal 17β-estradiol 50-100 mcg daily is the preferred formulation over oral estrogen because it avoids hepatic first-pass metabolism, reduces thrombotic risk, and has more favorable effects on lipids and blood pressure 2.
Oral alternatives if transdermal is not feasible:
- 17β-estradiol 1-2 mg daily, or
- Conjugated equine estrogens 0.625-1.25 mg daily 2
Special Consideration: Prior Endometrial Cancer
Even in women who had hysterectomy for low-risk endometrial cancer (Stage I-II, low grade), estrogen-alone therapy is reasonable, as randomized trials show no increased recurrence rates 2. Wait 6-12 months after completing adjuvant treatment before initiating 2.
Common Pitfall to Avoid
Do not reflexively prescribe combination estrogen-progestin therapy to post-hysterectomy patients simply because it's a common formulation. This exposes women to unnecessary breast cancer risk without providing endometrial protection they no longer need 1, 4.