How should a premenopausal woman who has undergone Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAHBSO) take Oestrogel (estradiol)?

How to Take Oestrogel After TAHBSO

For a premenopausal woman who has undergone TAHBSO, Oestrogel should be initiated immediately after surgery and applied daily to clean, dry skin (typically the abdomen or thighs), using the lowest effective dose that controls symptoms, and continued until at least age 51. 1, 2

Initiation and Timing

• Start HRT immediately after surgery to maximize benefits and minimize development of menopausal symptoms 1
• Do not delay initiation—early estrogen replacement is critical for preventing long-term consequences including cardiovascular disease, osteoporosis, cognitive dysfunction, and early mortality 1, 2

Dosing Strategy

• Begin with 0.75-1.5 mg estradiol daily applied as transdermal gel 3, 4
• The 0.75 mg dose is the lowest practical dose that effectively controls moderate to severe vasomotor symptoms and improves vaginal maturation 4
• Titrate to the minimal effective dose that controls symptoms, typically assessed at 3-6 month intervals 3
• Doses can be flexibly adjusted within the 0.5-1.5 mg range with predictable, dose-proportional absorption 5

Application Technique

• Apply gel to clean, dry skin on the abdomen or lateral thighs 6, 7
• Allow gel to dry completely before dressing 7, 8
• Rotate application sites to minimize local skin irritation (occurs in only 1.7% of patients) 8
• Apply at the same time each day for consistent estradiol levels 5

Duration of Treatment

• Continue until at least age 51 (the average age of natural menopause) 1, 2
• This is not optional—premature discontinuation increases risks of cardiovascular disease, osteoporosis, and early mortality 1
• Reassess need for continuation at 3-6 month intervals, but do not prematurely discontinue in women under 51 3

Key Advantage: No Progestogen Required

• Because you have had a hysterectomy, estrogen-only therapy is appropriate—you do NOT need progestogen 1, 2, 3
• This provides a more favorable safety profile compared to combined estrogen-progestogen therapy 1
• Women with an intact uterus require progestogen to protect against endometrial cancer, but this does not apply after hysterectomy 3, 7

Monitoring and Follow-up

• Reassess symptom control and need for dose adjustment every 3-6 months 3
• Monitor for adequate symptom relief including vasomotor symptoms, mood changes, sleep disturbance, vaginal dryness, and sexual dysfunction 1
• Consider bone density assessment tailored to individual risk factors, particularly given premature surgical menopause 9
• Ensure vitamin D and calcium supplementation, along with weight-bearing exercise 9

Critical Pitfalls to Avoid

• Do not withhold HRT due to age concerns—if you underwent TAHBSO while premenopausal, HRT is indicated regardless of current age until at least 51 1, 2
• Do not add unnecessary progestogen—this increases side effects without benefit in women who have had hysterectomy 1, 3
• Do not use oral estrogen preferentially—transdermal delivery avoids first-pass hepatic metabolism and provides more physiological estradiol levels 7, 8
• Failing to prescribe HRT after premature surgical menopause is a significant missed opportunity to prevent long-term morbidity 2

Contraindications

• HRT is contraindicated only if you have a personal history of breast cancer or venous thromboembolism 1
• For women with genetic breast cancer risk (such as BRCA mutations) who underwent risk-reducing TAHBSO, HRT should still be considered if younger than age 51, as the benefits outweigh risks 9, 1