Is progesterone (progestin) added to estrogen (estrogen therapy) for menopausal symptoms in women without a uterus (hysterectomy)?

From the Guidelines

Answer

Progesterone (progestin) is not added to estrogen therapy for menopausal symptoms in women without a uterus (hysterectomy) [ 1 ].

Key Points

• Estrogen-only therapy is recommended for women with menopausal symptoms who have undergone a hysterectomy, as the addition of progesterone is not necessary to protect against endometrial hyperplasia [ 1 ].
• Estrogen-only therapy, such as conjugated estrogens (0.625-1.25 mg/day) or estradiol (0.5-2 mg/day), can be initiated for the management of menopausal symptoms [ 1 ].
• The dosage and duration of estrogen therapy should be tailored to the lowest effective dose for the shortest duration necessary to alleviate symptoms [ 1 ].
• The use of estrogen without progestin has generally been restricted to women who have had a hysterectomy because unopposed estrogen use increases the risk for endometrial cancer in women with an intact uterus [ 1 ].
• The USPSTF found convincing evidence that estrogen (specifically, oral conjugated equine estrogen, 0.625 mg/d) is of moderate benefit in reducing the incidence of fractures [ 1 ].
• There is adequate evidence that the use of estrogen alone results in a small reduction in the risk for developing or dying of invasive breast cancer [ 1 ].
• However, the USPSTF found adequate evidence that its use is also associated with moderate harms, including the risk for stroke, gallbladder disease, and urinary incontinence, as well as a small increase in the risk for DVT [ 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

• Key point: Progestin is not necessary for women without a uterus.
• Main idea: Estrogen therapy can be used alone in women without a uterus. The answer is no, progesterone (progestin) is not added to estrogen therapy for menopausal symptoms in women without a uterus (hysterectomy) 2

From the Research

Progesterone Addition to Estrogen Therapy

• For women without a uterus (hysterectomy), progesterone (progestin) is not required to be added to estrogen therapy for menopausal symptoms, as the risk of endometrial hyperplasia is not a concern 3, 4.
• Estrogen therapy alone is often recommended for women who have undergone hysterectomy, as it can provide effective relief from menopausal symptoms without the need for progestogen 3, 4.
• The addition of progestogen to estrogen therapy in women without a uterus may actually increase the risk of certain health problems, such as breast cancer, without providing additional benefits 3, 4.

Rationale for Progesterone Addition

• In women with an intact uterus, progesterone is added to estrogen therapy to reduce the risk of endometrial hyperplasia and carcinoma 5, 6.
• However, this rationale does not apply to women without a uterus, as the risk of endometrial hyperplasia is not a concern in these cases 3, 4.

Clinical Recommendations

• The decision to use hormone therapy in women without a uterus should involve an individualized risk/benefit analysis, taking into account the woman's specific symptoms, medical history, and preferences 3, 4.
• Estrogen therapy alone may be a suitable option for many women without a uterus, but the decision should be made on a case-by-case basis, with careful consideration of the potential benefits and risks 3, 4.