Recommendations for hormone therapy in hysterectomized women: importance of new data in clinical management

Abstract

Women with a prior hysterectomy with and without oophorectomy represent special cohorts among those who require menopausal hormone therapy (HT), as a progestogen is not required for endometrial protection. This is relevant in light of recent research demonstrating superiority of estrogen therapy alone compared with estrogen plus a progestogen with respect to breast cancer risk and perhaps even cardiovascular protection. No longer is it appropriate to lump all HT regimens together when advising patients. Unfortunately, there is a general reluctance in the healthcare community to prescribe HT even a decade after publication of the results of the Women’s Health Initiative trial. However, with subsequent research showing a favorable benefit/risk balance of short-term estrogen therapy in symptomatic, recently menopausal women, especially those who have undergone hysterectomy with oophorectomy, the need for educating patients and providers on the matter cannot be overemphasized.

Keywords:

• estrogen therapy
• hormone replacement
• hormone therapy
• hysterectomy
• menopause
• oophorectomy
• premature menopause

Financial & competing interests disclosure

VM Miller received research funding from National Institutes of Health AG44170, HD65987, HL83947. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Women who have undergone hysterectomy with either bilateral oophorectomy or unilateral oophorectomy before the natural age of menopause are at increased risk for all-cause mortality, cardiovascular disease, cognitive impairment and parkinsonism.

• Hormone therapy (HT) is recommended for women who experience early or premature menopause and should be continued at least until the natural age of menopause.

• HT is safest when initiated in younger women who are closer to the menopausal transition.

• Typically, progestogens are used to protect the uterus and are not used in women with a prior hysterectomy, although additional studies are needed regarding the role of progestogens in management of menopausal symptoms.

• The choice of estrogen products does not differ between women with and without a uterus.

• ET alone has been found to be safer than estrogen plus a progestogen that contains synthetic medroxyprogesterone acetate with regard to breast cancer and possibly coronary heart disease risk.

• Compounded bioidentical hormones, while similar in chemical structure to hormones produced by the ovary, are not regulated by the US FDA for purity, potency, efficacy or safety.

• Oral estrogens are subject to entero-hepatic circulation resulting in increased clotting proteins, triglycerides and C-reactive protein.

• Low-dose transdermal estrogen is associated with a lower risk of venous thromboembolism and stroke than oral estrogen.