Options for hormone therapy in women who have had a hysterectomy

To review postmenopausal hormone therapy for women who have undergone hysterectomy with or without bilateral oophorectomy and to make clinical recommendations regarding changes in regimens compared with those for women with their uterus in place.

We conducted a literature review, including a review of current guidelines.

When the uterus is absent, estrogen treatment is all that is needed when hot flashes and/or genital atrophic symptoms are associated with surgical or natural menopause. Reasons to add a progestogen to an estrogen-only therapy regimen after hysterectomy include the need to reduce the risk for unopposed estrogen-dependent conditions, chief among which are endometriosis or endometrial neoplasia. Multiple lines of evidence suggest that regimens containing both estrogen and progestogen versus estrogen alone are associated with a greater relative risk of breast cancer without additional improvement in relief of hot flashes or vaginal symptoms. When a bilateral oophorectomy is performed before natural menopause, the onset of menopausal symptoms, primarily vasomotor symptoms, genital tract atrophy, and/or a decline in sexual function, is rapid, and the symptoms are more severe. Thus, the need for a decision on the use of hormone therapy is accelerated.

The decision to use or not use menopausal hormone therapy in women without a uterus should involve an individualized risk/benefit analysis just as it should when the uterus is present. After hysterectomy, for most patients, current literature results favor not including a progestogen. Data suggest an attenuation of the potential cardiovascular benefit of estrogen therapy in this situation, yet no better protection against bone fractures and an increase in the risk for breast cancer when both estrogen and progestogen are used.