Hormonal Replacement treatment
A 38 year old lady presents for follow up after hysterectecomy and bilateral salpingo-oophorectomy due to severe pelvic pain associated with stage 4 endometriosis. The surgery was a success with removal of all the visible endometriosis.
- Iatrogenic menopause
- Severe endometriosis
- Follow up management
- Continuous oestrogen–progesterone HRT postoperatively
- Delay oestrogen administration for at least 12 months
- Progesterone only
- Prescribe oestrogen postoperatively
Continuous oestrogen–progesterone HRT postoperatively
Endometriosis is characterized by the presence of ectopic endometrium. It is a premenopausal disease, resolving after natural or iatrogenic menopause.The clinical presentation follows a spectrum ranging from asymptomatic to chronic pelvic pain and infertility.With no future desire for fertility, an age beyond 30 years, advanced endometriosis with request for definitive surgical treatment, hysterectomy with BSO is indicated.Surgically or medically induced menopause is associated with a swift and dramatic fall in oestrogen levels. This decline may relieve endometriosis-related symptoms, but can simultaneously trigger menopausal symptoms.
Treatment decision must balance the benefits of HRT to bone and cardiovascular health against the potential risks of reoccurrence or malignancy. The timing to initiate HRT after surgical menopause must be personalized to the patient, taking into consideration her age and past medical history.Best treatment modality is continuous oestrogen-progesterone HRT due to the increased risk of reoccurrence from oestrogen only HRT as well as the theoretical risk of malignancy.
Note: recurrence is possible even in the absence of HRT. There are reports of endometriosis recurrence in women not on any hormonal treatment (Fujiu et al., 2010; Bhat et al., 2014).
Important: Advise patients to seek medical attention if she experiences endometriosis-like symptoms , especially if she is on HRT.
- Gemmell, L. C., Webster, K. E., Kirtley, S., Vincent, K., Zondervan, K. T., & Becker, C. M. (2017). The management of menopause in women with a history of endometriosis: a systematic review. Human Reproduction Update, 23(4), 481–500. https://doi.org/10.1093/humupd/dmx011
- Soliman NF, Hillard TC. Hormone replacement therapy in women with past history of endometriosis. Climacteric. 2006 Oct;9(5):325-35. doi: 10.1080/13697130600868711. PMID: 17000581
- Fujiu K , Miyamoto H, Hashimoto S, Suzuki N, Takano Y, Teranishi Y, Sakuma H, Suzuki H. A case of diaphragmatic clear cell carcinoma in a patient with a medical history of ovarian endometriosis. Int J Clin Oncol2010;15:489–492.
- Bhat RA , Teo M, Bhat AK. Endometriosis after surgical menopause mimicking pelvic malignancy: surgeons’ predicament. Oman Med J2014;29:226–231.