HRT after hysterectomy and endometriosis: oestrogen only or with progesterone?

[Skyrmion]

Hi,

I finally decided to go on HRT and I have a history of stage 4 Endometriosis, with adenomyosis.

Pretty much exactly 3 years ago I had a hysterectomy and one of my ovaries (the one with a massive endometrioma) was taken out too.
I had massive infiltrations, endometriosis sitting at bowels and bladder, as per report it was "all clear" after the robot assisted surgery.

Now my question is - its recommended to use progesteron to prevent the estradiol triggering possible remains of the tissue.

I am 54 now, I was prescribed Estradot patches, and only after double checking with the GP he agreed that Utrogeston every night should be prescribed, and he did.

What are your opinions in terms of benefits and safety? Some say Estrogen on its own is safer, some say Progesteron aids sleep and is acting "anti anxiety", which I could do with.

What would you do?

Thank you!

I have pretty much the same medical backstory and I’m on dienogest along with the oestrogen as, for me, it controls the endo flare better. You definitely need progesterone (or a progestin like me) as any microscopic endo left over will be inhibited by it. They also think that those small endo deposits could turn cancerous which is also why women with wombs must take it. Oestrogen only does reduce cancer risks slightly in women without endo but for us it’s too risky.

In terms of breast cancer risk, longer term, estrogen-only is much safer and appears to reduce the risk of BC compared to women not on any HRT.

All the types of progesterone have a possible risks factor for breast cancer, but micronised progesterone is supposed to the lowest risk . The research there is available shows it appears to carry no risk for at least 5 years.

I'd not take progesterone simply for 'anxiety and sleep' because, to be honest it doesn't always help and can have side effects of its own.
I've used it for over 10 years and do not like it at all, (it affects my skin and sleep in a bad way) but it's better than the other sort I used.

I can't offer advice on what to do with endo, but my advice would be to see a real specialist (maybe privately if necessary) for an opinion. One thing I do know is that there are various opinions even between consultants and in complicated cases like yours you may need to find one who is an expert on this.

It also depends on how long you might use HRT and whether it's just a few years or longer term.

And if, without progesterone, it would be possible to have an annual scan to look for endo or take a course of progesterone now and then (eg every few months) rather than daily.

@Teaandchocolate2222 and @JinglingSpringbells

Many thanks for your responses!

tea, yes, that's what I gather from doing a lot of reading up about it, and a flare up is the last thing I want of course. Its a bit sad that neither the (otherwise very knowledgable and genuinely lovely) female pharmacist didn't know about the link to endo, when I asked her - and even the GP had top look it up and call me back.

Jingling,
as for how long I would take it - that is a really good question! How long do women take HRT in general? When, given that there's no menstrual cycle to go by, do you know that you're definitely post menopausal? And bloods wouldn't make sense while on HRT, or that's what I think at least.

I only picked up the Utrogestan yesterday and haven't started yet with either medication (I want to time the patch right so it can go on every 84 hours, and due to working late I would need the "evening change day" at a weekend, so I still have time to mull it all over. I tend to overthink in general, annoying trait. Some people just crack on with stuff! Anyway, I was told that both are very low doses, Estradot 0.25 and Utrogestan 100.

Thanks again!

I have endo but also still have a womb and periods. I have just started HRT and had to argue really hard for continuous progesterone as cyclical is recommended for those with a womb.

There is a belief that endo deposits tend to flare up with unopposed oestrogen, again not a huge amount of medical research done on this but from The British Menopause Society -

"Unopposed estrogen replacement is associated with a significant increase in the risk of endometrial hyperplasia that is both dose and duration dependent with exposure between one and three years.

• Non-hysterectomised women require progestogen administered for 12–14 days in a sequential regimen and daily in a continuous combined regimen to minimise the risk of endometrial hyperplasia and endometrial cancer associated with unopposed estrogen exposure.

HRT in women with endometriosis
Continuous combined HRT regimens should be considered in women following hysterectomy for severe endometriosis to prevent reactivation of residual disease and to potentially prevent malignant transformation of residual deposits. However, there is limited evidence available on this to guide clinical practice"

https://thebms.org.uk/wp-content/uploads/2026/02/14-NEW-BMS-TfC-Progestogens-and-endometrial-protection-FEB2026-B.pdf

How long do women stay on it?

Good question.

It all depends. I think there are some stats to say 'on average' it's about 5-7 years although I may be imagining that! I doubt there are many surveys that are up to date.

It also depends on circs. Some women are on HRT forever if they are also using it for bone protection or treatment.

The only way to assess is to have a 3-month break, suggested by my consultant, to see if symptoms are still there.

I want to time the patch right so it can go on every 84 hours,

assume your 84 hours is a typo?

Your dose is low.
Hardly anyone starts on a 25mcg patch. That tends to be for older women 60+ starting hrt for the first time.

Out of interest, why have you chosen a patch?
Estrogen gel is far easier to manage to change the dose, as it's under your control. And there is no faff around when to change it like a patch.

Can you see an expert? One option might be to use progesterone a few times a year to 'clear' any growth (which is something allowed usually privately for women who are intolerant to progesterone. ) But it would need monitoring, at a cost.

@EndoEndoNoNo

Thank you for the link! Lots to read up on for me, very helpful!

@JinglingSpringbells

I just saw my GP, and the patch was what he prescribed, options weren't discussed...I didnt even know about the gel (before I read it exists online yesterday), I had never heard of it. He did say though that typically younger women were given higher doses, I guess that makes me old now. :)
I figured out the 84 hours as the patch is to be taken twice a week, so I reckoned, say, 9am on a Tuesday and 9pm on a Friday would make it precisely so. Or is my thinking wrong?

I am in Ireland, if that makes any difference. As for going private, that would be an option if I find a specialist. Typically all the "good stuff" in terms of medical care is found in Dublin, and I'm in the West. But at least my health insurance would cover a consultant to some degree.

Thanks again!

@Skyrmion I am almost 52 and on Oestrogel pump of 0.6% two pumps which is the minimum dose as I started this one month ago. I apply it every morning, rub it in for 20 seconds (I do both thighs at once with both hands) then it dries in 2 minutes but I wait 5 until I put my clothes on.

The progesterone is important, I read as much as I could on it for endo from medical papers, British Menopause Society etc. Sadly we need to get informed for ourselves, nothing has changed in 25 years since I was diagnosed.

Unopposed oestrogen will potentially feed the endo deposits you still have and progesterone is definitely recommended for women who have had a hysterectomy and have a history of endo. In fact it was hard in my research to find supporting evidence for me to have continuous progesterone because I have a womb.

ESHRE European Society of Human Reproduction and Embryology Endometriosis 2022
https://www.eshre.eu/-/media/sitecore-files/Guidelines/Endometriosis/ESHRE-GUIDELINE-ENDOMETRIOSIS-20222.pdf

VI.3.e. Regimen of MHT (Menopause Hormone Therapy) in women with a history of endometriosis Evidence is limited with regards to the regimen of MHT in women with endometriosis (Baber, et al., 2016). Considering responsiveness of ectopic endometrial tissue to sex steroids, it seems advisable to use continuous estrogen-progestogen in those patients requiring MHT, in order to limit any abnormal estrogen-induced endometriosis proliferation in persistent endometriosis tissue.

Louise Newsom
https://www.drlouisenewson.co.uk/knowledge/endometriosis-and-hormones

Currently, there is a lack of high-quality research looking into the specific benefits and risks of HRT in women with endometriosis. There is a possibility that estrogen can reactivate endometriosis, giving rise to symptoms of endometriosis occurring in a some women.

Dr Chris Mann a consultant gynacologist surgeon was on a podcast with Louise Newsom
"I am very happy that they use it I would stress that I prefer them to have continuous HRT even if they’ve got a uterus we think, we don’t know for certain, but we think that the endometrial like tissue, the endometriosis, seems to be more susceptible to the cyclicity of oestrogen and progesterone that you get in a normal menstrual cycle so you can avoid that to a degree by giving continuous levels of HRT. That seems to be better in terms of symptom relief and they get the benefits of both oestrogen and progesterone.”

I even looked at US medical papers on it. I also follow doctors on social media who cover endo and women's health. It is sadly a case of suck it and see with HRT. I am the healthiest I have ever been endo wise so I am closely monitoring my body.

@EndoEndoNoNo

Thanks a million for sharing your research. And the website of Dr Louise Newson looks like a treasure chest of information, that's very helpful!

Do you find that your regime works for you (I know you said it's only been a month), but have your symptoms improved yet?

(Edited for formatting.)

@Skyrmion it hasn't got any worse endo wise so that is positive. Louse Newsom was really at the heart of raising awareness of the new HRT as opposed to the fear surrounding the ones from 1990s. I have her book and also one by Davina McCall who worked with Dr Naomi Potter. Both are well respected.

Peri symptoms wise mine are intermittent and have been for 4 years so I go through phases of it then completely fine albeit that I recognise I am not the person I was before peri. I feel the brain fog is maybe better.

But read up on it all. I had to go back for a second visit after my GP initially refused continuous progesterone because she said I would be bleeding all the time (I am not, just had a period as normal) I would be "all over the place" again, I don't feel that way. GPs are really good but they don't know everything which is why they refer you to "specialists" and even they don't know a lot about endo I find.

@EndoEndoNoNo
Thanks again for that, useful information about the Doctors - there's so, so much around when you dive into the rabbit hole of searching online, good to know those are well respected. I think I came across Louises name (might have been the sub reddit Menopause) but again, it's hard to know what you can believe and what's to be taken with a grain (or pound) of salt.

Something else I find conflicting information about: HRT protects cardiovascular health. Pharmacist confirmed that to me. It seems that the views have changed about this fact, it used to be deemed risky in that regard. Do I get this right, is that the case, it's "safe"? The leaflet of the Estrodot still claims (paraphrased) that the risk of cardiovascular events is higher when using HRT.

Anyone could shed light on this perhaps?

Thank you.

(Edited for spelling.)

I use the Potter clinic for consultations with menopause specialists. I was allocated Karen Aitken who I see (virtually) as she is a surgeon and therefore I felt had more experience with post hysterectomy and endo patients. She has been fantastic, so clued up with the latest guidance and information on safety. If you can I’d book an appointment with her and you will feel so much better being able to discuss any concerns or questions. She went into great detail about the cancer risks, heart health benefits and really helped me gain perspective on what I wanted to do. I do still make occasional appointments with her as I have wanted to tweak doses and try testosterone etc.

If you have no womb you do not need the protective action of the progesterone.
I had oestrogen only patches after my hysterectomy.
It is the progesterone element that causes the most problems. You are lucky not to.need it.

@Mischance it’s now deemed beneficial. Guidance changes all the time in medicine. I had my hysterectomy 5 years ago, but I will be asking about progesterone at my HRT review next month.
https://vm.tiktok.com/ZNR4GL4gE/

Thanks to all the pp for the info, I will go to my review armed with some facts.

You asked about cardio health and HRT.

I have no idea why the leaflet in Estrodot says that. It would appear to be out of date and possibly refers to data (WHI study) from 20 years ago which is now known to be flawed.

The research and opinions of specialists now is that transdermal estrogen reduces the risk of CVD if used within 10 years of menopause. (That means within 10 years of the last natural period.) It appears that the benefits are because estrogen keeps the arteries more flexible so they don't 'fur up' as much, and it can also have a beneficial effect on lipids in the blood stream.

Starting HRT later than 10 years doesn't have so much of a benefit.

The old data that showed HRT was linked to heart disease was because women using it were overweight, started HRT late in life (over 60) , some had existing health issues, and were on outdated HRT (mainly tablets.)

The OP has endometriosis which makes a difference.

@all
Thank you so much for your time and opinions, I really appreciate it. I will start on Tuesday with both medications, and hopefully get on fine with them.

@JinglingSpringbells
Thank you for confirming what I believed, regarding heart health, that is very helpful!

All the best to all of you.

@Teaandchocolate2222

Oh, and great recommendation! I will look her up - since it can be done online it might be a good option in case I need more information or having any doubts. Thank you.

I have the same history as you but I’m younger at 44 and kept both ovaries after hysterectomy, I take HRT, very low dose oestrogen for now (1/2 pump a day) as that’s all I need to keep any symptoms at bay (which began for me after hysterectomy) and I use utrogestan every night too. To be honest this has been ok. I started on higher oestrogen and it was too much and gave me issues but now seems mostly alright. Without progesterone I wake up a lot at night and feel more anxious / wired. I would prefer to take it cyclically as I’m still having cycles just no periods but GP says really I need it daily to stop any endo coming back.

@popsickle555
Glad to hear you're doing ok now! Half a pump, how much would that be in terms of micrograms, do you know?
I really would like to enquire about the gel, I wonder if it isn't “a thing” here in Ireland, since I wasn’t given the option…I need to find out!

Thank you!

I use Lenzetto spray which, for me, is far more convenient as it dries very quickly unlike the gel. They used to think
it was far more potent than it is so the actual dose per spray is a lot lower when you compare to gel or patches. There are easily google-able tables comparing the dosages.

Perfect, I will find a table, thanks!

Half a pump is a tiny amount.
1 pump is the same as a 25mcg patch.
1/2 pump is half that.

It's barely anything.

Thanks a lot, @JinglingSpringbells !

Yes I know it’s tiny, it’s all I need though for now. I’ve been tested several times and levels are bang on now with 1/2 pump daily. I did start at one pump but had migraines due to oestrogen being a bit high for me. Obviously everyone is different and will need to adapt dose.

a friend of mine (same age) was told to take 2pumps and also too much for her and is now on 1. I guess just go slow with it was my personal experience.

I am 53 and I have deep endometriosis and diffuse adenomyosis as well as suffering from a failed uterine ablation which is causing lots of pain. I am due a full hysterectomy and excision surgery any time now (been on a year long waiting list so far).

My endo gynae has recommended that I take both progesterone and oestrogen afterwards but as my mum has breast cancer and according to everything I read oestrogen only after hysterectomy carries the lowest BC risk I am opting for that alone.

I know it's not ideal but I would personally rather the recurring endo risk than the bc risk but had my mum not had bc I would have probably gone for the progesterone too but I will see how it goes, I will start with low oestrogen and work up and if I need the addition of progesterone then I will have to add it but that's my plan, for now at least.