Gynaecology conditions and HRT (DRAFT)

HRT following endometrial ablation

Continuous combined HRT (oestrogen and progestogen) should be used in women who have undergone endometrial ablation.  

Unscheduled bleeding should be investigated as per women who have not had this procedure – Unscheduled bleeding 

HRT following subtotal hysterectomy

Following subtotal hysterectomy the cervix remains in situ. It is difficult to know whether any endometrium remains following subtotal hysterectomy, and whether combined or estrogen-only HRT should be used (if required). If possible, the operating hospital should provide individual guidance.  

If unsure, combined sequential HRT can be used for 3 months as a progestogen challenge, if no bleeding occurs, it is unlikely there is residual endometrium and estrogen-only HRT can be used. If any bleeding occurs on sequential HRT, combined HRT should be used. If any unscheduled bleeding subsequently occurs on estrogen-only HRT, this should be investigated.  

Surgical menopause / Bilateral oophorectomy

Surgical menopause is the removal of both ovaries before a woman has completed menopause. Bilateral salpingo-oophorectomy (BSO) may be undertaken during hysterectomy or as a standalone procedure.  

Menopause symptoms can be severe due to the sudden loss of ovarian function in pre/peri-menopausal women. Loss of libido is often more marked.  

Management 

• HRT is useful for managing symptoms and risks for those who are eligible. HRT is recommended for those under 45y without contraindications to reduce the risk of osteoporosis and cardiovascular disease.  Early Menopause <45y – Management , Premature Ovarian Insufficiency (Menopause <40) Not all women are eligible. 

• A full pre-operative discussion should occur about the pros and cons of ovarian conservation dependent upon the indication for hysterectomy 

• Not all women will be eligible for HRT following surgery e.g. when awaiting final histology to exclude oestrogen driven cancers. 

• Advice regarding HRT should be provided by the hospital performing the surgery pre-operatively and post-operatively (to the patient in the clinic letter and on discharge paperwork). 

• Lifestyle measures and alternatives should be considered in those women who cannot have HRT – HRT Alternatives and Adjuncts  

• HRT should be continued until the age of 51, unless there are contraindications, and then a risk-benefit discussion should be undertaken. 

• Oestrogen-only HRT can be used in women who have had a total hysterectomy (who do not have endometriosis or oncological causes) 

•  For prescribing advice see HRT  

The BMS has produced guidance: 13-BMS-TfC-Surgical-Menopause-JAN2023-A.pdf (thebms.org.uk) 

HRT and endometriosis

Endometriosis is not a contraindication to HRT, but it can be a caution dependent upon exacerbation of symptoms. 

Inducing menopause (with GnRH analogues or surgery) can be a (short-term) treatment offered to some women to manage endometriosis. HRT is important for these women to reduce the risks of early menopause including osteoporosis and cardiovascular disease, as well as providing adequate symptom control.  

If required, continuous combined HRT (oestrogen and progestogen) is advised in women with endometriosis, even following total hysterectomy, until the age of natural menopause (age 51). This is due to the risk of stimulation +/- malignant transformation of endometrial deposits.  

The operating surgeon may advise holding HRT for 3 months post-operatively to enable regression of residual areas which were not safe to excise.  

After age 51, changing to estrogen-only HRT (due to a better safety profile) may be considered, but must be balanced against risk of reactivation and potential malignant transformation, which can occur many years later.  

HRT should be reviewed if endometriosis symptoms occur.  

The BMS has produced guidance on induced menopause in women with endometriosis: 10-BMS-TfC-Induced-Menopause-in-women-with-endometriosis-NOV2022-A.pdf (thebms.org.uk) 

Fibroids

• Fibroids are common. They usually stop growing after the menopause.   

• Fibroids are not a contraindication to HRT. They may continue to grow in response to the hormones in HRT, however these doses are usually lower than naturally released hormones.  

• Women with fibroids <3cm, and a cavity <10cm can still be offered an 52mg LNG-IUD as part of HRT (and this may also help with perimenopausal bleeding symptoms)  

• If women are suffering with symptomatic fibroids they should be referred to gynae for further input.  

• See the Remedy page relating to fibroids for further information - Fibroids 

Resources

Patient Resources  

14-WHC-FACTSHEET-Induced-menopause-info-for-women-NOV2022-A.pdf (womens-health-concern.org) 

07-WHC-FACTSHEET-Fibroids-NOV2022-A.pdf (womens-health-concern.org) 

Information | Endometriosis UK (endometriosis-uk.org) 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.