A hysterectomy is both sudden and prolonged. The surgery itself can leave a woman in the hospital for 2-3 days. The recovery period can be up to eight weeks, and rarely fewer than six. But unlike with some surgeries, the effects often don’t fade into memory. Particularly when you have a hysterectomy that includes removal of the ovaries before you enter natural menopause, you can experience sudden and lasting hormonal upheaval.
This can be a significant challenge, both mentally and physically. The impact of surgical menopause can not only complicate recovery, but fundamentally change the way you live your life. For some women, it is devastating. When a hysterectomy is coupled with a removal of ovaries, the aftermath can be uncomfortable, painful, emotionally distressing, and even dangerous. For this reason, many women seek hormone replacement therapy.
Hormone replacement therapy for women without a uterus has traditionally been estrogen-only. However, there may be meaningful benefits of progesterone treatment after hysterectomy. Both approaches have pros and cons, risks and rewards, and taking a closer look at your options is essential to developing a treatment plan that works for you.
Understanding Hysterectomy and Bilateral Oophorectomy
There are many reasons to have a hysterectomy. These include:
- Heavy periods with intense, prolonged bleeding
- Uterine fibroids
- Pelvic pain caused by endometriosis, inflammatory disease, or adenomyosis
- Cancer of the uterus, ovaries, or cervix
- Uterine prolapse
Of course, a heavy period doesn’t mean an instant hysterectomy. Nor does anything else on the list. Your quality of life has to be measured along with the efficacy of other treatment options, your lifestyle, and your personal preferences (including whether you want to have children). That’s why it is important to have all the information and understand the potential impact on your physical and emotional well-being.
The removal of the uterus alone does not mean that you enter menopause immediately. However, it does often mean that you will enter perimenopause and menopause at an earlier age and may wish to initiate hormone replacement therapy (HRT) to alleviate the resulting symptoms as well as minimize long-term health risks. Although not always needed, hormone replacement therapy is often desired.
But when a hysterectomy is combined with a bilateral oophorectomy—the removal of both ovaries—a woman immediately enters menopause. In these cases, symptoms can be severe enough that HRT becomes significantly more appealing. Furthermore, HRT may be strongly recommended to prevent osteoporosis and other health conditions associated with surgically-induced menopause.
At that point, there are options.
The Rationale and Risks of Estrogen-Only Treatment
Traditionally, it has been understood that when there is no uterus, there is no need for progesterone treatment. After all, progesterone’s primary role is to regulate the menstrual cycle and prepare your body for pregnancy, largely by fluctuating in relation to and opposing the effects of estrogen. Its absence is also generally considered less disruptive than the absence of estrogen. Thus, the thinking goes, only estrogen therapy is needed to counteract the debilitating symptoms of surgical menopause in women without a uterus.
And this may be true some of the time. However, there are risks to unopposed estrogen beyond those involving the uterus. In some cases, certain medical conditions are aggravated when estrogen is used as monotherapy. The most common of these is endometriosis—which may persist even after removal of the uterus. When the ovaries are not removed, evidence also suggests that extended use of unopposed estrogen increases the risk of ovarian cancer. Additionally, some studies indicate that estrogen-only therapy slightly increases the risk of breast cancer, although the evidence is far from conclusive. As a result of these factors, there are times when progesterone is added to treatment both for women whose hysterectomy includes bilateral oophorectomy and those who retain their ovaries.
The Benefits of Progesterone Treatment After Hysterectomy
While the conversation regarding progesterone after menopause has largely focused its impact on the uterus, the medical community is increasingly recognizing the value of progesterone beyond the endometrium. Most importantly, progesterone is associated with a plethora of critical central nervous system functions, and the dramatic drop in progesterone that follows bilateral oophorectomy may have a significant impact on mood, cognition, and neurogenesis. In fact, multiple studies have found strong evidence of progesterone’s neuroprotective effects. As one research cohort from the University of Southern California notes:
[Progesterone therapy] is a critical avenue of investigation as the non-reproductive functions of [progesterone receptions] have far-reaching implications for hormone therapy to maintain neurological health and function throughout menopausal aging.
Emerging evidence suggests one possible pathway between progesterone and emotional health after menopause: the gut-brain axis. A 2019 study on mice led Japanese researchers to conclude that “progesterone reduces depression and anxiety through changes in gut microbiota composition, particularly by increasing the Lactobacillus spp. Population.” While more research is needed to confirm this phenomenon, it does provide an intriguing argument for the use of progesterone treatment after hysterectomy with oophorectomy.
The evidence for progesterone treatment after surgical menopause is growing and it is compelling—and thus far, there are no well-documented risks to its use. It’s important to note that while combined estrogen-progestin therapy has been associated with increased breast cancer risk, estrogen-progesterone combination therapy has not. However, whether or not progesterone is needed is a personal question, and the answer may largely rely on your symptoms, goals, and priorities.
Getting The Right Post-Hysterectomy Treatment For You
As with most things in medicine, the decision to use progesterone treatment after hysterectomy comes down to the individual patient: you. Whether you choose estrogen-only or combination hormone replacement therapy depends on your unique needs. That’s why any hormonal treatment needs to be entered into with as much information as possible and should be guided by a practitioner who understands your symptoms, preferences, and risk factors. By working with the best hormone replacement practitioners, you create a plan that makes sense for you.
Ultimately, your treatment decisions must take into account your own evaluation of the risk/reward balance. After all, a hysterectomy is neither an end nor a beginning. It’s part of your life, and the right hormone treatment can help you keep living it the way you want to.
If you are considering progesterone treatment after your hysterectomy, BodyLogicMD can help. The BodyLogicMD network is comprised of top medical professionals specializing in women’s hormonal health and extensively trained in hormone replacement therapy. A BodyLogicMD-affiliated practitioner can evaluate your symptoms, listen to your concerns, and design a personalized treatment plan to help you achieve your health goals using the best therapies available today. Contact a local practitioner to schedule your first appointment, or take the BodyLogicMD Hormone Balance Quiz to learn more about the everyday impact of hormones.
Disclaimer: These statements have not been evaluated by the Food and Drug Administration. All content on this website is for informational purposes only. The content is not intended to diagnose, treat, cure or prevent diseases.
Charlotte is a patient care coordinator specializing in bioidentical hormone replacement therapy. She is committed to helping patients who struggle with the symptoms of hormonal change and imbalance explore their treatment options and develop effective strategies to optimize wellness.