Question 45

Withholding HRT Following Hysterectomy For Endometriosis

Dr N,

I recently had to have my ovaries removed due to "possible cancer of the ovaries". It turned out to be extensive scarring and endometriosis which I was diagnosed with in 1985.. The ovaries had the tubes ( filled with fluid) wrapped around them and were encased in extensive scar tissue. I have to admit I feel better now than I did before. However, the weight gain concerns me. I am or was exercising prior to the surgery ( 18th of April ). Following surgery I lost more weight and my appetite seems to have changed ( less). Because of the endometriosis I must try and go without HRT for at least 6 months. Is it a given that I will gain more weight? I did gain following my hysterectomy in 97. Is it possible that the condition of the ovaries prevented my body from getting the estrogen it needed ( FSH levels were normal) and therefore my hotflashes and other symptoms were due to the inability of my ovaries to get the estrogen into my bloodstream? In other words, i was in menopause because of the condition? I realize you get a lot of questions. The main one I have is regarding the weight gain. If you can answer, i would appreciate it.




I am sorry that you are having this difficulty.

If you would read the section of the web site, Ovarian Failure Following Hysterectomy, it addresses the issue of why you had hot flashes with normal FSH levels.

The weight gain is more frequent without HRT and the section of the web site, Menopause & Weight Gain, addresses this issue.

Some physicians such as yours believe that by withholding HRT for a time following hysterectomy there is less of a chance of a reoccurrence of endometriosis. I don't believe that this concept is valid. Like the endometrium, or lining of the uterus, endometriosis is stimulated and grows when it is stimulated by estrogen. It will regenerate when estrogen is given regardless of the the time interval it is withheld.

As such, I do not believe it is reasonable to withhold HRT in this circumstance.

In the event that endometriosis recurs following surgery, further treatment will be required.

Discuss with your physician. If you desire to take HRT at this time, that is your decision and you are entitled to do just that.

I have included below an abstract, or summary of the results of a study performed by researchers from the John Hopkins School of Medicine, which supports this view.

Please let me know what and how you do.

Dr N

Timing of estrogen replacement therapy following hysterectomy with oophorectomy for endometriosis.

Obstet Gynecol 1998 May;91(5 Pt 1):673-7 (ISSN: 0029-7844)

Hickman TN; Namnoum AB; Hinton EL; Zacur HA; Rock JA
Division of Reproductive Endocrinology and Infertility, Johns Hopkins
School of Medicine, Baltimore, Maryland, USA.

OBJECTIVE: To determine whether the immediate initiation of estrogen replacement therapy (ERT) in the postoperative period increases the incidence of symptom recurrence following total abdominal hysterectomy(TAH) with bilateral salpingo-oophorectomy (BSO) for the treatment of endometriosis.

METHODS: In a retrospective cohort study, 95 women who underwent TAH with BSO for endometriosis at the Johns Hopkins Hospital during 1979-1991 and who subsequently received ERT were identified by computer search. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. Pain recurrence in patients who started ERT within 6 weeks after surgery and in those who delayed ERT for more than 6 weeks was compared and adjusted for length of patient follow-up and other covariates.

RESULTS: Sixty women began ERT within the immediate postoperative period, and four (7%) of them had recurrent pain; 35 women began ERT more than 6 weeks after surgery, and seven (20%) of them had recurrent pain. The mean length of follow-up was 57 months. The difference in the crude rate of symptom recurrence following early and delayed initiation of ERT after TAH with BSO was not statistically significant (P =.09). Controlling for length of patient follow-up, no significant differences were observed between the two groups. Adjusting for covariates of stage, age, and postoperative adjunct medroxyprogesterone therapy, those who started ERT more than 6 weeks after surgery had a relative risk of 5.7 (95% confidence interval 1.3, 25.2) for pain recurrence.

CONCLUSION: Although the number of patients in the study was too small to reach statistical significance in all analyses, these findings suggest that patients who begin ERT immediately after TAH with BSO are at no greater risk of recurrent pain than those who delay ERT for more than 6 weeks.