Hormone Replacement Therapy (HRT)/(MHT) Specifically in Endometriosis Patients

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Remember, the information on my website, podcast, Instagram, and any other ways I communicate and/or produce content is educational information only and not medical advice. Always check with your qualified medical professional before making any changes to your treatment plan for endometriosis or any other health problems. See my full disclaimer here.

Note on HRT/MHT verbiage

There’s a language shift in the menopause community from Hormone Replacement Therapy (HRT) to Menopausal Hormonal Therapy (MHT). I think this is a helpful shift, but I continue to use HRT throughout this website because I find more people are familiar with the term.

Can I use estrogen HRT if I have endometriosis? 

In general, yes. Many people with endometriosis safely use HRT to alleviate menopausal symptoms with no repercussions to their endometriosis. However, every person is individual in their reactions to it and there is a risk for worsening symptoms or disease recurrence. Talk to a menopause specialist knowledgable in endometriosis about the risks vs benefits. You deserve a detailed conversation about your individual situation, symptoms, and treatment goals. Unfortunately, too many providers refuse HRT to endometriosis patients for the mere fact of having endometriosis, causing unnecessary suffering in menopause for many. But it’s not black and white. There are nuances that should be discussed so that you can make the best decision for yourself. 

“Existing guidelines in this area emphasize the lack of evidence, but suggest that women should not be denied HRT treatment simply because of a history of endometriosis (Al Kadri et al., 2009; Dunselman et al., 2014). Our review indicates that women with a history of endometriosis should be carefully counselled about the possibility of disease recurrence after the menopause (Fig. 2). Although the absolute risk is unclear and likely to be low, women should be advised to seek help if they experience endometriosis-like symptoms, rather than suffer in silence. Furthermore, clinicians should adopt a cautious approach in cases of recurrence, keeping in mind the possibility of malignant transformation. For postmenopausal women with recurrent, treatment-resistant symptoms, consideration should be given to obtaining tissue for histology in order to exclude the possibility of malignancy, especially if other unusual or suspicious symptoms are present.” [(1) The management of menopause in women with a history of endometriosis: a systematic review]

Risk-benefits analysis

The use of any medication requires a risk-benefits analysis. What are the benefits and the risks, and will we have more benefits than risks? The goal for most of us is to have a good quality of life. If we have really bothersome menopause symptoms that have made that difficult, such as depression, insomnia, forgetfulness/lack of concentration, or hot flashes, that can really negatively impact us. Unfortunately, for some of us, menopause symptoms are severe and can last for years.

Benefits of estrogen

As I mentioned on my HRT Risks vs Benefits page:

“There are numerous potential benefits to be gained by women taking HRT. Symptoms of the menopause such as hot flushes, mood swings, night sweats, and reduced libido improve. In addition, taking HRT has also been shown to reduce future risk of cardiovascular disease, osteoporosis, type 2 diabetes, osteoarthritis and dementia. Most benefit is afforded when women start HRT within 10 years of their menopause.” [Newson Health Menopause Society’s Easy Prescribing Guide]

Menopause before age 45

Early menopause is associated with serious health risks.

The 2022 European Endometriosis Guidelines have a short section on HRT, which says clinicians should be aware that people with endometriosis who have undergone an early bilateral salpingo-oophorectomy have an increased risk of diminished bone density, dementia, and cardiovascular disease. It then recommends as a Good Practice Point that clinicians continue to treat people with a history of endometriosis after surgical menopause with combined estrogen-progestogen at least up to the age of natural menopause.

Read more detailed information in the guidelines under the section Endometriosis and Menopause.

Risks of estrogen HRT

Potential risks with endometriosis include symptoms recurrence, disease recurrence, and malignant transformation of endometriosis. I talk about the limited evidence we have on this on my page HRT and Endometriosis – A Look at the Evidence. 

Keep in mind that while these are risks, they are not a guarantee. It depends on multiple factors, such as your HRT formulation, whether you had complete excision or not, your individual body, and more. Many people with endometriosis successfully use HRT in menopause with no issues.

I talked about the general risks on my HRT Risks vs Benefits page, mentioning that while there are risks of taking HRT, after the WHI study in 2002, fears of HRT were overblown, unnecessary, or not applicable to people of all ages or on all hormone formulations. Subsequently, this caused a hormonephobia in society and scared many patients and providers away from using and prescribing HRT. If you have fears in general about HRT, definitely take a look at that page to clear up common misconceptions.

How high do estrogen levels get with estrogen therapy?

I summarized this section from the info menopause specialist Christina Saldanha, PA-C gave in my podcast episode 151 on HRT/MHT. Thank you Christina for such excellent information.

Estrogen levels in menopause on estrogen therapy are much lower than estrogen levels in a person’s cycling years or during the perimenopause peaks. Additionally, the amount of estrogen used in estrogen therapy is typically much lower than the estrogen amount in birth control.

• Estradiol fluctuates throughout a person’s cycle between 30-400 pg/ml.
• Estradiol in perimenopause goes up and down like a roller coaster, sometimes being undetectable and sometimes reaching 700 pg/ml.
• Estradiol in postmenopause is typically less than 30 pg/ml.
• On Zoladex (a GnRh agonist similar to Lupron that typically lowers estradiol to menopausal levels), their website (2) says one study on 33 patients found after 8 weeks their estradiol levels lowered to an average of 21.6 pg/ml.
• On HRT, estrogen levels are typically steady and rise to 50-100 pg/ml. 

What type of HRT combinations are recommended for people with endometriosis?

“Low-quality evidence suggests that HRT can be prescribed to symptomatic women with a history of endometriosis, especially in young patients with premature menopause. Continuous or cyclic combined preparations or tibolone are the best choices. HRT improves quality of life in symptomatic post-menopausal women, who should not be denied the replacement therapy only due to their history of endometriosis. Based on low-grade literature evidence, we recommend to prescribe combined HRT schemes; tibolone could be considered.” [(3) Hormonal Replacement Therapy in Menopausal Women with History of Endometriosis: A Review of Literature]