Endometriosis and HRT

Advice on how to treat and manage symptoms

Endometriosis affects one in ten women
Hormones, particularly oestrogen and progesterone, play a major role in the condition
Various hormone treatments are available, plus surgery is an option

Endometriosis is the second most common gynaecological condition after fibroids. According to Endometriosis UK, one in ten women of reproductive age (between puberty and menopause) have endometriosis – it affects 1.5 million women in the UK [1].

What is endometriosis?

The word endometriosis comes from the Greek words ‘endos’ (inside), ‘metra’ (womb) and ‘-osis’ (disease). With this in mind, endometriosis is a condition where tissue similar to the lining of the womb grows elsewhere in the body. This tissue can grow on the ovaries, fallopian tubes and around the bowel and bladder.

Endometriosis can cause heavy, painful periods, pain in your abdomen and pelvis, and for some women, problems with fertility. Around one in ten women have endometriosis and of those who have symptoms, there are many treatments available to manage the condition and reduce the symptoms and associated pain.

Treatment for endometriosis

Treatment can be very effective and really improve symptoms. Treatment usually involves limiting or stopping the production of the hormone oestrogen. This is because oestrogen encourages the tissue to grow, both those inside and outside of the womb. It is the presence of the cells elsewhere in the body that causes the unwanted symptoms.

There are various treatments available such as the combined oral contraceptive pill, a hormone-containing coil and painkillers. In more severe cases, or when those treatments have not improved symptoms, you may need surgery. Surgery aims to remove or destroy the tissue found outside of the womb, known as endometriotic lesions or deposits. Keyhole surgery using a camera (laparoscope) inserted through small incisions in your abdomen is a common procedure used to destroy these endometrial deposits. In some cases an operation, such as a hysterectomy (removal of your womb) or removal of the ovaries is needed. Although these operations are often successful in improving endometriosis symptoms, they can lead to a surgical menopause occurring.

Surgical menopause is when oestrogen suddenly stops being produced in the body, due to such types of operations (or certain medications). It can cause a sudden onset of menopausal symptoms, which can be severe and disabling and have a negative impact on the quality of your life. Having the right type and dose of HRT is really important in these cases, and often improves menopausal symptoms considerably, as well as protecting your health for the future.

What about HRT?

If you have had an early surgical menopause (under the age of 45 years), it is very important that you receive hormones – especially oestrogen – as without HRT or the contraceptive pill you have a greater risk of developing heart disease, stroke, osteoporosis and diabetes.

Replacement oestrogen comes in the form of a tablet, patch, gel or spray. The safest types are ones that are absorbed through the skin, as there is no risk of clot or stroke with these preparations.

For the majority of women, the benefits of HRT outweigh any risks.

Risks of HRT

Once the endometriosis is successfully treated, you will not usually have any problems with taking HRT or have a recurrence of symptoms.

Currently, there is a lack of high-quality research looking into the risks of HRT in women with endometriosis. There is a possibility that oestrogen can reactivate endometriosis, giving rise to symptoms of endometriosis occurring in a small number of women. However, if your endometriosis has all been removed by your surgery then this should not happen.

Types of HRT

RELATED: HRT doses explained

If you naturally enter into perimenopause or menopause (rather than due to medical or surgical intervention), you should be offered combined HRT – this contains both oestrogen and progesterone (or progestogen).

If you are thought to have some endometriosis remaining after a hysterectomy, for example around your bowel or bladder, you will usually be given a progestogen with oestrogen, to reduce the risk of any endometriosis tissue being stimulated by the oestrogen. All those with a womb need to take progesterone or a progestogen, if they are taking replacement oestrogen. People with endometriosis are usually given progesterone or a progestogen daily, which helps to reduce any symptoms and the chances of endometriosis recurring.

The safest type of progestogen or progesterone is micronised progesterone, which is body identical and derived from the yam vegetable. It is taken orally as a tablet daily.

Women who have had endometriosis and a hysterectomy can usually take ‘oestrogen-only’ HRT if their surgeon is confident that all the endometriosis tissue has been removed. If you take oestrogen-only HRT after hysterectomy, you have a lower risk of developing breast cancer in the future, than women who do not take HRT.

Add-back hormone replacement therapy – where HRT is taken to alleviate side effects of certain medications used to treat endometriosis – has been found to reduce loss of bone mineral density and counteract menopausal symptoms [3].

However, very occasionally endometriosis can reactivate spontaneously without taking any oestrogen. It is therefore important to report any recurrence of endometriosis symptoms such as pelvic pain, or bleeding from the vagina, bladder or bowel.

Regardless of whether you have had a hysterectomy or not, taking testosterone in addition to combined HRT can often really help improve your energy levels, mood, concentration and libido.

RELATED: My story: endometriosis

References

[1] Endometriosis UK: facts and figures

[2] Endometriosis | Treatment summaries | BNF | NICE

[3] Edmonds D.K. (1996), ‘Add-back therapy in the treatment of endometriosis: the European experience’, Br J Obstet Gynaecol. Oct;103 Suppl 14:10-3. PMID: 8916980.