As researchers learn more about the effects of estrogen replacement therapy (ERT) on the body, women are asking more questions about whether ERT is right for them. If you are considering whether to start or stop taking ERT, consider the following when making your decision:

• If you have early menopause after a hysterectomy and oophorectomy (or a while after a hysterectomy), your health professional will probably recommend that you take ERT. ERT replaces some or all of the estrogen that your ovaries would be making at this time in your life. Without the estrogen, you may have menopausal symptoms. You would also be at risk for having weaker bones later in life. For most women in their 20s, 30s, or 40s, ERT benefits outweigh the slight risk of blood clots that comes with taking estrogen.
• If you are near the age of natural menopause (around age 50), talk to your health professional about the risks and benefits of starting ERT after hysterectomy and oophorectomy. In large groups of women in their 60s and older, slightly more women on ERT develop breast cancer or ovarian cancer or have a stroke than do women not taking ERT.^{1, 2}
• If you are near the age of natural menopause (around age 50), you may not need to take ERT after hysterectomy and oophorectomy. Talk to your health professional about either stopping ERT and using other treatments that don't use hormones, or continuing ERT beyond menopausal age (at as low a dose as possible).
• If you smoke, try to quit smoking before taking ERT. At any age, your risk of blood clots (deep vein thrombosis) is slightly increased when you take estrogen. It's best not to combine this risk with smoking, which increases your risk for cardiovascular disease.
• ERT does not lower risks of heart disease and dementia, as was once thought.

For more information about other treatments, see the topics Menopause and Perimenopause and Osteoporosis.

What is a hysterectomy, and why is it done?

A hysterectomy is the surgical removal of the uterus. Hysterectomy is sometimes used for gynecological problems that haven't improved with other treatment. These problems include abnormally heavy menstrual bleeding, uterine fibroids, endometriosis, chronic pelvic pain, and uterine prolapse. Less commonly, hysterectomy is a lifesaving treatment for uncontrollable bleeding during childbirth or for cancer.

What is an oophorectomy, and why is it done?

An oophorectomy is the surgical removal of the ovaries. About half of American women who have a hysterectomy also have their ovaries removed (bilateral oophorectomy).³

When taking hormone therapy after an oophorectomy only (the uterus is not removed), it's important to take estrogen plus progestin (hormone replacement therapy, or HRT). The progestin protects the uterus from the increased risk of estrogen-related endometrial cancer.

Sometimes oophorectomy is intended to treat a condition that is triggered or made worse by the ovaries' hormone changes, such as severe, untreatable premenstrual syndrome (PMS), endometriosis, or premenopausal breast cancer. In other cases, ovary removal is done to reduce the possibility of ovarian cancer (which is rare but difficult to detect). Oophorectomy may also be performed to remove a growth on the ovary or ovaries.

What is estrogen replacement therapy (ERT)?

Estrogen replacement therapy (ERT) is the use of man-made (synthetic) estrogen to replace the natural estrogen normally produced by your ovaries. ERT is available in pill form (oral form) or as a skin patch, vaginal ring, or skin cream or gel (transdermal form).

Why is ERT prescribed?

Until menopause (usually around age 50), the ovaries make most of your body's estrogen. When the ovaries are removed (oophorectomy), estrogen levels suddenly drop. This change causes early menopause and increased osteoporosis risk (your body's estrogen helps keep bones strong).

Historically, women in their 20s, 30s, and early 40s-before menopausal age-have been prescribed ERT after hysterectomy with oophorectomy or ERT with progestin after oophorectomy alone. (Without progestin, ERT can lead to uterine cancer.)

Although oophorectomy causes a sudden drop in estrogen, hysterectomy alone can lead to a more gradual, yet early decline of estrogen (premature ovarian failure) in some women. In either case, keeping estrogen levels up protects against early bone density loss and helps prevent menopausal symptoms.

ERT may not be necessary for most women after the age of natural menopause (around age 50). Until further research clarifies this question, there are no current ERT treatment guidelines for older women to follow. Women taking ERT can consider:

• Continuing ERT beyond menopausal age to treat menopausal symptoms (using as low a dose as possible).
• Stopping ERT and using other symptom treatments that don't use hormones.

For more information, see the topic Menopause and Perimenopause.

Some doctors prescribe testosterone along with estrogen to help relieve the fatigue, headaches, loss of sexual desire, and depression that can affect women after oophorectomy.⁴ (The ovaries help produce low levels of testosterone in a woman's body.) This is not a widely used therapy, because long-term safety of testosterone therapy is not yet known.

What are the benefits of ERT after hysterectomy with oophorectomy?

Estrogen replacement therapy reverses the effect of low estrogen and therefore:

• Reduces osteoporosis risk. ERT slows bone loss and promotes some increase in bone density.⁵
• Reduces the frequency and severity of hot flashes.⁵
• Prevents or reverses vaginal dryness and irritation caused by low estrogen.
• Slows the decline in skin collagen levels. Collagen is responsible for the stretch in skin and muscle.
• Reduces the risk of dental problems, such as tooth loss and gum disease.
• May help prevent depression and sleep problems related to hormone changes.⁶

What are the risks of ERT?

Estrogen replacement therapy increases your risks of:⁷

• Stroke. ERT use slightly increases the risk of stroke, similar to estrogen-progestin stroke risk.¹
• Blood clots. A recent small study suggests that oral ERT slightly increases a woman's risk of life-threatening blood clots (deep vein thrombosis or pulmonary embolism), but a transdermal (patch) ERT does not. When taken orally, ERT seems to increase a clotting factor in the blood; this is less likely to happen with ERT that is absorbed through the skin.⁸
• Breast cancer. The Million Women Study has shown that, in women using ERT for 10 years, the number of breast cancers is slightly higher than normal. It appears that ERT causes breast cancer in 5 per 1,000 women.² Although the Women's Health Initiative (WHI) trial found no increase in breast cancer over 7 years of ERT use, experts continue to take the breast cancer risk seriously.¹
• Gallstones. Women who use estrogen replacement therapy are more likely to have gallstones that cause symptoms than women who do not use ERT. (High estrogen levels are linked to gallbladder disease.)
• Ovarian cancer (which is rare). In women using ERT over 5 years, the number of ovarian cancers is slightly higher. Using ERT causes ovarian cancer in about 0.4 per 1,000 women. (This is the same as 1 in 2,500 women.) This risk only applies to women who have their ovaries and are taking estrogen.

Do not use estrogen treatment if you:

• Have unexplained vaginal bleeding.
• Have active liver disease or long-term impaired liver function. (Estrogen applied to the skin via cream, gel, or patch does not stress the liver to the same degree as estrogen pills).
• Have a personal history of breast cancer, ovarian cancer, or stroke.

If you are a smoker, try to quit smoking.

Talk to your health professional about your risks versus benefits if you have a family history of breast cancer, ovarian cancer, stroke, or blood clots.

If you need more information, see the topic Menopause and Perimenopause or Osteoporosis.

After having a hysterectomy and oophorectomy (or a hysterectomy only, followed by early menopause), your choices are to:

• Take estrogen replacement therapy (ERT).
• Use other treatment measures for menopausal symptoms and osteoporosis prevention.

The decision about whether to use or continue using estrogen replacement therapy (ERT) takes into account your personal feelings and the medical facts.

Deciding about estrogen replacement therapy

Reasons to use or continue using estrogen replacement therapy (ERT)

Reasons to not use or not continue using estrogen replacement therapy

You have had a hysterectomy and oophorectomy (or a hysterectomy only, followed by early menopause) in your 20s, 30s, or 40s AND: You need a treatment for severe menopausal symptoms and have considered or tried other treatment options. You need a treatment for preventing early bone loss and osteoporosis. You have no personal or family history of stroke, breast cancer, or ovarian cancer. You have a family history of stroke, breast cancer, or ovarian cancer, but you and your health professional consider your risk to be small and will watch closely for such health problems. You are older than 55, have talked with your health professional about continuing to take ERT, have considered other treatment options, and have decided that ERT benefits outweigh the possible risks to you. Are there other reasons you might want to use ERT?

You have had a hysterectomy but have not had your ovaries removed, and you are having no symptoms of early menopause. You have a personal history of stroke, breast cancer, or ovarian cancer. You are a smoker. You have reached the average age of menopause (age 50), when a woman's estrogen levels naturally decline, and you would like to taper off of ERT. Are there other reasons you might not want to use ERT?

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about taking estrogen replacement therapy. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I had an oophorectomy and hysterectomy in my 20s, 30s, or 40s.	Yes	No	NA*
I have had a hysterectomy in my 20s, 30s, or 40s, followed by early menopause.	Yes	No	NA
I am younger than menopausal age (50).	Yes	No	NA
I am older than menopausal age.	Yes	No	NA
I am a smoker.	Yes	No	NA
I need a treatment for severe menopausal symptoms and have considered or tried other treatment options.	Yes	No	Unsure
I need a treatment for preventing early bone loss and osteoporosis.	Yes	No	Unsure
I have a personal or family history of stroke, breast cancer, or ovarian cancer.	Yes	No	Unsure
I take ERT and am beyond the age of natural menopause.	Yes	No	NA
I have risk factors for osteoporosis and am concerned that low estrogen in my body will increase my risk.	Yes	No	Unsure
I have osteoporosis and have tried or seriously considered non-ERT bone-protecting treatments.	Yes	No	NA
I have considered other treatment options, such as vaginal lubricants for dryness and irritation; antidepressants for hot flashes and mood-related problems; and vitamin D, calcium, and bisphosphonate medicine for preventing osteoporosis.	Yes	No	NA

*NA=Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use estrogen replacement therapy.

Check the box below that represents your overall impression about your decision.

Leaning toward taking estrogen replacement therapy

Leaning toward NOT taking estrogen replacement therapy

• Hysterectomy
• Menopause and Perimenopause
• Endometriosis

Citations

1. Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701–1712.

2. Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419–427.

3. American College of Obstetricians and Gynecologists (1999). Prophylactic oophorectomy. ACOG Practice Bulletin No. 7. Obstetrics and Gynecology, 94(3): 1–7.

4. Khastgir G, Studd J (2000). Patients' outlook, experience, and satisfaction with hysterectomy, bilateral oophorectomy, and subsequent continuation of hormone replacement therapy. American Journal of Obstetrics and Gynecology, 183(6): 1427–1433.

5. Speroff L, Fritz MA (2005). Menopause and the perimenopausal transition. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 621–688. Philadelphia: Lippincott Williams and Wilkins.

6. Rapkin AJ, et al. (2002). The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders. Current Psychiatry Reports, 4(6): 419–428.

7. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321–333.

8. Scarabin PY, et al. (2003). Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet, 362(9382): 428–432.

Author	Kathe Gallagher, MSW
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman
Associate Editor	Terrina Vail
Primary Medical Reviewer	Joy Melnikow, MD, MPH - Family Medicine
Specialist Medical Reviewer	Carla J. Herman, MD, MPH - Internal Medicine
Last Updated	May 26, 2006