Replacing Hormones after Hysterectomy

Estrogen therapy after hysterectomy found to be saving lives of many women

/ Author:  / Reviewed by: Robert Carlson, M.D Beth Bolt, RPh

(RxWiki News) After a woman goes through a hysterectomy (surgical removal of the uterus), she may benefit from estrogen therapy. The estrogen hormone has been shown to lower the risk of a number of health problems in women. 

However, a recent study found that the use of estrogen therapy has sharply declined over the past decade, and this decline may be linked to early deaths among women who have had hysterectomies.

This study showed that estrogen therapy was associated with a lower risk of death among younger postmenopausal women.

According to the study's authors, the decline in the use of estrogen therapy is likely due to misleading information that was published 10 years ago.

"Talk to your gynecologist about the possible benefits of estrogen therapy."

This study was conducted at Yale School of Medicine and led by Philip Sarrel, MD, Professor Emeritus of Obstetrics, Gynecology and Reproductive Sciences. The research team wanted to show how the sharp decline in estrogen therapy use over the past decade was directly related to the increased number of early deaths in many hysterectomized women aged 50 to 59.
A hysterectomy causes early menopause if the ovaries are also removed (if menopause hasn't happened already). Estrogen production then decreases sharply after the procedure. Estrogen regulates all the body's internal systems that allow it to function properly. 
In the 1990s, most hysterectomies included oophorectomies, but this practice has since changed. The ovaries are only removed if they are diseased. 
A hysterectomy alone will cause a woman to stop menstruating, but will not force her to go into early menopause. Menopause can be caused only by removal of the ovaries, regardless of the status of the uterus. 
For this study, the researchers looked at previously published data on the decline of estrogen therapy use from the past decade. They argued that the decline was largely due to the media reporting misleading information about a specific kind of hormone therapy in the early 2000s.
The study authors explained that this decline began in 2002 when the Women's Health Initiative (WHI) released a report announcing the early end of the Estrogen Plus Progestin Trial due to negative side effects from the hormones. However, the trial used women who had not gotten a hysterectomy, and only tested one specific combination hormone medication that included both estrogen and progestin.
In 2004 and 2011, WHI released reports on the Estrogen-Alone Trial for hysterectomized women that showed estrogen therapy alone had positive effects on the risk of death, especially in women ages 50 to 59. Despite the findings from the 2004 and 2011 reports, estrogen therapy remains a controversial treatment and is rarely used. 
"Estrogen therapy in postmenopausal women continues to be a controversial topic both among healthcare providers and the lay public.  When I was a resident at Duke from 1992-1996, the use of estrogen therapy in postmenopausal women was routine. The subsequent Women's Health Initiative brought many of these practices into question," Andre F. Hall, MD, physician and owner of Birth and Women's Care, P.A., told dailyRx News.
"While still controversial, I believe the benefits of postmenopausal estrogen therapy outweigh the potential risks of this medicine. I further agree with the position statement of the American College of OB/GYN which states the lowest dose of medication, over the shortest period of time to address symptoms is the most appropriate approach to addressing the use of this therapy," said Dr. Hall.
The 2011 report showed a higher rate of death of roughly 13 per 10,000 per year in this age group who were not using estrogen. The researchers of the current study were able to turn this statistic into an actual number representing the estimated amount of extra premature deaths.
The researchers also found that, for women aged 50 to 59 years, there were different rates of decline since 2002 in estrogen therapy over ten years, with a 60 percent decline by 2004, a 71 percent decline by 2006 and ultimately a 79 percent decline by 2010.
After combining all this data into a formula and averaging the ranges of potential estimates for both women with and without ovaries, the researchers estimated that the actual extra death toll was between 40,292 and 48,835 lives.
The average death rate was approximately the same in both 2004 and 2011, meaning that neither report affected the use of estrogen therapy. The percent of hysterectomized women in the US using estrogen therapy dropped from roughly 90 percent in 2002 to roughly 30 percent by 2004 due to the media-induced public scare.
The study also revealed that the use of estrogen therapy is still declining since the 2011 report.
The authors expressed hope that the actual population estimate of the excess death toll will better communicate the meaning and significance of the data from the WHI-Estrogen-Only Therapy report to the general public, the media and healthcare providers.
The findings showed that estrogen therapy reduced post-hysterectomy death mainly by reducing deaths from coronary heart disease — a condition that becomes more likely after having a hysterectomy. The estrogen therapy supports normal and stable blood flow through the arteries, helping prevent atherosclerosis specifically.
Atherosclerosis is a chronic disease that thickens and hardens the walls of the arteries and inhibits normal circulation. Breast cancer mortality has also been reduced because of estrogen therapy.
There were a few limitations to this study. For one, the researchers only considered in-hospital hysterectomies, despite the fact that out-of-hospital procedures have become popular in recent years. This may have made the death toll estimates too low.
Also, the authors only used data on oral estrogen therapy because the effects of vaginal estrogen, bioidentical preparations (synthesized hormones that are identical in structure to natural hormones), and transdermal (given through a patch on the skin) estrogen on the death toll of hysterectomized women have not been studied enough or at all.
This study was published in the July 18 edition of the American Journal of Public Health.
The Centers of Disease Control and Prevention (CDC) provided funding.
Review Date: 
July 25, 2013
Last Updated:
August 2, 2013