Hormone replacement therapy

I’m so sorry you’re going through this — you’re definitely not alone.
Even after a hysterectomy, some people with endometriosis continue to experience pain, especially if there was residual endometriotic tissue left behind. Estrogen in hormone replacement therapy (HRT) can stimulate any remaining endometriosis lesions, potentially causing cramping or pelvic pain, even years after surgery.

Studies show that unopposed estrogen (estrogen-only HRT, especially without progesterone) can sometimes reactivate or worsen symptoms of endometriosis, even after a total hysterectomy and bilateral oophorectomy. This is especially true if any microscopic disease remained.

A few options you might consider discussing with your doctor:

• Switching to combined HRT (estrogen + progestogen or progestin), even if you no longer have a uterus. Progesterone can help counteract the stimulating effect of estrogen on endometriosis.
• Adding a progestin alone (like norethindrone acetate or dienogest) to your current estrogen therapy.
• Using tibolone, a synthetic steroid with mixed hormonal activity, which may reduce endometriosis-related symptoms and is approved in some countries for postmenopausal symptoms.
• Non-hormonal treatments for vaginal atrophy, such as vaginal moisturizers or hyaluronic acid-based products.
• Selective estrogen receptor modulators (SERMs) like ospemifene, which may improve vaginal atrophy without stimulating endometriotic implants, though more research is needed in this specific context.

And finally, a pelvic pain specialist or gynecologist experienced in managing endometriosis after menopause may be helpful — there are tailored approaches depending on whether your symptoms are due to residual endometriosis, pelvic floor dysfunction, or something else.

You deserve relief, and there are options beyond standard HRT. You’re not alone in this — and it’s absolutely okay to advocate for a different treatment plan that better suits your needs and priorities.