I’m 44 and having heavy and irregular bleeding with severe cramping outside of my period, which has always been painful and is getting worse. Diagnosed with endometriosis at 24 and have had excision. I also have PMDD and menstrual migraine. I do not tolerate progestin-only treatment and feel best around day 5-7 of my cycle, when estrogen increases and progesterone is low. Combined hormonal birth control worsens pelvic pain. What are the pros and cons of getting a total hysterectomy with ovary removal but then taking HRT after (estrogen and possibly testosterone and micronized progesterone). Want to protect my future health but also get rid of the severe and unpredictable pain and bleeding (because nothing else has helped).
Endometriosis
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Hormone Replacement After Ovary Removal
Surgery that removes both ovaries causes immediate surgical menopause, which usually comes with sudden symptoms like hot flashes. Therefore, hormone replacement therapy (HRT) after this kind of surgery is a key part of managing symptoms and protecting your long-term health. However, an important question to consider is whether you actually need a hysterectomy or the removal of both ovaries in the first place, since removing just the uterus (or even a single ovary) will not cause menopausal symptoms.
If both the uterus and ovaries are removed, managing the resulting menopause usually only requires a low dose of estrogen to prevent symptoms and support your health. If the uterus is still present but the ovaries are gone or not functioning, then hormone therapy will include both estrogen and a form of progesterone (progestin or natural progesterone). Using both hormones protects the uterus and reduces the risk of uterine cancer.
Another hormonal consideration is that some testosterone in your body is converted into estrogen, and this may also slightly increase progesterone production. There is some health benefit to taking estrogen without synthetic progestins, as estrogen-only therapy has a lower risk of breast cancer compared to combined estrogen–progestin therapy. However, this higher breast cancer risk might not apply when using natural progesterone instead of a synthetic progestin. Overall, hormonal management after surgery has many nuances and requires careful planning. It is not a one-size-fits-all approach.
Hysterectomy Considerations for Endometriosis and Adenomyosis
Adenomyosis (highly related to endo) is almost impossible to diagnose with 100% certainty without removing the uterus and having a pathology evaluation. If adenomyosis is strongly suspected and you do not plan to have more children, then a hysterectomy (removal of the uterus) may be beneficial. On the other hand, if you still want to have children, a hysterectomy is not necessary to achieve a good result from endometriosis excision surgery. Depending on what was done with the last excision, when it was done and by whom, it could be that you need a higher level excision or simply that endo grew back and a re-excision may help.
In some situations, a hysterectomy can make it easier for the surgeon to completely remove endometriosis, but this is not always the case. Furthermore, in most cases the surgeon can preserve some or all of your ovarian tissue with minimal risk. This means that removing both of your ovaries is often not required.
Every case is highly individualized and depends on factors such as prior surgeries, imaging results, and personal health history. The longer you have had endometriosis (especially if imaging or examinations show significant issues), the more likely it is that your pelvic anatomy has become distorted by progressive endometriosis and scar tissue (fibrosis). In these complex cases, it is very important to seek out the most skilled endo expert surgeon available to optimize the endometriosis excision, reduce the risk of complications, and help you with personalized hormonal strategies.