Hormonal Replacement Therapy in Menopausal Women with History of Endometriosis: A Review of Literature

Abstract

Hormonal replacement therapy (HRT) is effective in treating the symptoms of menopause. Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity with a tendency towards invasion and infiltration. Being an estrogen-dependent disease, it tends to regress after menopause. Nevertheless, it affects up to 2.2% of postmenopausal women. Conclusive data are not available in the literature on the appropriateness of HRT in women with endometriosis or a past history of the disease. The hypothesis that exogenous estrogen stimulation could reactivate endometriotic foci has been proposed. The aim of this state-of-the-art review was to revise the current literature about endometriosis in perimenopause and menopause and to investigate the possible role of HRT in this setting of patients. An electronic databases search (MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) was performed, with the date range of from each database’s inception until May 2019. All of the studies evaluating the impact of different HRT regimens in patients with a history of endometriosis were selected. 45 articles were found: one Cochrane systematic review, one systematic review, five narrative reviews, two clinical trials, two retrospective cohort studies, 34 case reports and case series. Some authors reported an increased risk of malignant transformation of endometriomas after menopause in patients assuming HRT with unopposed estrogen. Low-quality evidence suggests that HRT can be prescribed to symptomatic women with a history of endometriosis, especially in young patients with premature menopause. Continuous or cyclic combined preparations or tibolone are the best choices. HRT improves quality of life in symptomatic post-menopausal women, who should not be denied the replacement therapy only due to their history of endometriosis. Based on low-grade literature evidence, we recommend to prescribe combined HRT schemes; tibolone could be considered.

The role of hormone therapy before hysteroscopic myomectomy

“…Dienogest is a progestogen used explicitly in the preoperative treatment for hysteroscopic myomectomy [60], with excellent results in inducing endometrial atrophy with consequent reduction of operating time, infusion volume, and bleeding during the procedure. Dienogest is an orally active progestogen, primarily aimed for the medical treatment of endometriosis [61,62], combining the advantages of both 19-nortestosterone and progesterone classes of progestogens [63][64][65][66][67][68]. The positive effects of dienogest have also been documented for polyps, uterine septa, and tubal sterilization [30,69,70].…”

Endometriosis in Menopause—Renewed Attention on a Controversial Disease

“…Progesterone administration (oral or intrauterine system) has been proposed as a reliable alternative treatment in patients with contraindication for surgery, but, up to date, no extensive data is available and further studies are needed regarding progesterone use in postmenopausal endometriosis [44,45].…”

Progestogens as a component of menopausal hormone therapy: the right molecule makes the difference

“…For patients with current symptomatic endometriosis who require MHT, a continuous combined estrogen plus progestogen regimen or tibolone is appropriate. 51 , 52 In patients with a history of endometriosis, including those who have undergone hysterectomy, the possibility of residual endometrial tissue (e.g. lesions on the bowel) is frequently unknown.…”