J Clin Gynecol Obstet
Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access
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Journal website https://www.jcgo.org

Letter to the Editor

Volume 13, Number 1, March 2024, pages 23-24

An Examination of the Association Between Types of Menopausal Hormone Therapy (Estrogen-Only Hormone Therapy Versus Combined-Hormone-Therapy Versus Tibolone) and Endometriosis Progression in Peri/Postmenopausal Women With a Previous Hysterectomy

Lucy Chiua, e, Pavitra Nanayakkarab, c, d

aRoyal Melbourne Clinical School, University of Melbourne, Melbourne VIC 3052, Australia
bJean Hailes for Women’s Health and Epworth Freemasons Hospital, Melbourne, Australia
cAmbulatory Gynaecology Unit, Royal Women’s Hospital, Melbourne, Australia
dMonash University, Melbourne, Australia
eCorresponding Author: Lucy Chiu, Royal Melbourne Clinical School, University of Melbourne, Melbourne VIC 3052, Australia

Manuscript submitted March 23, 2024, accepted March 29, 2024, published online March 31, 2024
Short title: EO-HT vs. C-HT vs. Tibolone
doi: https://doi.org/10.14740/jcgo964

To the Editor▴Top 

In a menopausal woman with a previous hysterectomy, estrogen-only hormone therapy (EO-HT) is currently believed to be the most effective for managing climacteric symptoms and preventing health consequences of a hypoestrogenic state [1]. However, in women with estrogen-dependent conditions such as endometriosis, there is a body of literature and guidelines which recommend the preferred use of combined-hormone-therapy (C-HT) or tibolone [1]. This creates a clinical dilemma regarding how climacteric symptoms should be managed in women with a history of endometriosis and a hysterectomy. Few high-quality evidence was found, and most conclusions drawn have been heavily reliant on case-studies. Despite this, a recent systematic review suggested that C-HT and tibolone should be used as the preferred menopausal hormone therapy (MHT) option in these women [2]. There are few other systematic reviews on this topic, and most conclude a non-significant association between any type of hormone therapy and endometriosis progression in these women [3, 4]. This lack of significant association between types of MHT and endometriosis progression is further supported by a recent retrospective analysis following the use of different MHT in 330 women with a history of endometriosis and hysterectomy [5]. In this study, 10 recurrences were observed in those using MHT, and interestingly, the discontinuation of MHT in all cases of recurrence resulted in the resolution of symptoms [5]. Despite this, the lack of definitive association between types of MHT and the known protective effect of MHT in symptomatic women means MHT should not be withheld, even in women with a history of endometriosis and hysterectomy. As such, clinicians should appreciate that recurrences can occur and present variedly in these women, where common presentations include pelvic pain and pelvic vaginal bleeding [3, 5]. Further research, particularly larger-scale observational studies are needed for stronger evidence to be drawn.


We would like to acknowledge the Melbourne Medical School for providing an opportunity for students to engage in clinical research as part of the Medical Student Research Project. Further, we would like to extend the thanks to the librarians at the University of Melbourne for developing appropriate search terms to appropriately explore the entire scope of the clinical question developed.

Financial Disclosure

None to disclose.

Conflict of Interest

None to disclose.

Informed Consent

Not applicable.

Author Contributions

LC carried out the systematic analysis of journals related to the given topic, including screening, selection of journals to draw conclusions for this manuscript. PN was involved in the conception of the research question, editing and review of the manuscript.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.


EO-HT: estrogen-only therapy; C-HT: combined hormone therapy; MHT: menopausal hormone therapy

  1. Flores VA, Pal L, Manson JE. Hormone therapy in menopause: concepts, controversies, and approach to treatment. Endocr Rev. 2021;42(6):720-752.
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  2. Zanello M, Borghese G, Manzara F, Degli Esposti E, Moro E, Raimondo D, Abdullahi LO, et al. Hormonal replacement therapy in menopausal women with history of endometriosis: a review of literature. Medicina (Kaunas). 2019;55(8):477.
    doi pubmed pmc
  3. Gemmell LC, Webster KE, Kirtley S, Vincent K, Zondervan KT, Becker CM. The management of menopause in women with a history of endometriosis: a systematic review. Hum Reprod Update. 2017;23(4):481-500.
    doi pubmed pmc
  4. Al Kadri H, Hassan S, Al-Fozan HM, Hajeer A. Hormone therapy for endometriosis and surgical menopause. Cochrane Database Syst Rev. 2009;1:CD005997.
    doi pubmed
  5. Tanmahasamut P, Rattanachaiyanont M, Techatraisak K, Indhavivadhana S, Wongwananuruk T, Chantrapanichkul P. Menopausal hormonal therapy in surgically menopausal women with underlying endometriosis. Climacteric. 2022;25(4):388-394.
    doi pubmed

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