Menopausal Hormone Therapy and Endometriosis
Endometriosis is an estrogen-dependent disease. For some patients, severe endometriosis necessitates them to undergo surgical menopause with bilateral salphingo-oophorectomy, with or without a hysterectomy.
These patients may experience exaggerated vasomotor symptoms due to the sudden decline in estrogen levels. Estrogen therapy in this group of women can be a double-edged sword — needed to overcome the severe menopausal symptoms, but with a risk of reactivating the endometriotic foci with a potential for malignancy.
Therefore, combined Estrogen & Progestogen Therapy is preferred rather than estrogen alone, and should be considered in younger women, and if moderate to severe VMS is present.
Treatment should be individualised based on age, disease severity, family history, co-morbidities and severity of symptoms. Evaluation of the risks and benefits of MHT use is carried out taking into consideration the possible resurgence of endometriosis and the small possibility of endometriosis related malignancy.
Women with endometriosis who go on MHT after menopause should be regularly monitored with yearly pelvic ultrasounds. A biopsy is necessary in case of any suspicious recurrence.
Tibolone may be used as an alternative to estrogen progestogen therapy for treatment of menopausal symptoms.
Menopausal Hormone Therapy and Fibroids
MHT is not contraindicated in menopausal women with fibroids. Annual pelvic ultrasounds are advised as MHT may increase the volume and size of asymptomatic fibroids.
A low resistance pulsatility index (PI) in the uterine arteries in women with asymptomatic fibroids is associated with increased fibroid growth and can be used as a screening tool prior to initiating MHT.
Tibolone may be used as an alternative in women with fibroids who require menopausal therapy.
Menopausal Hormone Therapy and Hypertension
Menopause by itself is a risk factor for hypertension and cardiovascular disease.
MHT is not contraindicated in women with well-controlled blood pressure.