Hormone Replacement Therapy Use After Bilateral Salpingo-oophorectomy for Severe Endometriosis

INTRODUCTION: Definitive surgical management of severe endometriosis involves excision with hysterectomy and bilateral salpingo-oophorectomy (BSO). Women who are less than 50 years old at the time of BSO have an increased morbidity, including risk of cardiovascular disease, osteoporosis, sexual dysfunction, dementia, and overall mortality. These risks are mitigated by hormone replacement therapy (HRT) use through the average age of menopause. Previous studies show relatively low rates of HRT postoperatively when BSO is performed for all benign indications. HRT use specifically in patients with severe endometriosis is not well studied, and its rate may be lower given perceptions about risks, lack of standard prescribing guidelines, and concerns about endometriosis recurrence. OBJECTIVE: We aim to investigate the rate of HRT use among patients undergoing BSO for severe endometriosis and hypothesize that preoperative counseling increases HRT use postoperatively. Secondarily, we aim to describe rates of recurrent endometriosis symptoms and surgery in those taking postoperative HRT. METHODS: This retrospective cohort study compares patients who used HRT to those who did not after definitive surgical management of severe endometriosis. Patients were included if they were between the ages of 18 and 50 and rendered surgically menopausal for severe endometriosis. Procedures were performed by fellowship-trained minimally invasive gynecologic surgeons at an urban, tertiary care referral center between January 2016 and December 2020. We included HRT use of any systemic estrogen/progesterone combination for any postoperative duration in the HRT group. We excluded patients with medical contraindications to HRT or incomplete records. RESULTS: 140 patients met inclusion criteria. 70% (n=98) used systemic HRT at some point postoperatively, of whom the majority (58.2%, n=57) used systemic estrogen alone, whereas 41.8% (n=41) used estrogen and progesterone. Patients who used HRT were more likely to be younger (38.6±4.9 vs. 40.8±5.8 years, p=0.022) and nulliparous (54.1% vs. 33.3%, p=0.024) compared to patients who did not use HRT. Patients who used HRT were more likely to have been counseled by their surgeon about HRT (93.9% vs. 54.8%, p<0.001) and more likely to be referred to a menopause HRT specialist (69.4% vs. 23.8%, p<0.001). In our multivariable analysis, counseling by surgeon at any time remained a predictor of increased HRT use (OR=4.6, 95% CI 1.1–18.9) when controlling for postoperative menopausal symptoms and referral to a menopause HRT specialist. There were no differences in recurrence of endometriosis symptoms (21.4% vs. 16.7%) or repeat surgery (19% vs. 14%) between patients who did versus did not use HRT. CONCLUSIONS: Patients with severe endometriosis who undergo definitive surgical management with bilateral oophorectomy should be prescribed HRT to mitigate the long-term health effects of surgical menopause. A discussion of HRT perioperatively should be included in the surgeon’s counseling, and when feasible patients should be offered referral to specialists in menopause management. HRT use appears to pose minimal risk of recurrent endometriosis surgery, although more studies are needed (Tables 1 and 2).