Hysterectomy and oophorectomy: Should I use estrogen replacement therapy (ERT)?

Get the facts
Compare your options
What matters most to you?
Where are you leaning now?
What else do you need to make your decision?

1. Get the Facts

Your options

Use estrogen replacement therapy (ERT) after hysterectomy and oophorectomy.
Don't use ERT. Try other treatment for menopause symptoms and to prevent osteoporosis.

Key points to remember

Until menopause, the ovaries make most of your body's estrogen. When your ovaries are removed (oophorectomy) during a hysterectomy, your estrogen levels drop. Estrogen replacement therapy (ERT) replaces some or all of the estrogen that your ovaries would be making until menopause.
Without estrogen, you are at risk for weak bones later in life, which can lead to osteoporosis. ERT lowers your risk by slowing bone thinning and increasing bone thickness.¹
If you are in your 20s, 30s, or 40s, you may want to use ERT to avoid early menopause after oophorectomy. But if you have already gone through menopause, you probably don't need ERT after your ovaries have been removed.
Early menopause can cause hot flashes and other symptoms. ERT lowers the number of hot flashes you have, and it makes them less severe when you do have them.¹ ERT also helps with other early menopause symptoms, such as vaginal dryness and sleep problems.
ERT does have risks, including a slight risk of stroke, blood clots, and breast cancer. But for most women in their 20s, 30s, or 40s who have had their ovaries removed, the benefits of ERT are stronger than these risks.
Instead of ERT, you might try other prescription medicines to help with early menopause symptoms and to prevent osteoporosis. And you may be able to prevent bone thinning if you take vitamin D supplements and eat foods that are rich in calcium.

FAQs

What are hysterectomy and oophorectomy?

A hysterectomy is surgery to remove the uterus. Most of the time, a hysterectomy is done to treat a problem with the uterus, such as heavy menstrual bleeding, uterine fibroids, or endometriosis.

An oophorectomy is surgery to remove the ovaries. Oophorectomy (say "oh-uh-fuh-REK-tuh-mee") may be done because of a growth on one or both ovaries, or to treat severe premenstrual syndrome (PMS), endometriosis, or breast cancer. It may also be done to lower the risk of ovarian cancer.

About half of American women who have a hysterectomy also have their ovaries removed during the same surgery.²

What is estrogen replacement therapy (ERT)?

ERT is the use of man-made estrogen to replace the natural estrogen made by your ovaries. ERT is available as a pill, a skin patch, a vaginal ring, or a skin cream or gel.

Until menopause (around age 50), the ovaries make most of your body's estrogen. When your ovaries are removed, your estrogen levels suddenly drop. This causes early menopause. It can also increase your risk of osteoporosis and bone fractures, because estrogen helps your bones stay strong.

ERT keeps estrogen levels up, which protects against bone thinning and helps prevent menopause symptoms.

If you are in your 20s, 30s, or 40s, you may want to use ERT to avoid sudden early menopause after having your ovaries removed. But if you have already gone through menopause, you probably don't need ERT after an oophorectomy.

What are the benefits of ERT after hysterectomy and oophorectomy?

Estrogen replacement therapy (ERT):

Lowers your risk of osteoporosis. ERT slows bone thinning and helps increase bone thickness.¹
Reduces the number of hot flashes that you have, and it makes them less severe when you do have them.¹
Prevents vaginal dryness and soreness caused by low estrogen.
Slows the loss of skin collagen. Collagen puts the stretch in skin and muscle.
Reduces the risk of dental problems, such as gum disease and tooth loss.
May help sleep problems and moodiness linked to hormone changes.³

What are the risks of ERT?

Estrogen replacement therapy (ERT) increases your risk of:⁴

Stroke. ERT slightly increases the risk of stroke. This means that in 1,000 women over age 60 who use ERT, about 1 extra stroke per year will occur.⁵
Blood clots. Estrogen slightly increases the risk of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism). This means that out of 1,000 women who take ERT, about 1 extra blood clot will occur.⁶ Blood clots can be deadly. This risk is greatest in the first year of ERT use.
Breast cancer. A very large study, called the Million Women Study, shows that in women using ERT for 10 years, the number of breast cancers is slightly higher than normal. Over the 10-year period, about 5 extra breast cancers occurred among every 1,000 women.⁷ Another study found no increase in breast cancer in women who took ERT for 7 years, but experts still take this risk seriously.⁸
Gallstones. Women who use ERT are more likely to have gallstones that cause symptoms. (High estrogen levels are linked to gallbladder disease.)
Dementia. ERT may increase the risk of dementia.

You should not take ERT if:

You have unexplained vaginal bleeding.
You have liver disease or other problems with your liver.
You have breast cancer, ovarian cancer, uterine cancer, or blood clots or have had a stroke.

If a close family relative has had breast cancer, ovarian cancer, a stroke, or blood clots, ERT may not be right for you. Talk with your doctor about the risks and benefits.

What other treatment might you try instead of ERT?

Instead of ERT, you might try other prescription medicines for menopause symptoms.

Antidepressant medicines can lower the number of hot flashes you have. And they can make hot flashes less severe when you do have them. Some women have side effects such as headaches, an upset stomach, and problems sleeping.⁹ It's not clear how safe this medicine is if it's taken for a long time.
Clonidine, a medicine to treat high blood pressure, can also reduce the number and severity of hot flashes.¹⁰ Some women have side effects related to low blood pressure.
Gabapentin (Neurontin), an antiseizure medicine, also lowers the number and severity of hot flashes.¹¹ Possible side effects include sleepiness, dizziness, and swelling.

You might also try black cohosh or dietary soy to manage hot flashes.

To reduce your risk of osteoporosis, eat foods that are rich in calcium, and take vitamin D supplements.

You might also try other medicines to prevent bone thinning. For more information, see the topic Osteoporosis.

Why might your doctor recommend ERT after hysterectomy and oophorectomy?

Your doctor might recommend ERT after hysterectomy and oophorectomy if:

You are in your 20s, 30s, or 40s.
You need treatment to prevent early bone thinning and osteoporosis.

2. Compare Options

	Take estrogen replacement therapy (ERT)	Don't take ERT
What is usually involved?	You take a daily pill, you wear a patch or a vaginal ring, or you use a skin cream or gel. You use ERT until the age of menopause (around 50).	You can try other prescription medicines to help with early menopause symptoms, such as antidepressants, clonidine, or gabapentin (Neurontin). You can try black cohosh or dietary soy for hot flashes. You can take vitamin D supplements and eat foods that are rich in calcium to try to prevent bone thinning, or you can try other prescription medicines.
What are the benefits?	You have a lower risk of osteoporosis. ERT slows bone thinning and helps increase bone thickness.¹ You have fewer hot flashes. And the ones you do have may not be that bad. ERT also helps decrease other menopause symptoms, such as vaginal dryness, sleep problems, and moodiness related to hormone changes.	You may be able to lower your risk of osteoporosis without ERT. You avoid the risks of ERT. You avoid the costs of ERT. If other treatments don't work, you can try ERT later.
What are the risks and side effects?	ERTslightly increases your risk of stroke, blood clots, and breast cancer. Side effects of ERT include breast tenderness, bloating, and upset stomach. ERT may increase your risk of gallstones and dementia. You should not use ERT if: You have unexplained vaginal bleeding. You have liver disease or other problems with your liver. You have breast cancer, ovarian cancer, or uterine cancer.	Other prescription medicines have side effects, such as: Headaches, upset stomach, and problems sleeping (antidepressants). Problems linked to low blood pressure (clonidine). Sleepiness, dizziness, and swelling (gabapentin). You may be at risk for bone thinning and osteoporosis because of the loss of estrogen. Your menopause symptoms may be hard to live with.

Personal stories

Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

For more information, see the topics:

Personal stories about deciding to use estrogen replacement therapy

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"Since having my uterus and ovaries removed, I've been taking ERT. This makes a lot of sense to me, because my ovaries would be producing estrogen until I hit menopause. When I'm the age I'd expect to be menopausal, around age 50, I expect I'll stop or reduce the estrogen I'm taking. That'll depend on what experts recommend by then. "

— Josie, age 35

" I started taking ERT after a radical hysterectomy and spent a number of months struggling with moodiness and feeling depressed. It was probably because of the big changes in hormones after my ovaries were removed. I worked closely with my doctor to make adjustments to my hormone replacement. She replaced the oral estrogen with a patch. Now, I've been doing well for more than 5 years. "

— Carla, age 28

"I took ERT for many years after having my uterus and ovaries removed in my 30s. I figured I'd take it for the rest of my life, since that is what my doctor said I should do. However, I recently heard about the latest research on the risks of taking hormones, and my doctor and I decided that I really don't need to take ERT. If I had risks for osteoporosis and needed the estrogen to keep my bones strong, I'd take a low dose, but I don't have any worries about weak bones. "

— Anna, age 64

"I had a hysterectomy and oophorectomy in my early 40s, but I didn't take ERT because my family has a history of breast cancer that's linked to estrogen. The sudden menopause after having my ovaries removed was pretty bad, but I took really good care of myself with exercise, a good diet, and a lot of tricks for handling hot flashes, and I got through it after a while. "

— Estella, age 58

3. Your Feelings

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to use estrogen replacement therapy (ERT)

Reasons not to use ERT

I need something to help me manage hot flashes and other menopause symptoms.

I think I can handle my menopause symptoms on my own.

More important

Equally important

More important

I feel that the benefits of ERT are worth the risks.

I'm very worried about the risks of ERT.

More important

Equally important

More important

I feel that ERT offers me the best protection against thinning bones.

I think I can reduce my risk for thinning bones without ERT.

More important

Equally important

More important

The thought of using ERT for many years doesn't bother me.

I'm not sure I want to take any medicine for many years.

More important

Equally important

More important

My other important reasons:

More important

Equally important

More important

4. Your Decision

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Using ERT

NOT using ERT

Leaning toward

Undecided

Leaning toward

5. Quiz Yourself

Check the facts.

1. Can ERT lower your risk for osteoporosis?

Yes
No
I'm not sure

You're right. Without estrogen, you are at risk for weak bones later in life, which can lead to osteoporosis. ERT lowers your risk by slowing bone thinning and increasing bone thickness.

2. Is ERT the only way to treat early menopause symptoms and prevent bone thinning?

Yes
No
I'm not sure

You're right. Other prescription medicines may ease menopause symptoms and prevent osteoporosis. And you may prevent bone thinning if you take vitamin D supplements and eat foods that are rich in calcium.

3. For younger women, do the benefits of ERT outweigh the risks?

Yes
No
I'm not sure

You're right. Taking ERT does have risks, including a slight risk of stroke, blood clots, and breast cancer. But for most women in their 20s, 30s, and 40s, the benefits of ERT are stronger than these risks.

Decide what's next.

1. Do you understand the options available to you?

2. Are you clear about which benefits and side effects matter most to you?

3. Do you have enough support and advice from others to make a choice?

Certainty.

1. How sure do you feel right now about your decision?

Not sure at all

Somewhat sure

Very sure

2. Check what you need to do before you make this decision.

Nothing. I'm ready to take action.
I want to discuss the options with others.
I want to learn more about my options.

3. Use the following space to list questions, concerns, and next steps.

References

Citations

Speroff L, Fritz MA (2005). Menopause and the perimenopausal transition. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 621–688. Philadelphia: Lippincott Williams and Wilkins.
American College of Obstetricians and Gynecologists (1999, reaffirmed 2005). Prophylactic oophorectomy. ACOG Practice Bulletin No. 7. Obstetrics and Gynecology, 94(3): 1–7.
Rapkin AJ, et al. (2002). The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders. Current Psychiatry Reports, 4(6): 419–428.
Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321–333.
American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Stroke. Obstetrics and Gynecology, 104(4, Suppl): 97S–105S.
American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Venous thromboembolic disease. Obstetrics and Gynecology, 104(4, Suppl): 118S–127S.
Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419–427.
Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701–1712.
Stearns V, et al. (2003). Paroxetine controlled release in the treatment of menopausal hot flashes: A randomized controlled trial. JAMA, 289(21): 2827–2834.
Pandya KJ, et al. (2000). Oral clonidine in postmenopausal patients with breast cancer experiencing tamoxifen-induced hot flashes: A University of Rochester Cancer Center Community Clinical Oncology Program study. Annals of Internal Medicine, 132(10): 788–793.
Guttuso T Jr, et al. (2003). Gabapentin's effects on hot flashes in postmenopausal women: A randomized controlled trial. Obstetrics and Gynecology, 101(2): 337–345.