Post-excision surgery: Is hormonal therapy right for you?

This conversation comes up again and again in my practice. My counseling may be a little different from mainstream, so I’m sharing some thoughts with you.

Hormonal treatment may be different if you have had fertility sparing surgery vs. if you have had a hysterectomy or if your ovaries have been removed.

We know that endometriosis is a hormonally driven disease, in part. Thus, medical efforts to control it have usually centered around use of hormone therapy. The typical options are:

Combination birth control (OCP)

Progestin-only birth control (POP)

Progestin IUD, Implantable (Nexplanon) or injection (Depo-Provera).

Norethindrone (a strong synthetic progestin)

Others of note include GnRH analogs and Danazol.

Hormones that have not been as well studied are the bio-identical ones like Progesterone and Testosterone.

The literature mostly suggests that using OCP, POP or IUD will slightly help decrease return of symptoms after excision, so that is what we traditionally offer. The problem is that for some people, the side-effect profile of the synthetic hormones is intolerable. I have seen severe depression, headaches, unbearable cramping, decreased libido and nausea (among other things).

So, my first-line is still to offer an IUD, such as Mirena, however we have the important conversation about what has been tried before and what has been helpful. If none of our usual armamentarium is going to work, I consider bioidentical progesterone with the caveat that it does not work as a contraceptive. We also don’t have as much data on bioidentical hormones simply because you cannot patent them and companies cannot make as much money from marketing them or researching them. But in over 2 decades of working with them I see a much better side-effect, tolerance, profile. I am now also seriously considering the use of topical testosterone or pellets when appropriate.

If you have had hysterectomy and are menopausal from age or from removing your ovaries, usually you will be offered estrogen. Typically, after hysterectomy, providers only give estrogen therapy, however if you also have endometriosis, I strongly encourage the addition of progesterone. This is partly theoretic. My concern is the small risk of malignant transformation of endometriosis in later years. I have seen this most often in patients with a history of endometriosis who are on estrogen-only therapy following hysterectomy.

-Shanti Mohling, MD