Link between HRT, fibroids and endometriosis

Q: Is it safe to opt for Hormone Replacement Therapy when one has fibroids or endometriosis?

A. Fibroids are muscular growths of the uterus which are usually non-cancerous.

Many of us (30 per cent of women) probably have fibroids but we may only learn about it if we go for an ultrasound examination, or have problems such as heavy, irregular menses.

Endometriosis, on the other hand, is a condition where the lining of the uterus is found outside the uterus, i.e. on the tubes, the ovaries and other pelvic areas.

These areas also bleed during menstruation, causing a collection of blood on the ovary (cyst) or inflammation/scarring between tissues behind the uterus and around the pelvic areas.

Endometriosis can cause pain, irregular periods and infertility.

Both fibroid and endometriosis feed on oestrogen hormones and can grow bigger/worse between the ages of 20 and 45.

After menopause, fibroids usually shrink and problems of endometriosis settle down.

Hormone Replacement Therapy (HRT) is prescribed for women experiencing bad menopausal symptoms to balance their declining oestrogen levels.

The type of HRT administered depends on whether her uterus is intact.

Both oestrogen and progesterone are given if the uterus is intact while only oestrogen is given if the uterus has been removed.

The amount of oestrogen in HRT is too low to cause an increase in the size of fibroids.

Small, asymptomatic fibroids are not a contradiction to starting HRT.

However it would be wise to monitor the size if the fibroids are large.

The increase (if any) is usually noted within three to six months of starting HRT.

HRT given in the form of patches and gels have been shown to increase fibroid size to a greater extent than oral HRT.

The treatment for endometriosis usually consists of surgery and medication (either injections or tablets) to decrease a woman's oestrogen levels, making her "pseudo menopaused".

As the main surgery for severe endometriosis consists of removal of uterus and both ovaries (pushing the woman to an earlier menopause), the use of HRT becomes an important issue.

HRT in the form of "only oestrogen" is contraindicated even though she has no uterus.

A combination of oestrogen and progesterone is usually safer and sometimes only given after three to six months.

This is to balance her menopausal symptoms and to prevent the recurrence of endometriosis. These women need to be monitored carefully for signs of recurrence.

Tibolone is an alternative as it helps symptoms of menopause and does not stimulate endometriosis left behind.

Dr Premitha Damodaran is a consultant obstetrician and gynaecologist with Pantai Hospital Kuala Lumpur.