Q: Do women benefit from progesterone post-hysterectomy?

You asked whether I’ve seen published evidence that hysterectomized women on estradiol may benefit from micronized progesterone. You’re wondering if treating a hysterectomized woman with “unopposed” estradiol would put her into an “estrogen dominant” situation with some (or all) of those unpleasant symptoms (bloating, constipation, trouble sleeping, weight gain, etc.). 

It’s a great question, and the answer is no: Without a uterus there is no clinical indication to add progesterone, and most women don’t love the effects of progesterone (while on the other hand estrogen is a “woman’s best friend”).

There is some evidence that the progesterone may mitigate some of the estrogen benefits to cardiovascular health. The endometrium is the only target tissue that really needs the “balance of adding progesterone.” I’d say less than 5 percent of my hysterectomy patients are on progesterone; we add it mostly because it can benefit sleep. While for a few women we add it, progesterone can actually contribute to bloating, fluid retention, etc. Our happiest patients are generally those on estrogen alone. 

And the Women’s Health Initiative actually found less breast cancer (vs. placebo) for those on estrogen alone (granted that was premarin, which we use little of now days, and may be not be a fair comparison to estradiol, which we mostly use now). The Women’s Health Initiative also identified a slightly increased risk of breast cancer with estrogen and progesterone (again, this may be due to the provera vs. micronized progesterone that we now use), and the cardiovascular outcomes were a bit better on estrogen alone. 

In summary, I’m not opposed to using micronized progesterone on hysterectomized women, but few actually benefit from it. Estrogen dominance is only a concern for the endometrium, usually in our polycystic ovarian or anovulation pts.

You said you’re asking on your own behalf as well as for the women you serve as a physical therapist. I appreciate what you do to educate women about their health!