Fibroids, Endometriosis, and HRT: Breaking Down the Myths

Added: 2026-05-30

[00:00:00]Hi guys, welcome back to my podcast. I'm Dr. Heather Hirs and today we're going to talk about hormone therapy and hormone therapy and fibroids, hormone therapy and endometriosis. I get constant DMs and questions about the use of menopausal hormone therapy with some of these other gynecologic conditions.

[00:00:20]And I want to break down the myths, the misconceptions, and the truth about using menopausal hormone therapy with either of these things. In today's episode, just a little disclaimer. It's been a very busy day here in New York City. I'm so excited because I'm here to have an event. And if you want to learn about events that I am hosting, definitely get on my email list. You can check the description in the podcast or if you follow me on any social media, get on my email list so that you can learn when more events are happening.

[00:00:51]But if you hear the sounds of New York City in the background in this episode, that's why. If you don't know me or you're new to the podcast, I'm Dr. Heather Hirsch. I've actually been doing this podcast since 2018. And I have been a menopause and midlife specialist for the last oh gosh 12 years or more. And I started my career actually after I completed fellowship training at Cleveland Clinic. During this two very informative years with my mentor, I learned so many of the things that most clinicians were taught about menopausal hormone therapy, its risks and benefits were wrong. And it was actually very disarming to feel that even the education I got at my top-notch residency and even a year of OBGYn residency wasn't really what was fact.

[00:01:40]Now, this is no more prominent than when it comes to hormone therapy and anything. And many clinicians, even though we've moved the needle very far, still are quite fearful about the use of menopausal hormone therapy. Patients really want to feel better, clinicians don't want to put patients at increased risk or harm. In fact, we take the hypocratic oath, do no harm. And one of the things that I find myself saying routinely is that if we do nothing because we don't know what to do, to me that is doing harm. So if you're a proactive woman and you've been thinking about menopausal hormone therapy and you've been told no for these reasons in today's show, I hope you feel armed with information and evidence to bring back to your clinician so that you can take this one step further. Now let's start with fibroids. What is a fibroid? Well, if your uterus is a big bowl, a fibroid is basically a big polip or extra surface area. It can form into the size of something as small as, well, maybe it's not small, but a golf ball up to something like a tennis ball or even bigger. When a fibroid get that big, it can sometimes press on some of your other organs, so can cause constipation or bloating. But many women have very small fibroids.

[00:03:02]When the uterus has increased surface area, that means more surface area that is responsive to hormones, whether that's your own body's hormones or hormones that are given to you, exogenous hormones. So, one of the issues with fibroids is that it can lead to heavier periods or irregular bleeding because again, that increased surface area is responding to your own body's hormones, which are your indogenous hormones. So if we were to go give a woman with fibroids hormone therapy, this may mean that she just may have irregular bleeding and that is okay. Why is it okay? Because it doesn't mean that there's anything wrong. It's just that the reason for the bleeding is because there's increased surface area of the uterus due to these fibroids. And that is the reason for the bleeding.

[00:03:48]Post-menopausal bleeding in and of itself isn't worrisome. So just bleeding alone is not the worry. The worry is that there's something nefarious going on in the uterus like a precancer. And fibroids are a very common reason that many women will have bleeding. So for this reason, the fact that fibroids can increase the risk of bleeding if a woman uses menopausal hormone therapy, some clinicians feel afraid to start that bleeding or that that risk is going to be too much. And so they simply do nothing and they say no, you can't use menopausal hormone therapy. But the fact is is that menopausal hormone therapy has so many known benefits, not just in alleviating the symptoms such as the hot flashes, the night sweats, the vaginal dryness, the brain fog, but also in keeping you healthy for the long term.

[00:04:43]Menopausal hormone therapy when started within 10 years can reduce the risk for heart disease, can reduce the risk for bone loss, and can help you live longer.

[00:04:51]So, simply having a fibroid, which may mean that when you start menopausal hormone therapy, you have some irregular bleeding, does not mean that you should not be able to use menopausal hormone therapy. Just because you or your doctor have more things to do or investigate or think about doesn't mean that you should avoid menopausal hormone therapy. In fact, how could you start this responsibly? Well, if you have known fibroids, know what your ultrasound looks like before you start hormone therapy. Know what the size of your ovaries look like. Sorry, know what the size of those fibroids are because again, if you do have bleeding, you can feel more confident that there's nothing wrong with your uterus, but that maybe the fibroids are in fact the problem.

[00:05:34]Now, a myomectomy is a procedure where fibroids can be removed. Do you need to go that far to start hormone therapy?

[00:05:40]No. Not unless your gynecologist and your surgeon think that it's medically necessary to have the procedure to remove the fibroids. But again, if the problem with starting hormone therapy is that you may have bleeding that needs to be worked up, that should not stop you from the major benefits of doing menopausal hormone therapy. Now, because you have fibroids, that means you still have your uterus, and so you are going to need to take a progesterone with that estrogen. The right amount of progesterone can also help reduce post-menopausal bleeding. Now, what if you and your clinician are worried that your fibroids will grow because of menopausal hormone therapy? I'm here to say after doing this for a decade, we really don't see the use of menopausal hormone therapy increase fibroid size.

[00:06:26]Simply just doesn't happen. The estrogen is too low to actually cause a growth of the fibroid. Now, you know, nothing is impossible and certainly that there could be cases where that has happened.

[00:06:38]But for the vast majority of my patients who have a history of fibroids, the hormone therapy or the estrogen in that hormone therapy is not causing their fibroids to grow. So, I don't feel that that is a concern either. Another reason your doctor may be a little hesitant in prescribing menopausal hormone therapy with fibroids is the concern for maybe having pain. And that's something I also don't routinely see when women take hormone therapy. Again, there shouldn't be any pain if the fibroid is not growing and the fibroid is not active.

[00:07:09]Nor is there an increased risk in those fibroids turning cancerous. In fact, fibroids have a very, very, very low percent of being precancerous or cancerous. But menopausal hormone therapy has not been linked to changing fibroids from benign to cancerous or precancerous. All right, let's move on to hormone therapy and endometriosis. In fact, this is something that I have been getting questions on almost daily.

[00:07:35]Endometriosis is a condition where tissue that is forming the uterine lining that responds to your own body's hormones is outside the uterus. So, it can be on the fallopian tubes, this tissue can be on the ovaries, this tissue can be just in the pelvic bowl.

[00:07:53]Sometimes in very severe cases it can be on your small intestines. I've even seen endometrial tissue in the lungs. What does this mean? Well, every month as women have a period, their estrogen peaks at ovulation and then goes down and then women bleed. And progesterone is the opposite. Progesterone actually goes the lowest at ovulation and then it peaks before your period. This causes the uterus to do that normal cramping which actually helps to expel the menstrual blood. Okay. Now, when that tissue is outside the uterus, that means you feel that cramping or that pain elsewhere. Think of it as like having cramps on steroids. It can be so painful that women with endometriosis miss work, miss school, spend days in bed because the pain is truly debilitating.

[00:08:43]And so because of this, many clinicians have been worried about using menopausal hormone therapy. So now you're a woman.

[00:08:51]Let's say you're in menopause or the very end stages of parmenopause. You're suffering with hot flashes, night sweats, and your doctor says you can't use hormone therapy because you had endometriosis. First of all, why would they say this, right? Same thing with the fibroids. Let's talk this out. Well, perhaps they're worried that it's going to flare the endometriosis because we just talked about what causes the pain, right? It's the rise in estrogen and then the fall and then the balance of the drop in progesterone and the rise in progesterone. And so the thought process is gosh, estrogen made this pain bad before when you were menrating. And a lot of the ways that doctors treat endometriosis is to either stop the fluctuations in hormones by using a birth control pill in many cases or actually stop you from making estrogen at all, which is actually inducing menopause with a medication like Lupron.

[00:09:42]So therefore, wouldn't it seem that giving you estrogen could reintroduce the pain? Well, interestingly, the answer in most clinical cases is no.

[00:09:52]Because post-menopausal estrogen is very, very low and often a steady dose.

[00:09:58]It does not seem to induce the same pain that my patients had in their younger years when they were menstruating when they had endometriosis. And those levels when you are menstruating are much higher. Those fluctuations are much wilder. So the use of post-menopausal estrogen, let's say a lowd dose transdermal patch or gel does not, I repeat, does not seem to induce pain for my patients. We want to do no harm, right? But again, if we say no because maybe it could cause pain or a symptom, but we then can't treat your hot flashes, night sweats, vaginal dryness, we can't prevent bone loss or heart disease. The imbalance is not totally right. you're getting denied major benefits when most women with endometriosis who take menopausal hormone therapy in my clinic do wonderful.

[00:10:48]Now, the addition of progesterone to all women who take menopausal hormone therapy with a history of endometriosis is something that most clinicians are now recommending because the idea is not so much that it will balance the estrogen and then cause less pain, but that if you have endometriosis elsewhere in the body, that balancing the estrogen with the progesterone will keep that endometriosis in general from flaring or going on to in very very very rare cases cause any type of precancer or cancer.

[00:11:21]So, most clinicians are now in agreement that if you as a patient had endometriosis in your history, if you're taking menopausal hormone therapy, take estrogen and progesterone. Now, you might think, of course, I should do that because I know that I need to take progesterone with estrogen if I have an intact uterus. But many women with a history of endometriosis end up with hysterctomies.

[00:11:44]Why? That's also the surgical treatment for endometriosis because the uterus is causing so much pain with every period. If we can take the uterus out if you're no longer of childbearing age or you simply just decide that that benefit is worth it for you, you may not have a uterus. And you may have heard me say many times that if you don't have a uterus, you don't need to take progesterone. But endometriosis, having that history is one indication.

[00:12:13]as a very astute clinician that we should just prescribe you progesterone with your estrogen even if you've had a surgical procedure like a hysterctomy.

[00:12:23]This can reduce flares or worries about that endometrial implants elsewhere in your body causing anything nefarious.

[00:12:30]So I want to make it clear. If you have a history of endometriosis, you are still a candidate for menopausal hormone therapy. And in fact, it can make your quality of life so much better even after you have spent probably decades suffering with severe pain. It is not fair for you then to have to suffer through permenopause and suffer through menopause. Menopausal hormone therapy since it's such a low dose does not seem to induce pain.

[00:12:58]And again, we recommend that you take a progesterone with your estrogen, even if you do or don't have your uterus. So, in this episode so far, we've discussed two main reasons, two gynecologic reasons why many women are denied menopausal hormone therapy, and they end up in my messages in my DMs asking me if this is true. And in fact, in both of these gynecology conditions, both fibroids and endometriosis, you can absolutely safely use estrogen. and then a progesterone.

[00:13:29]In both cases, estrogen progesterone is absolutely recommended. So, the message here is clear. Be proactive. Keep listening to podcast, shows, and books that help you stay informed. Work with your clinician to ensure that they're meeting your health goals. And I hope that in this episode, I've given you some thought process as to why your clinician may be worried about giving you menopausal hormone therapy. Right?

[00:13:54]With the fibroids, it's a worried that you might bleed or you might be in pain or it might increase the risk of cancer.

[00:14:00]And those things are not true. And with endometriosis, it may be again that menopausal hormone therapy. And with endometriosis, again, it may be that they're worried it's going to cause pain or it's going to cause um you to have um precancerous conditions um or just that it's it's going to lead to bloating or those symptoms again. And again, in my 12 plus years of doing menopausal hormone therapy in both women with fibroids and women with endometriosis, my patients excel. They do really, really well, and they deserve to get the benefits of menopausal hormone therapy, have their symptoms treated, and get their long-term health benefits. So, if this is you, I hope this episode has been helpful. If this episode doesn't necessarily pertain to you, but you're a clinician and you want to learn more, check out the Academy for Advanced Women's Health Medicine, cuz that's where I talk about this in depth. For my women who have a sister with fibroids, a daughter with endometriosis, a neighbor with both of these conditions, send this episode to them. Send it to somebody who you think it could help benefit them.

[00:15:07]And the message of mine is always clear.

[00:15:10]All women deserve a consultation for menopausal hormone therapy. The vast majority of women are excellent candidates for menopausal hormone therapy. I hope this podcast has been really helpful, especially if you're one of these women with either of these conditions. If this doesn't necessarily apply to you, send it to your neighbor who has maybe a history of endometriosis or your daughter or your friend who has a fibroid because I want them to feel armed and educated with evidence-based information. If you're a clinician listening to this show and you want to feel more confident in prescribing to women who are complex or have other gynecologic issues, definitely check out the Academy for Advanced Women's Health Medicine. My flagship course, how to prescribe and manage hormone therapy with ease and confidence will give you everything that you need to truly feel great prescribing menopausal hormone therapy to your patients with the utmost confidence. Now, I hope this podcast has been really helpful. I'm here filming in New York City and there's been a lot of activity today. So, I hope the background noise doesn't make you too anxious. And thank you so much for listening in. I hope you really enjoyed the show. Again, send it to somebody who will benefit and I'll see you next week for a brand new episode. Bye, guys.