USMC-Arlington Cemetary WreathsThe Mortality Toll of Estrogen Avoidance
by Jeffrey Dach MD

According to a Dr Philip Sarrel in a Yale study, 50,000 women died needlessly because of fear and avoidance of estrogen replacement after their hysterectomy.(3)  This Yale study made the headlines in Time Magazine and the LA Times declaring that 50,000 women’s lives could have been saved.(3,4)    Hysterectomy renders women estrogen deficient, which is a severe heath risk, leading to increased mortality.  Above Left Image Arlington Cemetary courtesy of wikimedia commons.

Philip Sarrell

The Mortality Toll of Estrogen Avoidance Yale University-
Published on Jul 18, 2013.

Watch this Video from Philip M. Sarrel, MD professor OB/Gyne Yale Medical School,  saying: “Estrogen therapy has been widely misunderstood, and may offer important benefits to women in their 50s who have had a hysterectomy.”

This information is not new. For many years now, many studies have shown reduced mortality as well as other health benefits of bioidentical hormones after hysterectomy.

Bioidentical Estrogen Hormones Reduce Mortality After Hysterectomy

OBGYN surgeon performing hysterectomyDr. Parker’s study followed 30,000 women for 24 years after their hysterectomy.  Half the patients had their ovaries removed and the other half had their ovaries preserved.  The group with their ovaries removed had a higher all cause mortality rate, and therefore Dr. Parker  recommended that women preserve the ovaries in the Pre-Menopausal age group.  Dr Parker also found that post-operative hormone replacement is very beneficial at reducing heart disease risk. (1)

In a second study, Dr Cathleen Rivera followed 1,000 Pre-Menopausal women (under age 45) after hysterectomy, and found that removal of the ovaries resulted in a disturbing 84% increase in death from heart disease.  However, if these women were given estrogen replacement after ovarian removal, they were protected with a 35% decrease in mortality from heart disease.(2)  I thought this was rather impressive.

Pregnant Horse Urine PremarinSecond Arm of Women’s Health Initiative-
Premarin Only for Women After Hysterectomy

The Second Arm of the Women’s Health Initiative showed reduced mortality in the Estrogen users after hysterectomy.  The women were in the 50-59 year age group, and the form of estrogen used in the study was Premarin, derived from pregnant horse urine. The study showed an impressive 27% reduction in mortality with Estrogen use.   This is amazing !

So what does this mean?  This means estrogen replacement for post-hysterectomy women is very beneficial, and denying women estrogen replacement caused 50,000 needless deaths.  Left Image: Pregnant Horse source of Premarin courtesy of wikimedia commons 

Here is the quote from the 2011 JAMA publication of the Women’s Health Initiative (8):

“Younger postmenopausal women (aged 50-59 years) who were randomized to Premarin estrogen (CEE) vs. placebo had a lower risk of death (0.35% [n = 65] vs 0.48% [n = 89], respectively; HR, 0.73″   Note: HR is Hazard Ratio.  This represents a 27% decrease in mortality for the estrogen users compared to placebo users (8)

Avoid Synthetic Hormones

Of course, women should avoid Progestins and other synthetic hormones such as medroxyprogesterone (MPA), known to be carcinogenic from the First Arm WHI data.   The use of natural bioidentical estrogen and progesterone in the proper balance is the preferred choice.  Bioidentical hormones are not chemically altered, having chemical structures identical to our own hormones, in ourselves.

Risks and Adverse Side Effects of Estrogen Excess-Estrogen Dominance

When used correctly, estrogen replacement is safe and beneficial.  However Estrogen Excess or Progesterone Deficiency can cause adverse effects, and represent a health risk.  This is called Estrogen Dominance which is to be avoided. This is the reason it is important to seek out a knowledgeable and experienced physician to prescribe and monitor your bioidentical hormone program.


Even though it has been known for decades that Estrogen Deficiency after hysterectomy is a health risk, and associated with increased mortality,  our misguided medical system has been denying estrogen replacement to thousands of women, causing needless suffering and increased mortality.  Over the past decade, we have quietly and diligently worked to counter this trend by prescribing Bioidentical Hormones to every woman who requests hormone replacement.  That has been our mission.

Articles with Related Interest:

Bioidentical Hormones Found Beneficial After Hysterectomy

Bioidentical Hormones Prevent Osteoarthritis

Bioidentical Hormones Prevent Heart Disease

The Safety of Bioidentical Hormones

The Importance of Bioidentical Hormones


Obstet Gynecol. 2009 May;113(5):1027-37.
Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study. Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, Shoupe D, Berek JS, Hankinson S, Manson JE. John Wayne Cancer Institute at Saint John’s Health Center, Santa Monica, California 90401, USA. Comment in:

OBJECTIVE: To report long-term health outcomes and mortality after oophorectomy or ovarian conservation.

METHODS: We conducted a prospective, observational study of 29,380 women participants of the Nurses’ Health Study who had a hysterectomy for benign disease; 16,345 (55.6%) had hysterectomy with bilateral oophorectomy, and 13,035 (44.4%) had hysterectomy with ovarian conservation. We evaluated incident events or death due to coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolus, and death from all causes.

RESULTS: Over 24 years of follow-up, for women with hysterectomy and bilateral oophorectomy compared with ovarian conservation, the multivariable hazard ratios (HRs) were1.12 (95% confidence interval [CI] 1.03-1.21) for total mortality1.17 (95% CI 1.02-1.35) for fatal plus nonfatal CHD, and 1.14 (95% CI 0.98-1.33) for stroke. Although the risks of breast (HR 0.75, 95% CI 0.68-0.84), ovarian (HR 0.04, 95% CI 0.01-0.09, number needed to treat=220), and total cancers (HR 0.90, 95% CI 0.84-0.96) decreased after oophorectomy, lung cancer incidence (HR=1.26, 95% CI 1.02-1.56, number needed to harm=190), and total cancer mortality (HR=1.17, 95% CI 1.04-1.32) increased.

For those never having used estrogen therapy, bilateral oophorectomy before age 50 years was associated with an increased risk of all-cause mortality, CHD, and stroke. With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.

CONCLUSION: Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer. In no analysis or age group was oophorectomy associated with increased survival.

Menopause. 2009 Jan–Feb; 16(1): 15–23.
Increased cardiovascular mortality following early bilateral oophorectomy
Cathleen M. Rivera, MD,1 Brandon R. Grossardt, MS,2 Deborah J. Rhodes, MD,1 Robert D. Brown, Jr., MD, MPH,3 Véronique L. Roger, MD, MPH,4,5 L. Joseph Melton, III, MD, MPH,5 and Walter A. Rocca, MD, MPH3,5

We conducted a cohort study with long-term follow-up of women in Olmsted County, MN, who underwent either unilateral or bilateral oophorectomy before the onset of menopause from 1950 through 1987. Each member of the oophorectomy cohort was matched by age to a referent woman from the same population who had not undergone any oophorectomy. We studied the mortality associated with cardiovascular disease in a total of 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy, and 2,383 referent women.

Results: Women who underwent bilateral oophorectomy before age 45 years experienced anincreased mortality associated with cardiovascular disease compared with referent women (HR, 1.44; 95% CI, 1.01–2.05; P = 0.04).

Within this age stratum, the HR for mortality was significantly elevated in women who were not treated with estrogen through age 45 years or longer (HR, 1.84; 95% CI, 1.27–2.68; P = 0.001) but not in women treated (HR, 0.65; 95% CI, 0.30–1.41; P = 0.28; test of interaction, P = 0.01). Mortality was further increased after excluding deaths associated with cerebrovascular causes.

Conclusions: Bilateral oophorectomy performed before age 45 years is associated with increased cardiovascular mortality, especially with cardiac mortality. However, estrogen treatment may reduce this risk.

From a clinical perspective, our findings suggest that women who underwent bilateral oophorectomy at a young age are at increased risk of cardiovascular death, especially of cardiac death. This increased mortality may be attenuated by adequate estrogen treatment. Our findings provide new evidence to guide the individualized assessment of the risks and benefits of prophylactic bilateral oophorectomy in young women.1,4–6,8,14 This preventive practice currently involves approximately 4.5 million women older than 55 years living in the United States who have undergone bilateral oophorectomy before reaching natural menopause.28,34

In addition, our findings provide observational evidence for a long-term cardiovascular protective effect of estrogen either naturally produced by the ovaries or given as treatment to women who underwent bilateral oophorectomy at younger ages. These findings emphasize the importance of estrogen treatment after the surgery.6,9–14

We focused our analyses on age at estrogen deficiency rather than on the length of estrogen treatment after the surgery to study the combined effects of age at the surgery and length of treatment.

Several studies have shown increased cardiovascular mortality in women who experienced early menopause (before age 45 years) from either natural or medical causes,35–40 and a statistical model has linked prophylactic bilateral oophorectomy before age 65 years with an increase in overall mortality and coronary heart disease mortality.1,4,5

Similarly, in the Women’s Health Initiative Observational Study, hysterectomy plus oophorectomy performed over a broad age range was a significant predictor of cardiovascular disease during a short-term follow-up.28

Recent analyses from the Women’s Health Initiative Coronary Artery Calcium Study showed an increased risk of subclinical coronary artery disease in women who underwent both hysterectomy and bilateral oophorectomy and were not treated with estrogen compared to women who underwent hysterectomy alone. The increased risk was independent of traditional cardiovascular risk factors.12

Our results for estrogen treatment after bilateral oophorectomy are consistent both with findings from previous clinical studies40–44 and with findings from animal studies. Primates who underwent premenopausal oophorectomy and did not receive exogenous estrogen had significantly accelerated atherosclerosis compared with those that did not have oophorectomy

This study showed that women who underwent early bilateral oophorectomy are at increased risk of death involving cardiovascular disease, especially cardiac diseases. However, treatment with estrogen through age 45 years or longer may reduce this risk. These findings, in conjunction with the results of other studies,1,4,5,8 have important clinical implications and should prompt a reassessment of prophylactic bilateral oophorectomy in premenopausal women.6,14


American Journal of Public Health. Accepted on: Feb 18, 2013 The Mortality Toll of Estrogen Avoidance: An Analysis of Excess Deaths Among Hysterectomized Women Aged 50 to 59 Years.  Philip M. Sarrel, MD, Valentine Y. Njike, MD, MPH, Valentina Vinante, MD, and David L. Katz, MD, MPH

Objectives. We examined the effect of estrogen avoidance on mortality rates among hysterectomized women aged 50 to 59 years.
Methods. We derived a formula to relate the excess mortality among hysterectomized women aged 50 to 59 years assigned to placebo in the Women’s Health Initiative randomized controlled trial to the entire population of comparable women in the United States, incorporating the decline in estrogen use observed between 2002 and 2011.
Results. Over a 10-year span, starting in 2002, a minimum of 18 601 and as many as 91 610 postmenopausal women died prematurely because of the avoidance of estrogen therapy (ET).
Conclusions. ET in younger postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall. Our data indicate an associated annual mortality toll in the thousands of women aged 50 to 59 years. Informed discussion between these women and their health care providers about the effects of ET is a matter of considerable urgency. (Am J Public Health. Published online ahead of print July 18, 2013:)

Time Magazine


Hormone-Replacement Therapy: Could Estrogen Have Saved 50,000 Lives?
By Alexandra Sifferlin July 20, 201316
Dr. Philip Sarrel, professor emeritus of obstetrics, gynecology and reproductive sciences at Yale University School of Medicine and lead author of the study, said in a video discussing the study that none of these women, who were aged 50 to 59 at the start of the study, lived to reach their 70s. Most died of heart disease, bolstering the connection that earlier studies had found between estrogen-only therapy and a lower risk of heart problems among women who had a hysterectomy.
Read more:

LA Times


Avoiding estrogen therapy proved deadly for nearly 50,000: study
By Eryn Brown This post has been updated. See below for details.
July 18, 2013, 3:44 p.m.

Huffington Post


Huffington Post – David Katz, M.D. Director, Yale Prevention Research Center
Estrogen and Evidence  Posted: 07/23/2013 2:48 pm

Web MD


Did Avoidance of Hormone Therapy Harm Certain Women?
For older women without a uterus, estrogen may save lives, researchers say
The use of hormone therapy — both estrogen-only and the combination of estrogen plus progestin — declined greatly after the U.S. Women’s Health Initiative Study found in 2002 that combination therapy had ill effects, including an increase in breast cancer, heart disease, stroke and blood clots. Prescriptions for both regimens plummeted even though the research didn’t apply to women without a uterus or to women on estrogen-only therapy, said Sarrel, who is a consultant for Noven Therapeutics, which makes an estrogen patch.

They found that use of estrogen-only therapy in U.S. women aged 50 to 59 declined nearly 79 percent between 2001 and 2011.
During that time, at least 18,000 excess deaths occurred because of estrogen avoidance and possibly more than 91,000, depending on the calculations used, Sarrel’s team said. For this reason, their best estimate — of about 50,000 deaths — may be conservative, said Sarrel.




April 6, 2011, Vol 305, No. 13  Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women With Prior HysterectomyA Randomized Controlled Trial FREE  Andrea Z. LaCroix, PhD; Rowan T. Chlebowski, MD, PhD; JoAnn E. Manson, MD, DrPH; Aaron K. Aragaki, MS; Karen C. Johnson, MD, MPH; Lisa Martin, MD; Karen L. Margolis, MD, MPH; Marcia L. Stefanick, PhD; Robert Brzyski, MD, PhD; J. David Curb, MD, MPH; Barbara V. Howard, PhD; Cora E. Lewis, MD, MSPH; Jean Wactawski-Wende, PhD; for the WHI Investigators

The HRs for total mortality and the global index of chronic diseases differed by age as previously suggested.7

Younger postmenopausal women (aged 50-59 years) who were randomized to CEE vs placebo had a lower risk of death (0.35% [n = 65] vs 0.48% [n = 89],
respectively; HR, 0.73 [95% CI, 0.53-1.00]) compared with no increased risk among women in their 60s (1.00% [n = 254] vs 0.96% [n = 253], respectively;
HR, 1.04 [95% CI, 0.88-1.24]), and a slight increased risk of death among women in their 70s (2.02% [n = 258] vs 1.83% [n = 239], respectively; HR, 1.12 [95% CI, 0.94-1.33]; P = .04 for interaction). A similar pattern was observed by age for women randomized to CEE vs placebo for the global index of chronic diseases with a possible overall benefit among younger women (aged 50-59 years: 1.04% [n = 184] vs 1.22% [n = 217], respectively; HR, 0.85 [95% CI, 0.70-1.03]) and possible harm among the oldest women (aged 70-79 years: 4.04% [n = 466] vs 3.56% [n = 423], respectively; HR, 1.15 [95% CI, 1.01-1.32]; P = .009 for interaction).
Dr. Tim Bilash Announces New Findings Refuting Previous Studies on Hormone Replacement Therapy, Offers Free Consultations
Dr. Timothy Bilash, MD’s has announced his new research findings that refute a 2002 WHI study that post menopausal women should not take estrogen.


Bioidentical Hormones could have saved 50,000 Lives according to Dr. Philip Sarrel

Dr Cathleen Rivera followed 1,000 Pre-Menopausal women (under age 45) after hysterectomy, and found that removal of the ovaries resulted in a disturbing 84% increase in death from heart disease.  However, if these women were given estrogen replacement after ovarian removal, they were protected with a 35% decrease in mortality from heart disease. I thought this was rather impressive.

The 2nd arm of the Women’s Health Initiative also showed reduced mortality in the estrogen users (50-59 yrs) after hysterectomy.  They showed a 27% reduction in mortality with estrogen use.  So this supports the hypothesis that estrogen deficiency is associated with increased mortality and other health risks, while estrogen replacement for post-hysterectomy women is very beneficial.  Of course, women should avoid Progestins and other synthetic hormones such as medroxyprogesterone (MPA) which is known to be carcinogenic from the First Arm WHI data.   The use of natural, bioidentical estrogen and progesterone in the proper balance is the preferred choice.  Bioidentical hormones are not chemically altered, having chemical structures identical to our own hormones, naturally occurring in ourselves.

for more:

Jeffrey Dach MD
7450 Griffin Road Suite 180/190
Davie, Florida 33314

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