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Risk Factors Explained · Reviewed by CION Oncologists · NABH Accredited
Oestrogen-Only HRT and Endometrial Cancer Risk
This page needs a precise headline rather than a scary one, because the imprecise version does real harm. The endometrial risk attaches to oestrogen given without a progestogen, to a woman who still has her uterus. It does not attach to HRT in general. Combined preparations — oestrogen with a progestogen — include that progestogen for exactly this reason, and with it the excess endometrial risk is largely removed. Women who stop appropriate combined HRT out of a general fear of “hormones and cancer” give up genuine benefit for a risk they were never carrying.
- The risk is about oestrogen alone — given to a woman who still has a uterus
- The progestogen is the protection — that is its entire purpose in a combined preparation
- After hysterectomy, oestrogen alone is correct — there is no endometrium to protect
- Risk rises with duration — which is why long-term unopposed use is the concern
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Which Arrangement Are You In?
The whole of this page reduces to one question: do you still have your uterus, and does your HRT include a progestogen? Four combinations, and only one of them is a problem.
| Uterus | Preparation | Position |
|---|---|---|
| Intact | Oestrogen + progestogen | Correct and standard. The progestogen opposes the effect of oestrogen on the lining, and the excess endometrial risk is largely removed. This is what most women with a uterus are and should be taking. |
| Intact | Oestrogen + hormone-releasing device | Also correct. The device delivers the progestogen directly to the lining at high local concentration, with less reaching the rest of the body. A well-established route for the progestogen component. |
| Intact | Oestrogen alone | This is the situation the page is about. Sustained unopposed stimulation of the endometrium, with risk of hyperplasia and carcinoma rising with duration of use. It should be clarified with your prescriber rather than continued. |
| Removed (hysterectomy) | Oestrogen alone | Correct. There is no endometrium to protect, so no progestogen is needed — and adding one unnecessarily has its own downsides. Oestrogen alone is the appropriate treatment after hysterectomy. |
How to check in two minutes: look at the name on your prescription or the packet. If it lists two hormones, or if you have a hormone-releasing intrauterine device fitted, you have progestogen cover. If it lists oestrogen only — and you have not had a hysterectomy — ask the prescriber directly. Occasionally a progestogen was stopped, or a device was removed and never replaced, and nobody joined the dots.
Did You Know? The link between unopposed oestrogen and endometrial cancer is one of the clearest cause-and-effect stories in cancer epidemiology, and it was learned the hard way. When oestrogen-only preparations came into wide use for menopausal symptoms in the 1960s and 1970s, rates of endometrial cancer rose sharply in the populations using them. When the connection was recognised and a progestogen was added for women with a uterus, the rates fell again. Few risk factors have been demonstrated so plainly by their own removal. It is the reason the progestogen component is not treated as optional, and the reason the arrangement is checked against whether a woman has had a hysterectomy. Sources: NICE guideline NG23 on menopause: diagnosis and management; British Menopause Society guidance on HRT; International Agency for Research on Cancer monographs on hormonal contraception and postmenopausal hormone therapy; NCCN Clinical Practice Guidelines in Oncology — Uterine Neoplasms.
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What the Risk Actually Looks Like
Some proportion is worth putting on this, without pretending to a precision the evidence does not support.
- Risk rises with duration. Short-term unopposed use carries considerably less risk than years of it. This is a cumulative-exposure mechanism, so how long matters more than the fact of any exposure at all.
- Hyperplasia comes first. Unopposed oestrogen produces endometrial hyperplasia well before it produces cancer, and hyperplasia is detectable and treatable. This is why bleeding on HRT is investigated rather than watched.
- Adding a progestogen largely removes the excess. The protection is not partial or theoretical. It is the reason combined preparations exist and it works.
- Local vaginal oestrogen is a different matter. Low-dose oestrogen used vaginally for dryness and atrophy acts locally, with minimal systemic absorption, and is generally not regarded as carrying the endometrial risk described here. It is also badly under-used for a very treatable problem.
And the balancing point that belongs on this page: HRT relieves menopausal symptoms effectively and has benefits for bone health, and the decision to take it involves several considerations of which endometrial risk is only one. The right response to this page is to check what you are taking — not to stop it.
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Check the Prescription. Do Not Stop the Treatment.
The problem is a specific arrangement, not hormone therapy in general — and stopping appropriate HRT out of fear costs real benefit.
When to Raise It With Your Doctor
Four situations in which the arrangement should be reviewed. None of them is a reason for alarm; all are reasons for a conversation.
You have a uterus and are on oestrogen alone
The core situation. It sometimes arises because a progestogen was stopped for side effects and never replaced, because a hormone-releasing device expired without being renewed, or because a prescription was issued without the surgical history being checked. Whatever the reason, it should be corrected rather than continued, and the correction is usually straightforward.
You are bleeding outside the expected pattern
Bleeding on HRT is often expected, which is exactly why real problems get waved through. Bleeding that starts after months of none, that persists beyond about six months on a continuous regimen, or that changes from an established pattern should be assessed rather than attributed. See bleeding while on HRT.
Your hormone-releasing device is due for renewal
If the device is providing your progestogen cover, it needs replacing on schedule. Once it stops delivering, the oestrogen becomes unopposed even though the prescription has not changed on paper — and nothing about your medication list would show it. This is an easy thing to lose track of over several years.
You had a hysterectomy but the cervix was left in place
A subtotal hysterectomy removes the body of the uterus and leaves the cervix. Some endometrial tissue can remain, so whether progestogen cover is needed is a judgement rather than an automatic no. If you are unsure exactly which operation you had, it is worth establishing from the records rather than assuming.
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Keeping This in Proportion
Pages about hormones and cancer cause a predictable harm: women stop treatment that was helping them, for a risk they were not carrying. So the balance deserves stating explicitly.
- Combined HRT is not what this page is about. If your preparation includes a progestogen, or you have a hormone-releasing device, the endometrial risk described here has been addressed.
- Menopausal symptoms are worth treating. Hot flushes, disrupted sleep and the cognitive and mood effects of the transition are not trivial, and HRT is effective for them. This is especially true after surgical menopause, where the change is abrupt and the long-term stakes for bone and cardiovascular health are higher.
- There are other considerations either way. Breast risk, cardiovascular factors, timing relative to the menopause and your own symptom burden all belong in the decision. Endometrial risk is one input, and in a woman on a combined preparation it is not the deciding one.
- Never stop prescribed HRT on the strength of a web page. Including this one. If something here has raised a question, bring it to the person who prescribed it — that is what the page is for.
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Common questions
Oestrogen-Only HRT & Endometrial Cancer — Frequently Asked Questions
Does HRT cause endometrial cancer?
Not HRT in general — the risk attaches specifically to oestrogen given without a progestogen to a woman who still has her uterus. That arrangement produces sustained unopposed stimulation of the endometrium and substantially raises the risk of hyperplasia and endometrial cancer, with risk increasing the longer it continues. Combined preparations include a progestogen for exactly this reason, and with it the excess endometrial risk is largely removed. If your HRT lists two hormones, or if you have a hormone-releasing intrauterine device providing the progestogen, this risk has been addressed. After a hysterectomy, oestrogen alone is the correct and appropriate treatment.
Why do I need a progestogen if I still have my uterus?
Because oestrogen tells the lining of the womb to grow, and progesterone is what tells it to stop. Without that opposition the lining proliferates continuously rather than maturing and shedding, which over time produces endometrial hyperplasia and can lead to cancer. The progestogen component is therefore not an optional extra or a matter of tolerability — it is the endometrial protection. It can be delivered as tablets, as part of a combined patch, or by a hormone-releasing intrauterine device, and the choice between those routes is about side effects and convenience rather than about whether protection is needed at all.
I have a uterus and I am on oestrogen only. What should I do?
Contact the person who prescribed it and ask about it directly — but do not simply stop the treatment on your own. This situation sometimes arises innocently: a progestogen was stopped because of side effects and never replaced, a hormone-releasing device expired without being renewed, or a prescription was issued without the surgical history being checked. The correction is usually straightforward, and it may involve adding an oral progestogen, switching to a combined preparation, or fitting a device. Depending on how long the unopposed exposure has continued, an ultrasound and possibly a sample of the lining may be advised as well.
Is vaginal oestrogen for dryness the same risk?
No, and this distinction matters because vaginal oestrogen is considerably under-used for a very treatable problem. Low-dose oestrogen applied vaginally as a cream, pessary or ring acts locally on the vaginal tissues with minimal absorption into the bloodstream, and is generally not regarded as carrying the endometrial risk associated with systemic unopposed oestrogen. It is highly effective for the dryness, discomfort and urinary symptoms that follow the menopause, and many women endure those symptoms unnecessarily because they have conflated local treatment with systemic HRT. If dryness is affecting you, it is worth asking about.
Should I stop my HRT after reading this?
No — and stopping appropriate treatment out of a general fear of hormones is a real and common harm. The action this page calls for is checking, not stopping. Look at your prescription: if it includes a progestogen, or you have a hormone-releasing intrauterine device, the risk described here has been addressed and nothing needs changing. If you have had a hysterectomy, oestrogen alone is correct. The only situation warranting action is having an intact uterus and taking oestrogen without progestogen cover, and even then the response is a conversation with your prescriber rather than abruptly stopping. Menopausal symptoms are worth treating, and HRT treats them effectively.
Medical disclaimer: This page explains the endometrial risk associated with unopposed oestrogen therapy and is reviewed by a CION oncologist, following NICE guidance on menopause, British Menopause Society guidance, and current NCCN guidance. It concerns oestrogen given without a progestogen to a woman with an intact uterus, not hormone replacement therapy in general. It is general health information rather than advice about your own treatment. Do not stop or change prescribed HRT on the basis of this page — raise any question with the clinician who prescribed it.