Hormone Replacement Therapy
Bilateral oophorectomy (removal of the ovaries) induces surgical premature menopause. Surgical menopause is a permanent state and is an acute deficiency of the hormones normally produced by the ovaries.
Without replacing these hormones, most women are likely to develop severe symptoms of oestrogen deficiency and can also develop female androgen deficiency. Consequently, they are at increased risk of developing conditions such as osteoporosis, cardiovascular disease and cognitive decline.
Hormone replacement therapy (HRT) is the most effective treatment. Yet many women are often not provided with factual, up to date evidence based information that outlines the benefits and risks of taking HRT, thus not giving them the opportunity to make an informed choice.
Unfortunately, many women who are struggling with menopausal symptoms are too frightened to take HRT. This is largely due to the Women’s Health Initiative Study in 2002 which boldly stated that HRT gives you breast cancer, the resulting headlines understandably spread fear and caused many women to throw their HRT away.
The study has since been criticised for failing to meet research study criteria and new research shows that taking oestrogen-only HRT following surgical menopause in fact reduces the risk of heart disease, bowel cancer, fractures, breast cancer, strokes and improves bone health.
For women who have had cancer, HRT is often dismissed as an option entirely but this should be assessed on a case by case basis.
Anyone with a history of cancer should seek specialist advice from their oncologist and a menopause specialist to create an individual plan that takes account of quality of life factors.
Our interviews with Dr Hannah Short and Diane Danzebrink offer helpful advice and suggestions regarding cancer and menopause. It is important to inform yourself with the facts and be your own advocate.
Oestrogen
Oestrogen replacement
Oestrogen replacement is available in the form of tablets, transdermal patches, gels and sprays.
For some women in surgical menopause with complex issues, oestrogen hormone implants are available; however, these are a fourth line treatment and can only be given under the care of a consultant gynaecologist. (more about these below)
Many women in surgical menopause will find that systemic HRT alone is not enough to help with symptoms of vaginal dryness.
Symptoms of vaginal dryness include: soreness, itchiness, dryness, bleeding, painful sex, multiple night time toilet trips, stress urinary incontinence, UTIs and any other vaginal, bladder and pelvic floor symptoms.
To help relieve and manage symptoms of vaginal dryness we would advise you to speak with your GP about using local oestrogen which comes in the form of creams, pessaries or a vaginal ring.
Read our interview with Jane Lewis for more about vaginal dryness and local oestrogen.
Benefits
Taking oestrogen replacement will not only help to manage your menopausal symptoms, it will also protect your long-term health and reduce your risk of developing osteoporosis and heart disease.
After a few months of taking oestrogen many women will find their menopausal symptoms have improved.
Your joints and bones may ache a little less, your sleep may be improved, your psychological symptoms such as low mood and irritability may be better.
It is important to remember that younger women are highly likely to need a higher dose of HRT than that of a woman in natural menopause and finding your “normal” range can take a lot of time and adjustments to your HRT regime.
Side affects
It is not uncommon to experience some side-effects when you first start taking HRT.
Common side effects include nausea and breast tenderness/pain, but these usually settle down within the first few weeks. If side effects persist, you may need to change the form of HRT that you take, for example change from patches to gels.
Blood tests
Blood tests are not always necessary. However, there is certainly a place for these in terms of checking your serum oestradiol levels alongside your symptoms, particularly in women who are still having symptoms. A simple blood test can also check that you are actually absorbing transdermal HRT.
For women with a history of PMDD and/or acute sensitivity to hormonal fluctuations, it is important to find a HRT regime that offers consistency – again, blood tests to keep track of your normal range can help with this. If you are on hormone implants your levels should be checked before every re-insertion.
Testosterone
What is testosterone and what does it do?
Testosterone is one member of a group of hormones called androgens. Testosterone is very important in women! It has a role in sexual function, energy levels, cognition, bone health, vaginal health and well-being. Around 50% of testosterone is produced by the ovaries and 50% by the adrenal glands.
Why do women in surgical menopause benefit from testosterone?
In women, the production of testosterone declines from the mid-thirties onwards. When the ovaries are surgically removed (surgical menopause), women may experience rapid and significant androgen deficiency symptoms. A lack of testosterone may result in low libido, depleted energy levels, increased tiredness, difficulty concentrating, low mood or headaches.
It is usually good practice to begin testosterone replacement once you have firstly reached a good and consistent level of oestrogen replacement.
What can you do if your GP won’t prescribe you testosterone?
Unfortunately, testosterone has to be prescribed off-license by GPs in the UK. Many simply do not feel comfortable prescribing due to lack of knowledge and training in this area, and many are reluctant to prescribe it unless it has been prescribed by a menopause specialist in the first instance.
If you are in surgical menopause and struggling with the symptoms mentioned above it is likely you will benefit from testosterone replacement.
We recommend that you ask your GP to refer you to a menopause clinic. Unfortunately, there are not many of these in the UK and waiting times can be long.
It will be useful to arm yourself with accurate and evidence-based information ahead of any GP appointments to discuss testosterone.
The BMS website has a lot of useful information that you can print off and take with you to your appointment. You can also refer to the NICE guidelines which states that testosterone can be considered for those who need it.
If your GP is unwilling to listen to you, we strongly recommend that you find one that is more willing. Remember that all patients have the right to be involved in decisions about their treatment and care.
How is testosterone given?
It is usually given in the form of a gel - Testogel or Tostran. You will only need a tiny amount as these forms of testosterone are licensed for men.
For example, one 50mcg sachet of Testogel should last between 7-10 days – rubbing a small pea-sized amount on to your skin.
Some private menopause clinics can order in and prescribe Androfeme1 which is licensed for women in Australia, however it is not available on the NHS.
Some women in surgical menopause cannot absorb transdermal testosterone very well and may require their testosterone in the form of a hormone implant. This needs to be done by a specialist at a menopause clinic. This is usually a last line treatment and can be difficult to come by many, including ourselves, have little choice but to pay for this privately in the UK.
Are there any side effects?
If you are using the gel we recommend that you don’t rub the gel into the same area. For example, if you apply it on the top of your thighs, rotate which leg you apply to. This will help prevent excess hair growth in this area.
Blood tests are advised 2-3 times a year to check that your levels do not get too high. If you have hormone implants your levels will be checked prior to re-insertion.
Hormone Implants
What are hormone implants?
A hormone implant is a small, slow-release pellet containing body-identical hormones. The small pellets are inserted into the fat under the skin (usually in the abdomen or the buttock) where they become absorbed. The hormones are then released slowly over a 4-6- month period. It is an easy and quick procedure carried out under local anaesthetic.
There are 2 types of implant: oestrogen and testosterone.
Oestrogen implants are used to alleviate the majority of menopausal symptoms.
Testosterone implants are used to improve the following symptoms that can all occur as a result of the ovaries being removed:
loss of energy
poor cognitive function
low mood
poor libido
Hormone implants are mostly used for women who have had a hysterectomy and bilateral oophorectomy (ovaries removed).
Benefits
There is continued symptomatic improvement due to the higher serum oestradiol levels obtained
Many younger women in surgical menopause benefit from higher-dose testosterone therapy
There is an improved response when other treatments have failed
Long-term bone protection
A consistent, slow release dose directly into the blood stream causes fewer fluctuations which is particularly beneficial for women who are highly sensitive to hormonal fluctuations
The implant is usually still active and producing pre-menopausal hormone levels up to two years after the last implant. This can have a hugely beneficial effect on well-being and bone density.
Risks
Bleeding at the insertion site a few hours after implantation
Localised bruising and discomfort at the wound site for a few days
Although rare, infection at the implantation site
Although extremely rare, the implant may be rejected
Symptoms can return as the implant comes to the end of its working life (4 – 6 months)
Tachyphylaxis - after repeated implants the hormones can accumulate in the body.
Women who use implants long-term can avoid tachyphylaxis by having their hormone levels checked and should be counselled prior to commencing treatment to avoid the risks
What is Tachyphylaxis?
Too frequent implantation or too high doses of oestrogen leads to supraphysiological oestradiol levels (levels greater than normally found in the body). This can in turn lead to the recurrence of symptoms even at these higher levels.
The recurrence of apparently oestrogen-deficient symptoms at these levels is due to the change of oestradiol levels from ‘very high’ to ‘high’ as women become accustomed to a higher threshold. Therefore, when some women request repeat implants for symptomatic relief, this can be caused by falling oestrogen concentrations rather than a deficiency of oestrogen.
You can avoid this happening by using the correct dose of hormones. The key to this is through the proper monitoring of serum oestradiol levels as well as seeking counselling for the risks prior to commencing treatment. The normal range of oestradiol during the ovarian cycle is between 100 – 1500 pmol/l, but oestradiol levels greatly exceeding these levels can be found in patients with tachyphylaxis.
It is important to note that many women in a premature surgical menopause do not feel any symptomatic relief at levels less than 500 pmol/l.
Progesterone
When is progesterone replacement needed?
Most women who have had a total hysterectomy are not advised to take progesterone.
However if you have had both of your ovaries removed but your uterus remains, a form of progesterone replacement is needed to protect the uterus from a build of cells which can lead to hyperplasia. (Endometrial hyperplasia is a precancerous condition in which there is an irregular thickening of the uterine lining)
Those who have a history of sensitivity to progesterone based treatments will usually have their uterus removed, along with their cervix, as part of their procedure when having their ovaries removed - removing the need to add back progesterone.
Endometriosis
Guidelines suggest that progesterone should be prescribed alongside oestrogen for women who have had a hysterectomy due to endometriosis, particularly those with severe cases.
The progesterone is prescribed to help prevent regrowth of endometriosis which can still happen despite a hysterectomy.
A hysterectomy can bring an end to the physical pain; however, it is not necessarily a cure for endometriosis. It is a major operation and it is important to fully discuss your options with your consultant.
Body Identical Progesterone
Generally women are less likely to have a negative reaction if the progesterone is body identical. Micronised progesterone (known as Utrogestan in the UK) is a capsule that you swallow and is body identical. It is the preferable one to take – especially if you are intolerant to progesterone.
Sleep
Some studies suggest progesterone can have a calming effect and aid with sleep. It increases the production of GABA (gamma aminobutyric acid), another chemical in our brain that works to help sleep.