Dr. Jerilynn C. Prior, Scientific Director, Centre for Menstrual Cycle and Ovulation Research

Ask Jerilynn |

What should I expect after early surgical menopause?

Q: 
I'm 47 and had my ovaries but not my uterus removed. However, following surgery I wasn't told what to expect, if I needed to take hormones, or what I might experience. My GP was as vague as my gynecologist.
I'm having 2-3 night sweats a week, my sleep is very interrupted and have 3-6 daytime hot flushes per week but all of these things are the same as before surgery. I even still have my usual libido and good vaginal lubrication. I thought I'd lose those with my ovaries. . . .

A: 

I don't blame you for being confused. It isn't usual that the ovaries are removed without also removing the uterus (hysterectomy). When a woman has her ovaries removed before she is 40 (with or without removal of the uterus) I recommend both estradiol (the molecularly or bio-identical estrogen) and progesterone (also the molecularly identical hormone taken by mouth, called Prometrium). Given your age of 47, there is no clear guideline about what to do - hence the lack of medical instruction. Your decision about estradiol and progesterone, or only progesterone, or nothing is best based on your quality of life and your own concerns or health risks. Let me outline how I would approach these choices.

Night sweats and sleep disturbances

It seems clear that you were perimenopausal before surgery-therefore your symptoms like hot flushes and night sweats didn't change that much. I'm glad that the hot flushes and night sweats seem not to be much of a problem for you. However, if I were you, night sweats causing waking two or more times a week and marked sleep disruption would be something for which I would ask for treatment. A good night's sleep is highly valuable!

Vasomotor symptoms (the term for both night sweats and hot flushes) are complex and relate to lots of things besides estrogen withdrawal. We know that stresses make them worse, whether that stress comes from economic, emotional, nutritional or physical sources. We also know that cigarette smoking is associated with hot flushes-that's an additional incentive besides all the other health risks, to work with your physician to quit smoking. Finally, being obese is associated with worse vasomotor symptoms, partly because of the unwanted insulation!

The combination of several night sweats a week and sleep disruption is a good reason to take 300 mg of Prometrium (oral micronized progesterone) at bedtime daily. Progesterone has been proven to increase rapid eye movement sleep and to decrease sleep disruption in a randomized controlled trial. Clinical evidence also suggests that Prometrium is effective for hot flushes and night sweats. You can stop it once a year and see if the hot flushes and night sweats have gone away (as they eventually do).

Sexual interest and vaginal lubrication

Your continued libido is evidence that sexual interest is based on a lot more than hormones (like an attractive and simpatico partner, opportunity, comfort with your body. . .). The moist vagina is because it takes very low doses of estrogen to sufficiently lubricate the vagina for intercourse. That amount is made-after the ovaries can no longer make high levels of estradiol, or have been removed-by conversion (aromatization) in muscle and fat cells of adrenal hormones into another natural estrogen called estrone. In the future, should you develop vaginal dryness (this could appear after a year or more following surgery) non-hormonal lubricants are the first choice, and if not sufficient, estrogen in minute amounts (like toothpaste on a toothbrush) on your finger and rubbed into the vagina once or twice a week will be effective (see this article for more information). We also know that progesterone acts on the same vaginal cells and may also help prevent vaginal dryness

Bone health

It's a good time to think about the health of your bones for the next 40+ years. If you have a close relative who's broken a bone with a fall from a standing height or less (fragility fracture), if you yourself have had a fragility fracture or a low bone density test, or if you have skipped three or more periods (when not pregnant or breast feeding) and worry about what you eat, then you may be at risk for low bone density. You are rapidly losing bone right now just because of the surgical removal of your ovaries. Therefore, for sure you need to follow the ABCs of Midlife Osteoporosis Prevention. If you have any of the above risk factors, you need to ask your family doctor to order a bone density test.

Should that bone density result in a level that is below normal (a T score of -1 to -2.5) or low (lower than -2.5) I think it would be prudent, if you have no reasons not to, to take oral micronized progesterone (OMP, bioidentical, Prometrium® or compounded oral micronized progesterone) 300 mg at bedtime daily plus transdermal estradiol (as a patch in doses of 25-50 ug twice a week or a gel of one pump a day) for the next five years or until you are 52. At that point, follow the instructions for stopping estrogen therapy.

I hope this is helpful for you.

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All the best,

Jerilynn

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