Menopause and HRT after Hysterectomy.
Many women undergo hysterectomy (surgical removal of the uterus or womb) for various gynaecological reasons. These include intolerable periods not controlled by medical means, fibroids, endometriosis, prolapse, and malignant or premalignant changes of the uterus, cervix or ovary.
Hysterectomy can either be TOTAL, where both the uterus and cervix are removed, or SUB-TOTAL, where the main part of the uterus is removed but the cervix is retained. If the cervix is retained, regular cervical screening by smears should be continued.
At the time of a hysterectomy, the ovaries may be conserved (left behind) or removed. The decision as to which type of hysterectomy is needed will be determined by the type of gynaecological problem, by past medical history, by family history and by the woman's wishes.
If one or both ovaries are conserved at the time of hysterectomy, 3 scenarios are possible:
- Continuing normal ovarian function.
The ovaries may continue producing hormones in their fluctuating manner until the normal age of menopause (usually 51 years of age). This fluctuating hormone production may cause symptoms of "premenstrual syndrome" (PMS), even in the absence of periods. This is because PMS symptoms are due to the changing hormone levels, and not due to the presence of bleeding. Estrogen deficiency symptoms, if they occur, would happen at the normal menopausal age.
For further information on PMS, www.pms.org.uk, nizagara-online.net
- Early ovarian failure-apparent.
Following a hysterectomy, the ovaries may stop producing hormones sooner than expected. This can even happen within 1-2 years following the hysterectomy when symptoms of estrogen deficiency may be noticed. If this happens, it is very important that these symptoms and the possible use of HRT are discussed with a doctor or practice nurse.
- Early ovarian failure-silent.
In some women, the conserved ovaries may fail early but the falling estrogen level may not cause the usual signs of estrogen deficiency. It is therefore recommended that following a hysterectomy with one or both ovaries conserved before the age of 45, a blood test should be taken approximately once per year to check hormone levels, for evidence of an early menopause. If menopausal symptoms have developed, blood tests are not required.
Importance of reporting symptoms of early ovarian failure, or detecting silent early ovarian failure:
- Estrogen deficiency symptoms can be unpleasant and effective therapy is available.
- Estrogen is very good for maintaining bone strength. If the production of estrogen is lost at an early age (before 45 years) then the individual is thought to have an increased risk of osteoporosis (bone thinning). Very effective treatments are now available to both prevent and treat osteoporosis.
For further information on osteoporosis, visit www.nos.org.uk
If the ovaries are removed (oophorectomy) at the time of the hysterectomy, a sudden loss of ovarian hormone production, in particular estrogen occurs. This sudden, surgical menopause may cause estrogen deficiency symptoms within a few days of the operation.
These symptoms include hot flushes and sweats. If surgical menopause occurs before the age of 45years, the risk of osteoporosis is increased.
HRT should then be considered for symptom control and/or for its protective effect on bone. Whether or not to commence HRT should be decided after a full discussion between the woman and a health professional, either when in hospital or after discharge home. This decision will be influenced by factors such as age at the time of operation, past history (including any medical reasons why HRT should not be taken) and family history. HRT is usually recommended if the operation causes an early menopause (<45 years) because of the significant increased risk of osteoporosis.Type of HRT following hysterectomy.
If HRT is commenced following hysterectomy, it is usually prescribed as an estrogen only preparation. This can be taken as a daily tablet, a weekly or twice weekly patch, a daily gel or a six-monthly implant. The particular type of prescription is tailored to suit the woman's needs and is chosen after consideration of individual preference, past history and cost. The most common prescription is estrogen HRT in a tablet form.
HRT using a combination of estrogen and progestogen (which is recommended when the uterus is still present), is often used after a hysterectomy if widespread endometriosis is found at the time of surgery.
Endometriosis is the presence of deposits of the lining of the uterus (endometrium)
out with the uterus, e.g. on the bladder, bowel and other organs in the body.
These deposits are sensitive to the hormones produced by the ovaries. After hysterectomy
and removal of the ovaries, there have been reports of endometriotic deposits
being stimulated following estrogen only HRT. It is thought that estrogen combined
with progestogen HRT is less likely to cause stimulation of these deposits, although
there is little scientific evidence to support this.
For further information on endometriosis, visit www.endo.org.uk and www.shetrust.org.uk
Role of testosterone after hysterectomy
If the ovaries are removed at the time of hysterectomy, as well as the estrogen level falling, there is also a 50% decrease in testosterone production. Some doctors recommend testosterone replacement along with estrogen replacement; testosterone helping energy levels, mood and libido. However testosterone replacement does not seem to be required by all and the ideal route and dose of testosterone for women is still being researched. It is therefore not routinely recommended following removal of the ovaries but can be considered for some women who do not fully benefit from estrogen replacement alone.
If the main part of the uterus has been removed but the cervix retained, it is currently uncertain whether HRT can be given in the form of estrogen only or estrogen combined with progestogen. The slight concern of using estrogen only, is that there may be some of the cells of the lining of the uterus in the cervical canal which could become thickened from the estrogen. This thickening can be prevented by adding in progestogen. To find out if progestogen is required, it may be suggested to use estrogen combined with cyclical progestogen for 3 months after your operation. If there is monthly bleeding in this time, it means that cells are present which are responding to the hormones so estrogen and progestogen should be used thereafter. (These hormones can however be given together continuously to avoid monthly bleeding). If there is no bleeding in the first 3 months, then estrogen can be given on its own thereafter.
Duration of HRT after hysterectomy.
If HRT is commenced because of an early menopause after surgery, it can be continued until the age of 50 years without concern about the increased risk of breast cancer. At around the age of 50, the decision as to whether or not to continue HRT should be made. This is the same decision that any woman becoming menopausal at the normal menopausal age would have to make, i.e. whether or not to commence HRT.
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Menopause and HRT after Hysterectomy
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