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Hysterectomy &
Cycling Hormones Answers,
by Dr. Joseph Collins Question:
Can
surgical menopause women use the menopause type questionnaire? Is the
menopause type approach different for women in surgical menopause? Does the
presence or absence of ovaries make a difference? Does the age at time of
surgery make a difference? Is it best to cycle hormones each month? Do the
receptors need "down time"? Answer: The
term "surgical menopause" implies that the ovaries were removed -
thus revealing that the surgery was a "total hysterectomy" or
"hysterectomy with bilateral oopherectomy." Women who have gone through a surgical
menopause may develop any of the twelve menopause types. However, type one
(Ideal Menopause) does not occur in this group of women (see page 84). The
few who did have some of all three
hormones were in the low end of the range and still had significant symptoms
that needed attention. This is an important point. Remember that both the
symptoms and the lab test have to be considered when identifying your
menopause type (pg 27). Women with hormone levels in the lowest quartile (the
lowest fourth of the reference range) are still deficient if they have
symptoms of deficiency. When interpreting lab results, remember that
laboratories reference range needs to be interpreted with symptoms in mind.
Lab work is only half of the diagnosis. (Review pages 47 through 50.) It
is interesting to note that women who have a history of polycystic ovary
disease may still have elevated testosterone even after a total hysterectomy.
This is because the adrenal glands, and not just the ovaries, are affected by
this condition. Use the Menopause Type Questionnaire as any woman would, but
make sure that hormone levels are monitored as well. (See page 57 "Not
An Ideal Menopause".) If
a woman has gone through a "partial hysterectomy" - and still has her
ovaries - she may not have the abrupt symptoms of surgical menopause.
However, these women appear to go through menopause 5 to 10 years earlier
than other women in their family who have not had surgery. It actually
appears that any type of surgery will put further stress on the adrenal
glands and ultimately affect menopause. Women who have had a partial
hysterectomy may develop any type of menopause. Age
at time of surgery does not make a difference physiologically - the same
rules apply concerning abrupt loss of ovaries and the stress to the adrenal
glands. However, I have noticed that younger women undergoing a complete
hysterectomy appear to be given more attention in regard to hormone
replacement when compared to women already in menopause undergoing a complete
hysterectomy. It's as if the need for testosterone is recognized in young
women in their 20s and 30s, but is overlooked in women in their 50s and
above. No matter what a woman's age, all three hormones are important for a
number of important functions. Concerning
cyclical hormone replacement therapy, we need to review a few points. In the
premenopause monthly cycle estradiol, progesterone and testosterone levels
are all at their lowest during the first half of the cycle - the follicular
phase. The follicular phase is from the first day of menstrual bleeding until
ovulation. After ovulation, luteal phase occurs. During the luteal phase all
three hormones are higher than they were during the follicular phase.
This elevation of all three hormones (or and imbalance in the elevation) has
been implicated in premenstrual disorders. After luteal phase, the hormones
all drop down to follicular levels. Follicular levels are the
"baseline" levels - the levels that exist before they are stimulated
to increase. These follicular levels are the hormone levels that are ideal
for postmenopause. Now,
consider this: At no time in the normal menstrual cycle does the body stop
all hormones. The natural cycle does not "stop all hormones for seven
days." In
the March issue of the American Journal Obstetrics & Gynecology they
report about a 24 month study involving four hundred nineteen women who were
postmenopausal for at least 3 years. These women were placed on continuous
estradiol (1 or 2 mg estradiol valerate) with continuous progestogen
(2.5 or 5 mg medroxyprogesterone acetate). All dosing regimens alleviated
menopausal symptoms. Of increased interest; this study involved women with
intact uteruses and the study reports most women had no bleeding even during
the first 3 months of treatment (1). Continuous therapy is an appropriate and
safe choice. A
1992 study revealed that daily continuous estrogen-progesterone
regimens are as effective cyclical hormonal therapy in decreasing bone loss
and stabilizing bone density (2). Continuous therapy provides protection
against osteoporosis. A
1999 study in which continuous transdermal estradiol was given to women who
had surgically induced menopause concluded that that estrogen replacement
therapy significantly improves heart function (3). Continuous therapy is as
effective as cyclical in preserving heart function. Cyclical
therapy gained it's popularity years ago when it was needed due to the high
incidence of breakthrough bleeding that occurred with HRT - most likely
related to the higher dosages that were used. The dosage of hormones that are
commonly used today were referred to as "low dose' as recently as 1993
(4). Based upon the fact that the normal
menstrual cycle does not involve "no hormone" days, and the fact
that continuous replacement therapy is as effective as cyclical therapy there
is no reason for a woman to put herself through the discomfort of monthly
hormone deprivation. So what
about receptor needing "down time"? This
down time should occur every night. Estradiol, progesterone and
testosterone all exhibit a 24-hour rhythm in which the levels are highest in
the morning or early day, and lowest at night. Please review "Once-a-day
Dosing" and "Matching Your Natural Patterns" in pages 277
through 280. If hormones are taken properly - once day - then the natural
24-hour rhythm will keep the receptors active. Please remember that for
decades your hormone levels never dropped below the normal baseline
follicular levels. Joseph J.
Collins, ND (1)
Heikkinen JE, Vaheri RT, Ahomaki SM, Kainulainen PM, Viitanen AT, Timonen UM.
Optimizing continuous-combined hormone replacement therapy for postmenopausal
women: A comparison of six different treatment regimens. Am J Obstet
Gynecol 2000 Mar;182(3):560-567 (2)
el-Hajj Fuleihan G, Brown EM, Curtis K, Berger MJ, Berger BM, Gleason R,
LeBoff MS. Effect of sequential and daily continuous hormone replacement
therapy on indexes of mineral metabolism. Arch Intern Med 1992 Sep;152(9):1904-9 (3)
Beljic T, Babic D, Marinkovic J, Prelevic GM. Effect of estrogen replacement
therapy on cardiac function in postmenopausal women with and without flushes.
Gynecol Endocrinol 1999 Apr;13(2):104-12 (4) Luciano AA, De Souza MJ, Roy MP, Schoenfeld MJ, Nulsen JC, Halvorson CV. Evaluation of low-dose estrogen and progestin therapy in postmenopausal women. A double-blind, prospective study of sequential versus continuous therapy. J Reprod Med 1993 Mar;38(3):207-14 |
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