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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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