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Progestins after hysterectomy. Answers, by Dr. Joseph
Collins Question: Is
it okay to take an estrogen-progestin combination if you had a total
hysterectomy. Everything I read say not too. My doctor has prescribed this
for me. I had been taking an estrogen since I was 29. I am now 43 and it
stopped working for me. Night sweats and hot flashes. Since starting the
estrogen-progestin combination I no longer have the hot flashes or night
sweats. My concern: Is there any harm in taking the progestin since I don't
have a uterus? Review of definitions:
The "progestogen" is a generic term for
all substances with progesterone like activity. The word
"progestin" refers to synthetic progestogens. The word
"progesterone" refers to the natural progesterone molecule. Answer: Estrogen-Progestin
combinations are customarily promoted for women with an intact uterus, so as
to decrease the incidence of uterine (endometrial) cancer. Unfortunately,
that had many of us believing that progesterone was only needed if a woman
has an intact uterus. Yes, inadequate progesterone (or “unopposed estrogen”) can
have significant consequences including increased risk of endometrial cancer.
However, it is important that we remember that there are progesterone
receptors in other tissues besides the uterus. Remember, in the female body
there is usually 20 to 170 molecules of progesterone to every molecule of
estradiol (1). Some forms of breast cancer may be due to low
progesterone. We know that progesterone has a positive influence on bone,
heart, brain and other tissues (2). Though
bio-identical estradiol and progesterone are the ideal choice, there are some
cases in which a synthetic progestogen is actually
preferable. Medroxyprogesterone acetate has been used to treat the signs
& symptoms of menopause without raising estradiol levels. (Natural
progesterone may raise estradiol levels.) In fact, this synthetic progestogen has been used to treat breast cancer (3). Norethindrone acetate, NETA can cause a significant increase in bone mineral
density, thereby decreasing the incidence of osteoporosis (4).
The effect of NETA on blood lipids is mixed. Estrogen replacement causes a
beneficial increase in HDL (good) cholesterol, which is reversed by the
addition of NETA. However, there are positive changes in other blood lipids
such as triglycerides, VLDL, the LDL sub-fraction profile and lipoprotein(a). These improvements may counteract the
adverse effect on HDL cholesterol (5). Another study found that women on estrogen & NETA had
improved well-being, (less anxiety and depression, increased vitality and
better self-control) as well as reduced sleep disturbances. They had
decreased vasomotor and somatic symptoms, and improved sex life, emotions and
cognitive function (6). Though
they lack the full properties of natural progesterone, there is considerable research
available suggesting that Medroxyprogesterone acetate, NETA and other progestins have positive actions that extend far beyond
endometrial protection. Bottom Line: Women
who have had hysterectomies can still receive benefit from the use of a progestin.
Though synthetic progestogens do not have all the properties of natural
progesterone, they do have documented benefits. It
is important to note that women who must avoid estrogen (because of estrogen
sensitive cancers) can be treated with progestins
to manage the symptoms of menopause. In these cases, these synthetic
progestogens are preferred, since natural progesterone is a precursor to
estradiol. Other Considerations: Also
consider herbal therapies for management of menopause symptoms. Note that Dong
quai has no true estrogen activity, so can be
of benefit in women needing to avoid estrogens. It has antitumor,
anti-inflammatory, and heart protesting properties as well as other actions
that benefit women (7). Black Cohosh should also be considered
since it does not stimulate tissue the way estrogen does, but can relieve
many menopause symptoms (8). Also consider using soy and other
“phytoestrogens” for management of menopause symptoms (9). Dr. Joseph Collins
(1) What’s Your Menopause Type? pg. 77- 80 (2) What’s Your Menopause Type? pg 65-69 (3) What’s Your Menopause Type? pg. 303 (4) What's Your Menopause Type? pg 303 (5) Farish E, Spowart K, Barnes JF, Fletcher CD, Calder A, Brown A,
Hart DM. Effects of postmenopausal hormone replacement therapy on
lipoproteins including lipoprotein(a) and LDL subfractions.
Atherosclerosis 1996 Sep 27;126(1):77-84 (6) Wiklund I, Berg G, Hammar M, Karlberg J, Lindgren
R, Sandin K. Long-term effect of transdermal hormonal therapy on aspects of quality of
life in postmenopausal women. Maturitas 1992
Mar;14(3):225-36 (7) What’s Your Menopause Type? pg 235 – 236 (8) What’s Your Menopause Type? pg 232 – 233 (9) What’s Your Menopause Type? pg 212 – 219 |
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