We compound
a significant amount of bioidentical
hormone replacement therapy at our
pharmacy and we often hear people use
the term "surgical menopause" to
describe their health situation. What
they are actually saying is that they've
had a total hysterectomy.
The purpose of this article is to point
out that there are no true similarities
between menopause and hysterectomy.
Menopause: Sometime in the late
forties or early fifties a woman's body
begins changing. What may have been a
long experience of basically regular
menstrual cycles starts to change.
Sometimes the period is missing and
sometimes they happen more frequently.
Then, the periods stop. This time of
variable periods is sometimes referred
to a perimenopause. One well accepted
definition of menopause is the lack of a
period for 12 consecutive months.
Menopause is a time when hormone levels
have declined. Estrogen levels fall
anywhere from 40% to 60%. Progesterone
and testosterone levels often fall more
than that. The critical thing to note is
that the hormone levels do NOT fall to
zero. The human body does not just stop
making hormones. While there are no
longer sufficient levels to stimulate
the release of a viable egg, the body is
still making and using all kinds of
hormones. Hormone levels continue to
decline over the succeeding decades, but
at a slower rate.
Surgery: A hysterectomy is the
surgical removal of the uterus, and an
oophorectomy is the surgical removal of
one or both of the ovaries. Surgical
removal of both the uterus and the
ovaries is often referred to as a total
hysterectomy, and removal of only the
uterus is known as a simple
hysterectomy. A hysterectomy with a
bilateral oophorectomy (removal of both
ovaries) causes a woman to abruptly stop
producing estrogen. Erroneously, this is
often called "surgical menopause." The
consequences of abruptly stopping the
production of hormones by surgery are
far more severe. Menopause is a slow,
natural decline in hormone levels.
Surgery is almost instantaneous.
Changing
Hormone Balance: Menopausal women
who want or need hormone replacement
therapy are in a completely different
situation than women who have undergone
surgery. During perimenopause it seems
that progesterone levels fall more
dramatically than estrogen levels. This
is understandable if you consider the
normal role of progesterone in a woman's
body. The word, progesterone, is derived
from PRO (means for) and GESTATION
(means pregnancy). When an egg is
released from the corpus luteum (the
sack where the egg is stored)
progesterone levels begin to rise. The
corpus luteum generates the increasing
progesterone levels for about two weeks.
If there is a pregnancy, the new fetus
takes over the job of stimulating the
release of progesterone. A baby
literally swims in a sea of
progesterone. If pregnancy does not
happen the corpus luteum "runs out of
steam" and the levels of progesterone
fall, rather abruptly. This falling
level stimulates the sloughing of the
endometrial lining and bleeding starts.
It is the FALLING level of progesterone
in relation to the levels of other
hormones that stimulates the beginning
of a period.
After menopause the body no longer
releases eggs so there is no corpus
luteum to stimulate progesterone. Of
course, without an egg there isn't a
pregnancy so there would be no fetus to
stimulate progesterone. The two reasons
for making progesterone are lost (corpus
luteum and pregnancy). This doesn't mean
that the need for progesterone declines.
The human body contains a myriad of
interacting reactions of checks and
balances. It is a very delicate
mechanism that can become imbalanced.
One particular imbalance that seems to
cause a lot of concern is the one that
occurs when progesterone levels fall
more than the offsetting estrogen levels
in a woman's body. Dr. John R. Lee
coined the phrase, "estrogen dominance"
to describe a situation where the
relationship between progesterone and
estrogen is out of balance.
Hormone BALANCE: The relationship
between progesterone and estrogen can be
described as a ration. The ratio of
progesterone to estrogen (as estradiol)
can vary widely between women, but
values above 200 are often associated
with a beneficial balance. That means
that progesterone levels 200 times
greater than estradiol are usually
preferred. At menopause this ratio often
falls far below 200. In the hundreds of
tests we've looked at over the years
ratios less than 15 are not unheard of.
Many women, then can benefit by using a
small amount of progesterone as a
supplement. We think it is best if a
woman uses a quality progesterone cream
approximately 25 days each calendar
month. Because progesterone rose and
fell during the productive years we
suggest that using progesterone
supplements according to a cycle pattern
best meets the need of the woman. Some
women do well using progesterone every
day, but we find that many more seem
happier when they use a small amount
(20mg in a transdermal cream) daily for
about 12 days, then twice daily until
the 25th, then stopping. This mimics the
rise and fall of progesterone and allows
a few days each month for the
progesterone receptors to clear and
become sensitive again.
The natural flow of hormones in the body
is often referred to as the "hormone
cascade." This demonstrates that there
is a process in the body whereby one
hormone can be transformed into another.
For example, cholesterol can become
pregnenolone, which can be converted to
progesterone. From progesterone the body
can make other hormones, like estrogen,
testosterone, DHEA, and cortisol.
Supplementing with progesterone, then,
may be sufficient to cause the body to
produce the other hormones whose levels
have fallen over time. This means that
not every menopausal woman may need
estrogen. The progesterone alone can be
enough when the hormone cascade process
is in place.
At menopause estrogen falls some and
progesterone falls a lot. Instead of
supplementing with estrogen combinations
menopausal women may want to first use a
physiologic amount of progesterone. If
symptoms occur simple tests can be
performed to evaluate the overall
hormone levels and changes can be made.
If tests reveal actual low levels of
estrogens they can be added to the
supplement mixture. Be clear that we
suggest adding estrogen only when
testing shows a deficiency.
Oophorectomy: Women who have lost
their ovaries are in an entirely
different situation. They have had their
"hormone factory" completely removed.
Their estrogen levels don't fall "some"
but almost all the way. The same is true
of progesterone and all the other
hormones that are produced in the
ovaries. This is an abrupt change and
very serious. Sadly, not everyone in the
health professions agree that loosing
ovaries is a significant health event.
Some women are left with no hormone
supplement and some are offered one of
the "one size fits all" commercial
products (some of which are derived form
animal sources such as mares). When this
doesn't help it is common for doctors to
prescribe any number of drugs designed
to ease the consequences of lost
hormones. It's sad that some doctors
think a psychotropic drug can substitute
for a natural human substance. This is
unkind, unprofessional, and harmful,
especially as there are natural hormone
supplements available and there are
special pharmacists all across the land
who know how to combine these natural
hormones into compounds that can do a
lot to help a woman fell more like
herself.
Women without ovaries need a wider range
of hormone supplements. Combinations of
estradiol and estriol are common. These
must be balanced with progesterone and
sometimes testosterone and DHEA need to
be added. Because the sex hormones are
central to so many other hormone systems
in the body a woman who has undergone
life-changing surgery may also need
supplements to help her thyroid,
adrenals, and pancreas. Then, the
possibility exists that adding those
hormones may upset any balance that may
have been achieved with the sex hormones
(estrogen, progesterone, etc.) Loss of
ovaries is a serious situation that must
be followed closely after the operation.
Failure to take it seriously is wrong.
Few people seem to be seriously engaged
in helping post-surgical women regain
their health and vitality.
Hysterectomy
with oophorectomy is NOT SURGICAL
MENOPAUSE.
It is a life-changing surgical
procedure.
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