Menopause is not always a natural event
A woman’s ovaries can stop functioning because of medical or surgical treatments that affect them.
When the ovaries are damaged by chemotherapy, radiation or they are surgically removed - a woman finds herself suddenly thrown into menopause.
All three of the ovary’s hormones; estrogen, progesterone and testosterone, decline significantly.
This type of menopause is called Induced Menopause.
When it is due to surgery, it can also be called Surgical Menopause.
The symptoms from Induced Menopause are often more intense and longer lasting than with a natural menopause.
The effects of a natural menopause can be bad enough.
But with induced menopause, when the loss of hormones is more sudden; the effects are often more dramatic and debilitating.
And induced menopause doesn’t just cause worse symptoms – it also causes worse long term health outcomes.
Induced Menopause is associated with increased risks for heart disease, stroke, dementia, depression, osteoporosis and some cancers.
There is now lots of research to show that induced menopause increases a woman’s risk of various health problems.
Our ovaries do much more than just regulate puberty, periods and fertility. The hormones they make play an important role in keeping us healthy and prolonging our life.
The younger a woman is when she has an induced menopause, the greater these long-term health risks are.
Induced menopause is a common cause of Premature Ovarian Insufficiency (POI)
If a woman is under 40 when she has the medical or surgical treatment, then she enters a menopausal state much earlier than nature intended. This brings with it all the same consequences and difficulties of Premature Ovarian Insufficiency (POI) See here for more information.
Taking HRT after Induced Menopause leads to better health outcomes and a longer lifespan
The fear of a link between HRT and breast cancer has made many women (and doctors) scared to use it. This is all based on a 20-year-old study that was badly reported. See here for more information.
Since then, the study has been looked at properly and many of it’s original conclusions have been rejected. The risks of breast cancer were exaggerated and the benefits of HRT were under-reported – especially in the case of induced menopause.
We now have lots of studies, including some that have used the original data from the study 20 years ago, to show strong evidence that women who have an induced menopause before the natural age of menopause should all be offered HRT.
One such study, called the Nurses Health Study, looked at over 30,000 women for 28 years. This showed that surgical removal of the ovaries before the age of 50 in women who never used HRT was associated with a 41% increased risk of dying from any cause.
But women who took HRT did NOT demonstrate this increased risk.
The study also found that death from lung cancer and heart disease were both increased in the women who did not use HRT, but NOT in the women who took HRT.
This study and several others, all show that taking HRT can undo the increased risk of dying seen in younger women after induced menopause.
The use of HRT is even recommended for women treated for certain gynaecological cancers.
Modern medicine has advanced so much that many women diagnosed with cancer are now able to survive. But many of the treatments for these cancers, especially cancers of the reproductive system, result in an induced menopause. This means we are seeing more and more women, who after surviving the horror of having cancer, chemotherapy, radiation and often surgery; are then having to face the ordeal of menopause.
Many women are denied HRT or do not want to take it because of understandable fear of cancer recurrence. But for many of these women, their menopause symptoms are so severe that they feel they have no quality of life.
The decision to take HRT should be one that each woman can make for herself. There are some women who feel so debilitated by their menopause symptoms, despite their best efforts with lifestyle changes and non-hormonal supplements or medications, that they would rather take the risk of cancer recurrence than continue as they are.
Such decisions are difficult – for women and doctors. And there is often not much research to help guide us. However, some studies have been done to see if there are particular types of cancer that are not linked with any recurrence in women who decide to take HRT. One large research review in 2021 found that women with certain types of ovarian, womb and cervical cancer, could take HRT after their ovaries were removed without any increased risk of the cancer coming back.
What is the best type of HRT to take for Induced Menopause?
Just like with natural menopause, there is no ‘one-size-fits-all’ HRT prescription.
Every woman is different. It mostly depends on what dose best helps the woman’s symptoms, rather than aiming for a specific level in a blood test.
Generally speaking, the safest way to take HRT is as follows:
Bio-identical (not synthetic - see here for more information)
Transdermal Estrogen (Fully funded Estradiol patches - see here for more information on estrogen replacement)
Micronised Progesterone - if you still have a womb, you must take some type of progesterone alongside the estrogen. The safest type of progesterone is body-identical micronised progesterone. This is available fully-funded in NZ as Utrogestan. See here for more information on progesterone (Sometimes progesterone is also given after hysterectomy for severe endometriosis, in case there are still some small endometrial deposits in the body that the surgery could not fully remove)
Higher dose (the younger the woman, the higher the dose of estrogen often needed to mimic the levels she had before the surgery)
Vaginal dryness/soreness can be a major symptom in Induced Menopause
With the dramatic drop in hormones that can occur after induced menopause, many women can develop severe vaginal symptoms. Our vaginas and vulvas are packed with hormone receptors for both estrogen and testosterone. These hormones keep 'our bits' happy and healthy. Without them, women can become very dry and sore down below and can also get increased urinary infections. This is distressing for many women and can often lead to them avoiding sex or any intimacy with their partners because it's too uncomfortable.
The good news is that a simple and safe treatment can be given to women in the form of a bio-identical estrogen cream. It isn't classed as HRT because not enough gets absorbed into the bloodstream - it just focuses its action locally on the vagina and vulva.
This is available in New Zealand as Ovestin cream which contains bio-identical estriol and is fully funded on prescription. The cream can be applied on the outside vulval area as well as inserted into the vagina. It is also available as a pessary to make insertion easier. It can be used alongside conventional systemic HRT or just on its own.
And don’t forget about Testosterone..
An often forgotten hormone in HRT is Testosterone. Before menopause, women make three times more testosterone than estrogen. It is not just a man’s hormone.
With surgical removal of the ovaries, a woman’s testosterone levels can suddenly drop by around 50%. This can lead to loss of libido, low energy and brain fog symptoms.
It is possible to replace testosterone to pre-menopausal levels with a bio-identical transdermal cream called Androfeme. This is available in New Zealand, but unfortunately not funded. See here for more information
Women who go through surgical menopause, not only have to deal with the impact of menopausal symptoms, but also the stress and pain of the surgery itself.
So as these women are trying to heal from their major surgery, they are also struck with symptoms that include low mood, anxiety, poor sleep and hot flushes.
If both her ovaries have been removed, the hormones plummet and a woman enters menopause instantly.
But even if the ovaries are left, there are other types of surgery that can sometimes lead to menopausal symptoms at an earlier or in a more severe form.
For example, removing a woman’s womb disrupts the blood supply to the ovaries, which can sometimes cause them not to function as effectively anymore. As a result, studies have shown that hysterectomy alone is associated with earlier onset of menopause and increased long-term health risks of cardiovascular and metabolic conditions.
Procedures that can cause or potentially accelerate Menopause:
Oophorectomy (unilateral or bilateral)
Ovarian surgery (eg cystectomy) – this is surgery that involves part of the ovary, but does not remove it entirely.
Medical words explained:
Whenever we add the ending ‘ectomy’ to an organ of the body, it means to ‘surgically remove that organ’
Appendicectomy – means to surgically remove the appendix.
Tonsillectomy – means to surgically remove the tonsils
But when we remove a womb, we don’t call it a ‘wombectomy’ or ‘uterusectomy’ because this sounds too clumsy.
Instead, we use the Greek name for womb (hystera) and also the Greek name for ovaries (oophoros, meaning egg-bearing)
Hysterectomy means surgical removal of the womb
Oophorectomy means surgical removal of one or both ovaries
Unilateral means one ovary is removed
Bilateral means both ovaries are removed
A hysterectomy is the second most common type of major surgery performed on women of childbearing age (the most common is caesarean section).
It is done to treat many different conditions that affect the uterus and either cannot be treated another way, or other treatments have not been successful.
Abnormal bleeding from the womb
Cancer - of the womb, cervix or ovary
Chronic pelvic pain
There are several different types of hysterectomy – the one a woman has depends on the reason she needs it. If the reason is cancer, then this often requires more organs and structures than just the womb to be removed. If the reason is abnormal bleeding, this can often be treated with removal of the womb only.
Subtotal or Partial Hysterectomy – removal of womb only
Total Hysterectomy – removal of womb and cervix (the lower part of the womb that leads to the vagina)
Hysterectomy with Bilateral Salpingo-Oophorectomy (BSO) – removal of womb and fallopian tubes and ovaries (sometimes only one tube and ovary is removed and this is called a unilateral salpingo-oophorectomy)
Radical Hysterectomy – Removal of womb, cervix, pelvic lymph nodes, the upper third of the vagina and some tissue on either side of the cervix.
Different ways to do a hysterectomy.
There are different approaches a surgeon can take to remove a woman’s womb. The one they choose depends on various factors, including what type of hysterectomy the woman needs.
Vaginal hysterectomy – the womb can be removed via the vagina. This means no surgical incisions are made
Laparoscopic hysterectomy – this is keyhole surgery and involves small holes in the abdomen to pass ports through to remove the womb.
Abdominal hysterectomy – this is the most major approach and involves a larger incision on the abdomen to remove the womb and other structures if necessary.
There are various reasons why one or both ovaries may be surgically removed:
Ovarian Tumours (benign or cancerous)
Severe PMS (premenstrual syndrome) or PMDD (premenstrual dysphoric disorder)
Ovarian cyst or abscess
Ovarian torsion (when an ovary twists and its blood supply is affected)
To prevent ovarian cancer in women at very high risk of developing it (i.e. women with BRCA1, BRCA2 or HNPCC gene mutations)
FURTHER INFORMATION AND SUPPORT
https://www.facebook.com/groups/surgicalmenopausenz - NZ based FB group to offer information and support
http://www.surgicalmenopause.co.uk/index.html - UK based website and support group
https://www.thesurmenoconnection.com/ - US based website with information and FB group.
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