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Surgical Menopause

    Basics

Overview

The decision to undergo prophylactic removal of the ovaries and tubes to lower the risk for cancer is a difficult and personal one. Women who undergo oophorectomy prior to natural menopause will experience menopause from the surgery.  Menopausal symptoms and the experience varies from woman to woman. Menopause can bring changes in a woman's health and well-being. Research has shown that menopause can be associated with the following:

  • osteoporosis (loss of bone density)
  • heart disease
  • decreased libido and other sexual side effects
  • hot-flashes 

Some women find hormone replacement alleviates their menopausal symptoms. However, research on hormone replacement is inconclusive regarding the benefits and risks to menopausal women.  Because much of the research has been conducted on women who experienced natural menopause, the applicability to women experiencing early surgical menopause is uncertain. 

In 2012, the North American Menopause Society released a position statement on hormone replacement therapy which included the following points important to woman considering hormone replacement therapy:

  • Hormone replacement therapy is the most effective treatment for the symptoms of menopause
  • Many woman can take hormone replacement therapy safely
  • Women with breast cancer, blood clots, heart disease or stroke should discuss these conditions with their health care provider.
  • Estrogen replacement therapy can be taken longer than estrogen/progesterone combination therapy.

It is important for each woman to discuss menopausal symptoms with their doctor and to weigh the potential benefits and relief from hormone replacement vs. their individual risks from hormone replacement or other menopausal treatments.

Menopausal side effects

Different women experience menopausal side-effects to differing degrees.  Some of the side effects reported by women include:

  • hot flashes
  • vaginal dryness
  • decreased libido or other sexual side effects
  • sleep disturbance
  • memory changes
  • mood changes
  • fatigue
  • weight gain
  • urinary incontinence

Some of these side effects can be alleviated or resolved with medications, or improved with supplements. It is important to note that medications and supplements can have their own risks and side effects. For some individuals, low-dose hormone therapy may be an option for addressing medical or quality-of-life issues not resolved any other way.

Research of hormone replacement therapy in premenopausal women with BRCA mutations who have not had breast cancer but had oophorectomy has been limited. One study which examined short-term hormone replacement after oophorectomy in BRCA carriers indicates that prophylactic oophorectomy prior to age 50 substantially lowers the risk for breast cancer. The breast cancer risk reduction was similar in women who took hormones for up to three years and women who did not take hormones post-oophorectomy. The long term effects of hormone replacement after oophorectomy are unclear at this time.

Types of hormone replacement

A woman’s body can make various types of estrogen, as well as progesterone, testosterone, and other hormones. Several hormone replacement options are available for women with surgical menopause containing varying amounts of these hormones.

Hormones may be categorized by the type of hormones contained in the preparation, how the hormones are delivered to the body, and how the preparation is made. For some women the choice of hormones depends on their symptoms, for example, a woman experiencing vaginal dryness, may find an estrogen-releasing device called a vaginal estrogen ring helpful. The ring works by providing estrogen to the vaginal walls and minimizing absorption into the body. For women who retain their uterus, preparations containing progesterone are chosen to protect against uterine cancer risk.

HRT vs. ERT

For high-risk women, oophorectomy brings two primary benefits when performed prior to menopause: reduction of ovarian cancer risk and reduction of breast cancer risk. It may seem contrary for high-risk women to receive hormones after removing their ovaries to lower their risk for breast cancer. However, hormone levels received through medication is generally less than what is normally produced by the ovaries during the premenopausal years. It isn't entirely clear what effect estrogen replacement therapy (ERT) or combined estrogen-progestin therapy (HRT) might have on cancer risk, particularly in high-risk women or breast cancer survivors. The multi-institutional PROSE study followed premenopausal women who carry a BRCA mutation for 3 1/2 years. Women who elected risk-reducing salpingo- oophorectomy (removal of ovaries and tubes) had a substantial decrease in breast cancer risk. Hormone replacement after oophorectomy didn't significantly change the breast cancer risk in the women in this study. It is important for women to discuss the risk of hormone replacement with their healthcare team to make an informed decision.

HRT are preparations of estrogen combined with progesterone. The progesterone protects against uterine cancer and is generally prescribed for women who are postmenopausal but still have their uterus. ERT are estrogen-only preparations appropriate for postmenopausal women who have had hysterectomies. Because they have no uterus, these women have no risk of uterine cancer and therefore don’t require progesterone.

The Women’s Health Initiative is a large, randomized study for hormone replacement after menopause. It reviewed women who took HRT, ERT or a placebo after natural menopause. It is important to remember that this study did not look at women with BRCA mutations or premenopausal women who experienced surgical menopause. The study demonstrated that HRT supplementation (estrogen plus progesterone) increased the risk for breast cancer in women who went through natural menopause. The study concluded, however, that ERT supplementation (estrogen alone) does not appear to raise the risk for breast cancer in this population. The study did not specifically consider women who underwent surgical menopause due to risk-reducing oophorectomy, so its applicability to the high-risk population who undergo early menopause is uncertain.

Bio-identical hormones

Some attention has been given to whether certain hormone preparations are safer or more effective than others.  “Bio-identical” hormones are hormone replacement preparations that are chemically identical to the hormones produced in the body; whether they originate in animals, plants, or are synthetic, they cannot be distinguished from the body’s own hormones. There is currently no conclusive evidence that "bio-identical" hormones are safer than other preparations.

Some physicians describe specially-made hormone compounds prepared by pharmacists as “bio-identical.” Compounded hormone replacement is described in more detail below.

Commercial vs. compounded hormone preparations

Certain hormone preparations, (including some bio-identical compounds), have been tested by the FDA and are available commercially by prescription. Other "compounded" hormone preparations contain individualized combinations of different hormones and are prepared on an individual basis by pharmacists. Some physicians feel these "compounded" hormones are safer than commercial preparations. However, this has not been demonstrated by scientific research. There may be risks associated with compounded hormones: they are neither tested nor approved by the FDA and are unregulated. Compounded preparation methods vary from one pharmacist to another, and from one pharmacy to another, so compounds may not be consistent. Some custom-compounded preparations are not covered by insurance plans. Custom-compounded hormones may provide certain benefits, allowing individualized doses and mixtures of different hormones unavailable in commercial products. Anecdotally, some women posting on the FORCE message board reported they found pharmacist-compounded hormone preparations relieved their menopausal symptoms more effectively than commercially available preparations. A list of hormone replacement therapy products was published in a 2001 International Journal of Pharmaceutical Compounding.

Some physicians follow patients who use these compounds by testing their saliva for hormone levels. However the reliability of these tests and optimal saliva hormone levels have not been established.

One study of previous research which compared hormone types determined the conclusions drawn were compromised because the research efforts were too small or had design flaws. The study's authors suggested there was not enough evidence to recommend bio-identical hormones over conventional hormones.

The North American Menopause Society (NAMS), a professional organization devoted to promoting women's health and quality of life through an understanding of menopause, published a position statement on compounded hormone replacement. The NAMS does not recommend custom-compounded products over well-tested, government-approved products for the majority of women. Nor does the Society recommend saliva testing to determine hormone levels.

It is important for women who have undergone surgical menopause or are considering prophylactic oophorectomy to discuss menopausal symptoms and management with their healthcare team. The menopause experience is individual. Response to hormone replacement appears to be individual as well.

Heart disease

Heart disease is the leading cause of death in American women. Risk of heart disease increases after menopause, regardless of your age.  The hormone estrogen protects premenopausal women from heart disease.  If you have surgical menopause, you lose the protective effects of natural estrogen and may need medical intervention to combat later health issues.

In addition to surgical menopause, risk factors for heart disease include:

  • smoking
  • sedentary lifestyle
  • diabetes
  • waistline of more than 35 inches
  • high blood pressure or cholesterol
  • family history of heart disease and genetic factors

Women with BRCA mutations may be more susceptible to cardiovascular disease. Researchers are studying whether the BRCA genes may play role in repairing damage to heart cells. This may be particularly important in women who have received certain types of chemotherapy that affect the heart.

Women in surgical menopause should maintain an ideal body weight, abstain from smoking, and consult with experts about reducing the risk for cardiovascular disease.

The role of hormone replacement therapy in managing risk for heart disease after surgical menopause remains an active area of research.  Research has focused on the time that hormone replacement begins and the duration of therapy. A Mayo Clinic study of women who had surgical menopause before age 45 indicated that estrogen replacement therapy may protect against heart disease associated with early menopause. A randomized controlled trial of hormone replacement therapy in women at the beginning of menopause found that both estrogen replacement therapy and estrogen and progesterone replacement therapy reduced the risk of death and hospital admission due to heart failure or heart attack over a 16-year period.  

Osteopenia and osteoporosis

Osteopenia refers to loss of bone density. Osteoporosis is a more serious loss of bone density which weakens the bones. Some degree of bone thinning occurs as a natural part of the aging process. Significant weakening of the bones, however, puts a person at increased risk for fractures (broken bones). Loss of estrogen through natural or surgical menopause can lead to increased weakening of the bones.

A bone density test can determine whether a person’s bones are weakened or are of normal density.  Health care providers categorize a person’s bone density as “normal,” “osteopenia,” or “osteoporosis,” as compared to others of the same age and gender. Health care providers often recommend a baseline bone density test before prophylactic oophorectomy or soon after and then on an annual or semi-annual basis after menopause.

Hormonal and nonhormonal medications can lower the risk for fractures due to loss of bone density. These medications may have side effects. Some, like hormones, may raise the risk for other cancers. Women with osteopenia or osteoporosis associated with menopause should be followed by endocrinologists or other health care professionals who are trained in managing menopausal symptoms. It is important for each woman to weigh the potential benefits and relief from hormone replacement vs. their individual risk for cancer or other risks associated with hormone replacement.

Weight-bearing or resistance exercise may lower the risk for osteoporosis in post-menopausal women. However, it is important to discuss exercise with your physician before starting any exercise routine. It is worthwhile to consult with a licensed physical therapist to assure that your exercise routine is safe and appropriate. Experts recommend post-menopausal women receive 1200 milligrams of calcium per day, either through their diet or through supplementation.

Memory changes

Women in surgical menopause often report memory loss or difficulty focusing on tasks.  Loss of estrogen through both natural and surgical menopause is known to affect memory. A number of studies have shown that women who undergo bilateral oophorectomy before the age of natural menopause are at increased risk of cognitive decline and dementia compared with women with intact ovaries.   

Many of these studies also showed risk of cognitive issues were eliminated if estrogen replacement therapy was begun immediately after surgery and continued through age 50 or longer.  Additional research is needed to better understand the effects of estrogen and progesterone replacement on memory and the optimal timing for hormone replacement.  Women in surgical menopause are encouraged to discuss the risks and benefits of hormone replacement therapy with their health care provider. 

In addition to hormones experts recommend a eating a healthy diet, avoiding alcohol, stimulating your brain through puzzles and reading, and making sure you get adequate sleep.  Ginkgo biloba and other supplements are rumored to improve memory; none have been proved effective through research. 

Hot flashes

Studies show hormones and certain non hormonal medications—antidepressants belonging to a class of drugs called selective seratonin reuptake inhibitors (SSRIs), for instance—may relieve some menopausal side effects such as hot flashes. One small randomized trial found venlafaxine (Effexor) alleviated hot flashes in postmenopausal women compared to a placebo. Another study found fluoxetine (Prozac) lowered the frequency of hot flashes more effectively than placebo in post menopausal women. Research on the effectiveness and safety of supplements such as soy or black cohosh has been inconclusive.

Products such as handheld fans and "chillows," which cool the body temperature, have been helpful for some women who experience hot-flashes.

Libido

Decreased libido is often associated with menopause. Hormonal and nonhormonal options are available for improving libido in women who are surgically menopausal. Some physicians recommend the addition of testosterone replacement for women who have loss of libido with menopause that isn't alleviated by ERT or HRT alone. One short randomized, prospective study found testosterone supplementation improves libido in women who experienced loss of libido due to oophorectomy. There is conflicting data, however, about the safety of testosterone and whether it may increase the risk for breast cancer.

A small preliminary study looked at the effects of the antidepressant bupropion (Welbutrin) on the libido of individuals who were not clinically depressed. The study suggested bupropion improved sexual arousal, overall sexual satisfaction, and satisfaction with intensity of orgasm when compared to placebo. However, this study was not specific to high-risk women who experienced surgical menopause.

Sleep disturbances

Some women report disruption in sleep patterns associated with menopause. Sleep disturbances may also cause menopause-related fatigue. One small randomized study compared insomnia in peri- and postmenopausal women who used the sleep aid zolpidem (Ambien) compared with those who took a placebo. Women who took zolpidem reported improved sleep over those who took a placebo.

Specialized sleep disorder clinics can sometimes assist with sleep disruptions associated with menopause.


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