Early Menopause.org

Booklet written by Ruth Burnham 2006, with contributions from Mr. Nick Panay, Consultant Gynaecologist

Purpose of Booklet

This booklet has been written for women who have just undergone major surgery, that will have resulted in a sudden surgical menopause. It is at this time of change and transition that a level of supportive information is greatly needed. This booklet will aim to guide you through the early stages following your surgery.

If you are reading this prior to undergoing surgery, do as much research as possible. Ask your consultant as many questions as you have on your mind, do not be worried to do so! It is important that you fully understand the type of surgical procedure you are going to have done and why.
What Is Surgical Menopause?
There are many ways in which women find themselves suffering with this condition. Surgical menopause can result from the following; endometriosis, ovarian cysts, fibroids, ovarian cancer, or pelvic organ prolapse are all reasons that your surgery may have come about. The result of having a hysterectomy with the removal of ovaries is referred to by the medical profession as a TAHBSO (total abdominal hysterectomy and bilateral salpingo oophorectomy), this is the removal of your ovaries and Fallopian tubes, and will put you into an immediate “surgical” menopause. Once your ovaries are removed, your body immediately stops producing oestrogen and progesterone. Your follicle stimulating hormone (FSH) will skyrocket in an attempt to make contact with ovaries that no longer exist.

Unlike a woman who goes through menopause naturally, you will wake up after a bilateral oophorectomy in a state of immediate oestrogen withdrawal. Your ovaries provide a lot of important feedback mechanisms. Hormone levels that used to tend themselves now require more self conscious monitoring. Your body will quite naturally make you aware of your changing hormonal status, and your specialist will keep regular checks on you, by testing of your hormone blood profile. There are no cut and dried answers, in that each woman is very individual, and what works for each of us is different. It is perhaps a good time to listen and learn from what our body is telling us, to help find the right approach, that will carry us forward.
Why It Occurs
A subtotal hysterectomy is where the body of the womb (uterus) is removed leaving the cervix in place. In a total hysterectomy; the womb (body and cervix) is removed. A Wertheim's hysterectomy means that the womb, part of the vagina, Fallopian tubes, ovaries, the peritoneum, lymph glands and fatty tissue in the pelvis are removed.

The symptoms following a surgical menopause are often immediate and severe. A woman will enter the operating theatre in a pre menopausal state, and come out of theatre in a post menopausal state. Your oestrogen level will rapidly decline. As much on hand care and support should be given to a woman as needed in this difficult time, in adjusting to your hormonal bodily changes.

Having undergone your surgery you will not need to be told that it is a life changing operation. It will leave you feeling weak, both physically and mentally. It is in this period of time that menopausal symptoms sometimes kick in with a vengeance, and that you will naturally feel most vulnerable, and need most support. On the up side the more you know, the better decisions you can make for yourself.
What Do Hormones Do
Oestrogen is the primary hormone responsible for female sexual characteristics. It is also vitally important to the physical function of a woman's health. It is a major player in the normal function of many organ systems far removed from reproduction. For example, the bones, the blood vessels, the brain, the gut and the immune system. A woman produces several types of oestrogen molecules. A limited amount of oestrogen is also produced by the adrenal glands from progesterone or testosterone. Oestrogen has many effects on a woman's body. When the ovary fails to produce oestrogen, some of the side-effects of a drop in levels of this complex hormone are listed below.

Vasomotor Symptoms - Hot flushes and night sweats are the cardinal symptoms of the menopause. It is thought that hot flushes and night sweats are due to a disturbance of the central thermostat located in the hypothalamus, this is kept stable by normal circulating oestrogen. Adequate and consistent levels of oestrogen will bring about a welcome reduction in night sweats, and an increase in sleep duration and quality.

Oestrogen is a major brain hormone - It is involved in the maintenance of blood flow to the brain. It has powerful effects, and also acts as a natural antidepressant. Oestrogen shares some brain receptors with serotonin, another hormone that affects mood. This may be why depression is a common result of low oestrogen levels. If oestrogen is not available to fill some of those receptors, serotonin supplies may not be adequate to maintain moods. All in all, oestrogen is intimately involved in your central nervous system function.

Oestrogen is important in maintaining tissue elasticity and strength - A decline in oestrogen is responsible for the increasing delicacy of a woman's skin. Two areas of oestrogen loss to the tissues and muscles are the vagina and urinary tract. This can in turn lead to vaginal atrophy (vaginal dryness) for some women. The thin dry vagina can result in painful intercourse (dyspareunia). An understanding and informed partner at this time can help, by sensitively supporting you with any sexual issues that your surgery may have raised.

The urinary tract also reacts to oestrogen deprivation - Infections can be more common and not as easy to treat. Incontinence is often due to loss of urinary tract muscle tone in response to low oestrogen levels. Adequate oestrogen intake (HRT) will help control an overactive bladder, and in doing so reduce excessive visits to the ladies!

Gum tissues are affected - oestrogen replacement can lower gum inflammation and the possible loss of teeth due to destruction of the fibres that hold them in place. Regular dental check-ups will ensure your continued optimum dental health.

Cardiac health - A lack of oestrogen in post menopausal women has become the leading cause of death in women. A surgical menopause increases the risk of heart attack significantly. However adequate intake of oestrogen has been shown to decrease both heart attacks and strokes significantly, in women with premature menopause. Some reasons for this include oestrogen's effects of lowering blood pressure, and relaxing the walls of the arteries, which improves cardiac output. Oestrogen also has the desired effect of lowering your cholesterol level.

Bone - Oestrogen plays a vital role in the process of bone formation. One of the most widely publicised effects of oestrogen is in the prevention of bone wastage known as osteoporosis. Without oestrogen, calcium is lost from the bones and not replaced, this leads to weakened bones that may break easily. After surgical menopause in particular, bones lose roughly 3% of their mass per year, for the first 5 years, and then about 1-2% a year thereafter.

If the amount of circulating oestradiol falls to menopausal levels - and that amount is ten fold less than before the menopause- then the amount of bone removed will not be matched by the new bone being laid down to refill the cavity. The result is bone loss. The sites at which bone loss can be most severe for a woman are the spine, hip and wrist. Regular bone density scans, otherwise known as dexa scans, are highly recommended. It is important to obtain an initial baseline reading of your skeletal, so that you have a starting point at which to work from for the future.

Memory - Oestrogen seems to be linked to memory itself, verbal memory in particular. Women with low oestrogen frequently have a sense of feeling “foggy”, and easily lose track of their thoughts, words, objects, or blocks of knowledge such as how to get from one location to another. Oestrogen is intimately involved in the function of the central nervous system, it is therefore not surprising that many women following their surgery may experience some psychological symptoms.

Migraine - There is a strong hormonal trigger between premature surgical menopause and the onset of migraine. Many women may become much more sensitive to the falling levels of hormones, that dramatically occur at the time of surgical menopause. It is the woman that becomes sensitive to these changes that will experience most difficulties. It is a balance of treating the migraine and the premature menopause symptoms appropriately. It may be comforting to know that you are not alone in suffering from migraine attributed to your surgical menopause, it is well described in the medical literature. The link between hormones and migraine is a very important one.

Depression – A premature menopause may be accompanied by feelings of loss of identity and a crisis of femininity, it may also bring with it a myriad of other emotional issues. A host of changing emotions may lead you to feel withdrawn and isolated from your natural peer group. A sudden loss of fertility can be heart rending, and deeply touch on a woman's sense of purpose in life. It is wholly understandable that inner turmoil and feelings of powerlessness, may ultimately lead to depression. Keeping a diary recording your emotions could be one way to feel as though you are able to gain back some control over what may be a time of feeling out of control over what is happening to your body.

Treatment/HRT
HRT, (Hormone Replacement Therapy) may or may not be prescribed before discharge from the hospital ward. This is entirely dependant upon the consultant you are under, and their general concensus on when to begin hormone therapy. Unless there is a compelling health related reason why you cannot, you should be able to start hormone therapy as soon as you feel a need to. If your surgery was performed due to endometriosis, then you may not be prescribed any HRT straight away. Your specialist team will be able to personally advise and support you.

The initial prescription of HRT given is generally at a lower starting dose, there is no 'right' starting dose. With a premature surgical menopause, your dose is going to gradually be increased. A woman under the age of 45 will need a higher hormone level, to replace that amount of oestrogen your body would have naturally been producing before your surgery. In general younger women need more oestrogen to control symptoms after surgical menopause.

It is usual that after your initial consultation with the doctor, that the next follow up appointment will be within 3 months. This is to give the prescribed HRT time to work, and also to observe any side effects or complications that may have arisen. These can then be reported back and discussed in more detail at your next visit. It is a good idea to make a list of notes about any medical symptoms or lifestyle issues that may be affecting you, and take them with you to your next appointment.

Finding the right HRT for you may take some time. You may need to try several different types, which can be delivered in many different ways. The current options of HRT that are available are;

Tablets – These are the most commonly used form of HRT. It is worth noting that because you have entered in to a premature surgical menopause, you will need a high dose of oestrogen. HRT in the form of tablets must first pass through the liver. In the long term this needs to be carefully considered.

HRT patches - These come in various dosages and you can be prescribed these for individual dosage requirement. The patches are small plasters, and they have improved greatly in terms of size and skin comfort. Patches are transdermally released across your skin, into the bloodstream. The patch generally needs to be changed twice weekly. Possible side effects- skin irritation/allergy.

Oestrogen gel - This is a relatively new preparation, and is quite easy to use. It can be applied to the upper leg or stomach. The gel works by releasing a consistent dose of oestrogen into your bloodstream, making this an effective HRT option. The advantage of the gel being that skin irritation is uncommon. The gel must be used on a daily basis.

Vaginal Ring - The vaginal ring has been designed for women whose womb has been removed. 'Menoring' releases oestrogen into your bloodstream. It is known to be effective in treating symptoms, like hot flushes and vaginal dryness. It should be changed every three months, and is a straight forward procedure to insert.

Vaginal creams - Oestrogen cream is directly applied into your vagina, in a measured dose with an applicator. It has a local effect on the lining of the vagina, and can be a beneficial treatment for specific vaginal symptoms, such as vaginal atrophy (vaginal dryness)

HRT implants - These are small pellets, containing oestrogen and are inserted under your skin. The implant usually contains a 6 month supply of hormones. They are surgically inserted into the fatty layers of your abdomen, under a local anaesthetic. An advantage of implants is that they can result in higher oestrogen levels, which for women after surgical menopause can very beneficial. However a woman may experience more unwanted side effects as the oestrogen in the implant runs out. Taxyphalaxis can also sometimes occur, this is a condition where your body has become used to having a certain level of circulating oestradiol. The brain then sends out messages that your body is feeling deficient of oestrogen, thus the return of unwanted menopausal symptoms. Another thing to consider is that if you were to experience intolerable side effects from the implant, though rare it might need to be removed. Locating it can sometimes prove difficult, rather like trying to find a needle in a haystack!

Nasal spray - 'Aerodiol' delivers oestrogen through your nasal passages. This creates a pulsed system of delivered oestrogen. It is unlike other forms of current HRT as it does not provide a constant dose of oestrogen, throughout the day. It is however an effective and easy to use therapy.

With so many HRT preparations now available, there must be one that suits you, it is worth persevering! The dosage with all HRT preparations will need to be regularly reviewed for you to try and achieve the maximum benefit at the lowest possible dose, whilst still providing effective symptom relief and protection.

It is important to note here that HRT may cause initial 'start up' effects. These may include; breast tenderness, nipple sensitivity, headaches, increased appetite, and leg cramps. Once your body adjusts to having normal levels of oestrogen again, any initial side effects should settle down.
Testosterone
For most women who have undergone a premature surgical menopause, they will also have a need to replace testosterone back into their bodies. Testosterone is mostly made by the ovaries. It therefore makes sense that what would have been naturally occuring levels of testosterone, are put back. Tiredness, loss of self esteem and libido can all be crushing to a woman having undergone a surgical menopause. Many studies have backed evidence to the benefits gained from testosterone therapy. Forms in which testosterone is administered for a woman in the U.K. is either as a tablet (Restandol) or as Testogel. Neither of these are currently licensed for use in women. The only licensed route of Testosterone for women is as an implant, this is usually given at the same time as your oestradiol implant, but can be implanted as a single treatment. Testosterone is an important addition to your HRT, and should not be overlooked as part of your hormone therapy. It is not just beneficial to men!

Quality Of Life Issues
Following your surgery you will inevitably feel weak both physically and mentally. While the physical scars heal much sooner than the emotional ones, it is important to be kind to yourself and to not expect too much too soon. For the first few months following your surgery you will need to allow yourself to rest more and think carefully about your nutritional intake. Eating a diet that is rich in soya and foods containing phytoestrogens can be highly beneficial, and may reduce some of your unwanted symptoms of hot flushes and night sweats.

Soya rich foods are said to lessen the risk of heart disease, and improve your bone density, not to mention keeping skin, hair and nails in good condition. In fact the addition of twenty five grams of soya into your daily diet, can successfully lower cholesterol levels. There are a vast array of natural remedies and alternative therapies now available. Many studies have been carried out into the efficacy of Red Clover against menopausal symptoms. This is welcome news for those women, following surgery who are unable to take conventional HRT.

Exercise is another form of positive self help therapy. After your six week check following your surgery, you can begin to take small, regular walks, for say 30 minutes at a time. When you exercise, you release endorphins from the brain that send feel good messages to your body. Weight bearing exercise is also another excellent and key part of dealing with preventative measures from osteoporosis. Setting yourself personal goals and aspirations may be a positive first step to take.

Oestrogen has many functions in various body systems, and one can begin to see why certain effects are likely to occur. Taking your prescribed HRT regularly is of utmost importance in gaining a steady stream of oestrogen into your circulatory system. It may be a good idea to link taking your therapy, with some other already established habit in your everyday routine. For many of us, surgical menopause represents the first time in our lives when we've been required to take a medication day in day out consistently.
Support
You may feel that you would like to seek some emotional support from someone that is not as closely related to you. You may wish to look for a trained counsellor who will listen and support you in a confidential setting. Your G.P. or Consultant may be able to suggest or refer you to such a person, or joining a Support Group can help, see the Further Information section at the end of this booklet. Providing a level of reassurance to you that you are not alone in feeling this way is one of the key stepping stones to moving forward.
Health Professionals
It is important to build a trusting working relationship with your specialist who is going to look after your long term menopausal care. This will enable you to feel as though you can openly air and discuss any worries, over any aspect of your treatment. You want to feel listened to, and your thoughts on choice of hormone therapy taken into account. A reassuring and sympathetic approach from a dedicated menopause team could be beneficial to you. A team of health professionals led by a consultant, may include input from a specialist menopause nurse, a Macmillan nurse, a dietician, a psychosexual counsellor, and a psychologist. These specialists may all be available for you to see via a referral. The widest input from your menopause team, will ensure you receive the best individualised treatment plan.

A premature surgical menopause is not an easy condition to come to terms with. It is not like breaking a limb, knowing in what time period it will heal. The consequences for a woman plunged into sudden menopause are complex and challenging. It is after all an invisible condition there are no visible outward signs to show the pain that you may be feeling inside. Recognition and support from those closest around will aid the grieving process that you may experience in feeling a profound sense of loss. This may be the key turning point to reaching a happier and healthier life ahead.

Further Information
Recommended Reading
The Premature Menopause Book – Kathryn Petras Quill Publishers
2002

Premature Menopause - A Multidisciplinary approach - Dani Singer

The Menopause HRT And You – Caroline Hawkridge Penguin 1999

Beat Menopause Naturally – Maryon Stewart Natural Health Publishing 2003

Osteoporosis The Silent Epidemic – Marilyn Glenville Kyle Cathie Ltd 2005
Support Groups
The Daisy Network www.daisynetwork.org.uk

Organisations
Women's Health, Tel 08451255254 Helpline Mon-Fri 9.30-1.30pm . www.womenshealthlondon.org.uk

Women's Health Concern www.womenshealthconcern.org

Marilyn Glenville- The Natural Health Practice
Tel 08458800915 www.marilynglenville.com

Maryon Stewart- The Natural Health Advisory Service Tel 01273487366 www.naturalhealthas.com