Surgical Menopause: Should You Take Estrogen After Your Hysterectomy?

Should you get hormone replacement therapy (HRT) after surgical menopause? The answer used to be very simple -- yes. Until the early 2000s, hormone therapy was routinely recommended not just for women who had their ovaries surgically removed, but for any woman entering menopause.

But things have changed in recent years as the risks of estrogen therapy have grabbed headlines and its benefits have been thrown into question. For many women undergoing surgical menopause, doctors still recommend hormone therapy. But finding a simple right answer isn't so easy anymore.

To help guide your decision, here are the pros and the cons of getting HRT after surgical menopause.

HRT and Surgical Menopause

So what is surgical menopause? It's menopause that develops suddenly after the ovaries -- the main producers of the hormone estrogen -- are surgically removed.

The removal of the ovaries is called an oophorectomy. The procedure is often combined with a hysterectomy -- removal of the uterus -- but not always. And in fact, women who only have their uterus removed will not go into surgical menopause. Their ovaries are still making estrogen. They'll go into menopause naturally when they get older, although sometimes a bit earlier than usual.

Estrogen plays a key role throughout the body. It affects the brain, the bones, the skin, the heart, the blood vessels, and more. While estrogen levels lower gradually during natural menopause, they plummet with surgical menopause. That sudden drop in estrogen can lead to menopausal symptoms that can be quite severe.

Hormone therapy after surgery -- either with estrogen and progestin or with estrogen alone -- is a way to counteract the supply of estrogen you've lost. Women who have both the uterus and ovaries removed usually just get estrogen replacement therapy (ERT) alone. But women who have only the ovaries removed need both estrogen and progestin. That's because estrogen alone can increase the risk of cancer in the uterus. Adding progestin removes this risk.

Rarely, if ever, will both ovaries be removed without the uterus. Often, only one ovary may be removed, which will negate the need for HRT at the time of surgery,

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HRT After Surgical Menopause: Pros and Cons

To give you a better sense of what to consider in your decision, here's a list of reasons you might lean toward getting HRT, along with a list of reasons against. Keep in mind that few if any of these pros or cons are definitive. Instead, you and your doctor have to consider them all and decide which apply.

The Pros: Reasons to Consider HRT After Surgical Menopause

  • You're young. By definition, women who go into menopause as a result of surgery aren't that old -- they're at least young enough to be premenopausal. And while the risks of getting hormone therapy in older postmenopausal women have grabbed headlines, there may be risks for younger women who don't get it.

    Estrogen affects the body in many ways. Many experts believe that it plays an important role in protecting younger women from disease. Doctors have long known that the risk of heart disease is much higher in women who had their ovaries removed before menopause. A 2006 study showed that women who had their ovaries removed before age 45 were 1.7 times as likely to die -- from any cause -- than average. Removal of the ovaries before menopause has also been linked to a doubled risk of Parkinson's disease and dementia. There's growing evidence that hormone therapy helps prevent these problems in young women.

    But how do these benefits fit with all we heard about the risks of hormone therapy? One of the studies that sent people into a panic about the dangers of HRT was the 2002 Women's Health Initiative. Critics point out that the average age of a woman in that study was 63. Hormone therapy may just have a different effect depending on the age at which you start it.

    So, many women who go into surgical menopause when they're under 50 go onto HRT. Then, when they hit the average age of menopause (51), they can decide whether to stay on it or not.
  • Your menopausal symptoms are severe and other treatments haven't worked. Some women find that their menopausal symptoms -- the hot flashes, the vaginal dryness, the sleep problems -- are unbearable and nothing seems to work. HRT can be quite effective in preventing and reversing many symptoms. For example, some studies show that it can cut the number of hot flashes by 75%.
  • Other health benefits. While perhaps not enough to justify getting HRT on their own, there are some other modest health benefits from hormone therapy. For one, it can slow down osteoporosisand increase bone density. Treatment with both estrogen and progestin seems to slightly reduce the risk of developing colorectal cancer.

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The Cons: Reasons to Lean Against HRT after Surgical Menopause

  • Your menopausal symptoms aren't bothering you, or other treatments work fine. Some women don't have very severe symptoms after surgical menopause and don't want or need treatment. Even if you do have acute symptoms, HRT is not the only way to control them. Other drugs or lifestyle changes can help. Talk to your doctor.

  • You're 50 or older. Many women who go into surgical menopause at 50 or older -- the natural time of menopause - decide not to get HRT. That's because their supply of estrogen would naturally drop during menopause anyway. There is some evidence that the older you are when you start HRT, the higher the cardiovascular risks - at least initially.

  • You have liver disease. Estrogen pills can put a lot of stress on the liver. So if you have liver disease, your doctor may not want you to take oral HRT. Other ways of getting estrogen - like patches and gels - bypass the liver and are safer options.

  • You're concerned about the side effects. HRT can also cause symptoms of its own. Many resemble the symptoms of premenstrual syndrome -- swollen and painful breasts, headaches, and nausea.

  • You're at a higher risk of health problems like:

o Strokes. Hormone therapy can increase the risk of stroke, although your odds are still very low.

o Blood clots. Oral estrogen, at least, may also raise the risk of blood clots. Estrogen patches and creams may pose a lower risk, but that's still unclear.

o Heart attacks. Combined estrogen and progestin therapy may slightly raise the risk of heart attack -- at least according to some studies.

o Breast cancer. The possible connection between breast cancer and hormone therapy is scary but uncertain. Several studies have shown that hormone therapy with both estrogen and progestin can cause a small increase in the risk of breast cancer. One large study found an increase of 8 more cases per 10,000 women.

But evidence is mounting that treatment alone with estrogen does not increase the risk of breast cancer unless it is used for more than 6 years.

Doctors tend to be cautious about using HRT in breast cancer survivors. There's concern that estrogen might trigger recurrence. Because of the conflicting information, talk over the latest research with your doctor.

o Ovarian cancer. The evidence is uncertain, but treatment with estrogen alone may increase the risk of ovarian cancer. However, this is a very rare cancer to begin with, so the risks are very low.

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Putting the Risks and Benefits of HRT in Perspective

If you're just glancing at list above, some of the risks of HRT might seem to overwhelm the benefits. Could a reduction in vaginal dryness possibly be worth an increased risk of cancer?

But look at the details. The risks of HRT -- while real -- are quite small for an individual person. For example, the 2002 Women's Health Initiative study found that ERT increased the risk of strokes by 39%. That sounds frighteningly high. But the actual number of people affected is very small. Out of 10,000 women who are not taking ERT, 32 have strokes each year. Out of 10,000 who are taking ERT, 44 have strokes each year. That's an increase of just 12 people out of 10,000.

On the other hand, when it comes to controlling the symptoms of surgical menopause, a huge number of women feel the benefits. One out of four menopausal women has severe hot flashes. Treatment with hormone therapy cuts down the number of hot flashes per week by 75%. So if a woman had 24 hot flashes per week, HRT would drop that number to six. That could make a big difference in the quality of her day-to-day life.

Weighing the Hormone Replacement Therapy Pros and Cons

When it comes to getting HRT after surgical menopause, deciding what to do isn't easy. The contradictory headlines in the media in recent years haven't helped. It's easy for a woman to feel like she's making the wrong choice, no matter what she does.

When you're deciding, you have to consider a lot of different factors, including your age, your family history, and your habits. Just take it slowly and don't allow yourself to be rushed into a decision you're not ready to make. Remember that both the potential long-term benefits and risks of hormone therapy are really quite small for any individual person.

You also need to regularly check in with your doctor about the latest research into HRT. Just a few years ago, hormone therapy went from seeming like a miracle cure to a medical fiasco. Now, expert opinion may be changing again.

Finally, don't discount your gut feelings. The decision to get hormone therapy after surgical menopause is personal. The right answer depends as much on your preferences as it does on the facts in your medical chart.

WebMD Medical Reference Reviewed by Nivin Todd, MD on July 8, 2018

Sources

SOURCES:

ACP Medicine web site: "Menopause."

British Menopause Society web site: "Further Evidence in Favour of HRT in Early Menopause."

Chen, WY et al, Archives of Internal Medicine, May 8, 2006; vol 166: pp 1027-1032.

Medscape web site: "Oophorectomy Before Menopause Linked to Increased Risk for Dementia, Parkinsonism."

National Cancer Institute web site: "How to Deal with Surgical Menopause."

National Institutes of Health Medline Plus web site: "Estrogen."

National Institutes of Health web site: "Facts About Menopausal Hormone Therapy."

National Women's Health information Center: "Menopause and Menopause Treatments." Practice Committee of the American Society for Reproductive Medicine, Fertility and Sterility, November 2006; vol 86: pp S75-S88.

Salpeter S.Climacteric, 2005; vol 8: pp 307-310.

WebMD Medical Reference: "Estrogen Replacement Therapy."

 

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