Surgical Menopause Is Untrue

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. There are, however, 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 as 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 sac 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 ratio. 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 a little 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 losing 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 - PreMARin). 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. 

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