Hormone Replacement Therapy (HRT)
Hormone Replacement Therapy” or “HRT”, refers to prescription estrogen (with or without a progestogen) intended to reduce menopausal symptoms and, in the case of surgical menopause, to minimize the various health risks associated with premature menopause (i.e., before 40). This page contains information on common questions people have about HRT. Specifics of estrogen, progestogen and testosterone can be found here:
How can I find a doctor that is knowledgeable in HRT for surgical menopause?
How long is hormone Replacement therapy necessary in surgical menopause? What age should I stop?
Does HRT come from horses urine? What HRT is suitable for vegans?
How often should I have blood tests when in surgical menopause and what do the results mean?
You may hear HRT and MHT (Menopausal Hormone Therapy) used interchangeably. There is no difference between the two; they both refer to the use of prescription medications to increase levels of sex hormones in the body. “Menopausal hormone therapy (MHT)” is the newer term; it has replaced “hormone replacement therapy (HRT)” in many professional and scientific circles over recent years. Either one is acceptable and they mean the same thing.
How can I find a doctor that is knowledgeable in HRT for surgical menopause?
It is important to be under the care of a healthcare professional who understands surgical menopause and your particular health concerns-- particularly your needs for hormone therapy to reduce the long-term health risks associated with surgical menopause. Access to a specialist can, and will, vary from country to country - depending on availability and the health care structure. We understand that this is sometimes a challenge. Our Provider Directory (a searchable map of peer recommended providers) was updated in February 2020 to include submissions of those health care professionals who have good knowledge of treating surgical menopause - use the filter option to see who has been submitted so far.
Many countries have menopause clinics or menopause specialists, and you can usually find these online - we would recommend searching through reputable organizations for accredited and knowledgeable practitioners. Some countries also have their own Menopause Society, so it is worth researching if there is an association near you to check for accredited and experienced practitioners. Some examples of such organizations can be found here: Australia and New Zealand, Britain, and USA.
We know that good care for surgical menopause can be hard to find, and the process can be frustrating. However, we encourage you to keep searching until you find someone knowledgeable and supportive, as the right doctor can make all the difference in terms of your quality of life. Our peer support team can help you search so do reach out to us if you cannot find anyone suitable for you on the IAPMD provider directory or through your National Menopause Association.
How long is hormone Replacement therapy necessary in surgical menopause? What age should I stop?
In surgical menopause, estrogen therapy should begin right after oophorectomy and should be continued until the average age at natural menopause (age 51). At that time, you should re-evaluate the risks and benefits with your physician.
There is some evidence that the benefits of estrogen on thinking and mood are time-sensitive in surgical menopause-- they are more beneficial the earlier they start following oophorectomy.
This advice holds regardless of what age you enter surgical menopause.
If you have a uterus, you will need combined HRT (estrogen and a progestogen to protect your uterus)
If you do NOT have a uterus, you will need estrogen only.
It is important to note that the typical guidance around length of estrogen use is generally addressed to those in natural menopause, and does not necessarily apply to those in surgical menopause, who have greater estrogen needs. The length of time you take estrogen should depend on your individual risks and benefits.
References
NAMS 2017 Hormone Therapy Position Statement (North America)
What if I want to avoid menopausal hormone therapy (HRT) in surgical menopause due to a history of Premenstrual Dysphoric Disorder or other hormone-related emotional symptoms?
We totally understand the concerns that people have when starting HRT - especially if you have a history of reacting negatively to hormone based treatments. However, HRT can help reduce or eliminate many of the physical risks that come in surgical menopause, and so it is strongly recommended that HRT is used where possible. If you choose not to use HRT, it needs to be an informed decision.
Several studies show that people with PMDD experience abnormal negative emotional reactions during hormone changes. However, recent studies ALSO show that these negative emotional reactions usually go away about one month after starting HRT. Therefore, if you can tolerate the symptoms in the first month following the start of HRT (or any changes in HRT), symptoms usually subside. So while it can be a difficult start, many can with PMDD can take HRT during surgical menopause.
If you’re concerned about your ability to cope with initial symptoms in the first month of HRT, we encourage you to start with a low dose and build up slowly. It is wise to be aware that this can be a difficult time of increased symptoms, and plan ahead to increase support from family, friends, and healthcare providers during this time. For example, some people are able to start HRT during a “quiet month” where there is less stress in their life. Some may also choose to see a supportive health care provider more frequently during the first month of HRT, or ask those around them to provide additional support during this time.
Short Answer: Yes, people in surgical menopause almost always need to take estrogen because surgical menopause causes very low levels of estrogen (lower than in natural menopause), which leads to major health risks without estrogen therapy.
If you are entering surgical menopause before the typical age of natural menopause (before age 51), experts from a variety of leading societies (linked below) strongly recommend taking estrogen at least until the age of 51, the average age of natural menopause, and to speak with your doctor to reevaluate the risks and benefits of estrogen use around that time. Most individuals in surgical menopause choose to continue estrogen therapy through age 60.
Expert Consensus indicating that estrogen is critical in surgical menopause:
NAMS 2017 Hormone Therapy Position Statement (North America)
Please note that these recommendations for estrogen in surgical menopause differ greatly from those in natural menopause, where estrogen is considered an optional method for controlling menopausal symptoms.
Need for estrogen to control symptoms in surgical vs. natural menopause: Surgical menopause is similar to natural menopause in that it can cause bothersome menopausal symptoms (hot flashes, night sweats, joint or muscle pain, increased mood or anxiety symptoms, vaginal dryness, and sexual difficulties).
Unique estrogen needs in surgical menopause (why it’s more important to take estrogen in surgical menopause): Estrogen in surgical menopause is about more than controlling the bothersome symptoms above-- it is also needed to protect against the unique long-term health risks associated with oophorectomy/surgical menopause. Because surgical menopause causes a more severe estrogen deficiency, over time it is known to increase the risk of many long-term health problems, including osteoporosis, cardiovascular disease (heart attack, stroke), Parkison’s disease, impairing mood or anxiety disorders, sexual pain or discomfort, vulvar or vaginal atrophy, and dementia. In addition, surgical menopause is linked with greater risk of early death from all causes.
Estrogen in surgical menopause greatly reduces or eliminates each of these risks, especially when it is started right after surgery.
In sum, whereas most people undergoing natural menopause can avoid HRT without much consequence to their long-term health, this is not the cause in surgical menopause.
Therefore, if you choose not to use HRT in surgical menopause, it needs to be a very informed decision with knowledge of potential long term risks, and we highly recommend that you discuss your decision with a trusted health care professional.
Some individuals in surgical menopause have a personal or family history of conditions that can be affected by hormones, and thus are more concerned about HRT risks. This is completely reasonable. Although the scientific research suggests that there are fewer risks of estrogen in surgical menopause than in natural menopause (because baseline levels are so much lower), it is important to speak with a knowledgeable provider about what is best for you. There are many adjustments that can be made (e.g., lower dose, slower titration, use of alternative medications, or supplemental use of local HRT) to ensure that you are both protected from long-term health risks while also avoiding or minimizing any possible HRT risks.
What is the difference between bioidentical and body identical HRT? Are hormones from a compounding pharmacy safer or more effective? Should I do salivary hormone testing to determine if I have a hormone imbalance?
Bioidentical and body-identical both refer to hormonal medications that have an identical chemical and molecular structure to the hormones made naturally by the human body. There is a common misconception that bioidentical hormones are only available through alternative (non-traditional medical) health care providers and associated “compounding” pharmacies. This is a myth-- in fact, bioidentical estradiol, progesterone, and testosterone are available at regular pharmacies via prescription by a traditional medical provider.
Nevertheless, some health care providers falsely claim that they offer more “natural” or “bioidentical” hormones via compounding pharmacies. In fact, the truth may be the opposite: since compounding pharmacies are not regulated by the government and are not required to demonstrate the safety and effectiveness of their product, they may be less potent and pure. In support of this notion, testing of hormonal compounds from these pharmacies has shown less consistency in formulation and dose than that of normal hormonal prescriptions, meaning that the levels could vary between doses in ways that compromise their effectiveness or provoke symptoms among hormone-sensitive individuals.
Further, many providers ask patients to pay for special saliva tests to determine hormone levels, then prescribe hormones from compounding pharmacies to “fix the hormone imbalance”. There are several scientific problems with this approach:
the idea of “estrogen dominance” or “hormone imbalance” has generally failed to find support in scientific studies.
hormone levels cannot be accurately tested using this “snapshot” method due to natural variation in levels month-to-month, day-to-day, and hour-to-hour.
salivary hormone levels are subject to greater error than blood levels
prescriptions from compounding pharmacies appear to be inconsistent in purity and dose.
In light of the scientific evidence, we affirm the positions of the Endocrine Society, the North American Menopause Society, and the British Menopause Society, all of whom recommend AGAINST salivary hormone testing and hormone treatments provided by compounding pharmacies.
If you are interested in switching from synthetic hormones (which are often more potent) to bioidentical hormones, talk with your gynecologist or other medical doctor about it. There are a variety of bioidentical options available for prescription that can usually be dosed to match the effectiveness of the more potent synthetic compounds.
Additional Reading:
Does HRT come from horses urine? What HRT is suitable for vegans?
Certain forms of old-fashioned/traditional HRT are derived from horses’ urine (specifically, the urine of pregnant mares). These types of HRT are known as conjugated equine oestrogens (CEEs).
However, plant-based HRT (derived primarily from yams) is widely available and in many places, such as the UK, is prescribed first line. This plant-based form of oestrogen is termed oestradiol and is “body-identical” (or regulated bio-identical), meaning that it has the same molecular structure as the oestradiol we produce in our bodies pre-menopause.
Transdermal (which means it is absorbed through the skin) oestradiol (e.g. gels and patches) is suitable for vegans. Oestradiol implants/pellets are also vegan-friendly. The vast majority of HRT tablets are not suitable for vegans as they tend to contain lactose and/or gelatine (constituents do vary between countries, however, so this is always worth checking).
In vegan patients who require progesterone-cover (e.g. in those who have not had a hysterectomy), the levonorgestrel intrauterine system (e.g. the Mirena-IUS) would be a suitable choice. For vaginal/vulval symptoms Intrarosa (prasterone) pessaries are vegan friendly.
Premarin is not suitable for vegans as it is extracted from the urine of pregnant mares.
How often should I have blood tests when in surgical menopause and what do the results mean?
Following your hormone levels via blood (or saliva) tests while taking HRT is generally not necessary if you are taking pharma regulated HRT. (The only circumstance in which checking hormone levels may be of value is if you are on custom-compounded non pharma controlled hormone replacement therapy (i.e. Hormones that are not tested and approved by official authorities) and this is mostly to be sure that you are not getting excessive amounts of hormones)
Recommended dosing should get you to adequate levels that will both relieve your symptoms and give you protective health benefits. If you are not getting relief with a certain type or dosage of HRT it is of more value to adjust this than to check your hormone levels.
What is most important is how you feel and how your symptoms are responding to a particular dose of HRT.
“Why don’t test results mean anything? Surely we need to know the levels?”
We know this is frustrating and we often want a clear answer in front of us in black and white, but the best course of action is to listen to your body and track any symptoms. If you are noticing symptoms do see your provider with tracking information - they can then adjust your HRT as needed.
Measuring levels can be inaccurate and often misleading. What is most important is how you feel and how your symptoms are responding to a particular dose of HRT. There really is no “standard” for hormone levels. an individual’s levels change throughout the course of a day and can be different day to day. Again, it's more about how you feel than any number or level.
“Testing hormone levels is not required to determine whether a woman has the “right amount” of hormones. The optimal hormone levels in postmenopausal women have not been established. How symptoms respond to a particular dose of hormones or non hormonal menopause medication is the only reliable guide.
Saliva testing is often a part of custom-compounded “bioidentical hormone therapy” with hormones. But saliva testing is not only unnecessary; it has also not been proven to be accurate or reliable. Because hormone levels vary day to day as well as throughout the day, even a blood test cannot accurately reflect the body’s hormone levels.
The common hormone test that may be appropriate is for the level of follicle-stimulating hormone (FSH) to help determine if a woman is in menopause, especially for women who do not have a uterus and thus cannot tell by their menstrual pattern that they are menopausal*.
NAMS does not recommend saliva testing to determine hormone levels and does not recommend custom-compounded products over well-tested, government-approved products for the majority of women”
* This would not be applicable for those in surgical menopause as you become post-menopausal straight after surgery.
This project was financially assisted by The Patty Brisben Foundation for Women’s Sexual Health. The views expressed herein do not necessarily represent those of The Patty Brisben Foundation for Women's Sexual Health.