Welcome to our guide for surviving surgical menopause. Congratulations for setting out to learn more about your body and her needs in this challenging time!

Because this site uses blogging software, this home page can be a little confusing and, frankly, isn't the best of places to begin reading. Instead, we suggest you begin by reading the "Introduction" tab above, and then move along to the "Table of Contents" page. Working from that to read one article after another in that order will make a great deal more sense for you. And don't forget, if you're looking for something specific, that there's a search field in the left side of the upper pink navbar. Still can't find what you need? Come join us on our forums and we'll try to help you out.

Vaginal atrophy gains new designation: GSM

Introducing 'Genitourinary Syndrome of Menopause' (free signup required to read) details a proposed change of terminology from "Atrophic vaginitis" and "Vulvovaginal atrophy."

The change, proposed by both the International Society for the Study of Women's Sexual Health and the North American Menopause Society, is based upon the fact that neither term is adequately accurate or encompassing, and many patients have discomfort using the word "vagina."

The new term, or its abbreviation GSM, is expected to be more tolerable, much as the way "erectile dysfunction" was easier for patients to discuss than asking them to say "penis."
The conference concluded that GSM is more accurate, inclusive, and less embarrassing than the older terms. In addition to easing conversations, the new term will be used to develop a tool to help standardize physical examinations so that women can take advantage of treatments such as vaginal moisturizers, vaginal estrogen, and estrogen mimics.
This doesn't really change the way we think about the issue, but we do need to be prepared to recognize the new term as it starts to be more widely used. And, really, if it helps anyone open the discussion, it's a great move.

Attitude and hot flashes: an editorial

May we groan with you about this article we just read? Hot Flashes? No-Sweat Attitude Spells Minimal Disruptions (free signup required).

Doesn't this sound nice and encouraging? Rah-rah? And look, not only do these women nurture their own health, but these skills can be taught.

But here's the thing about the subtext of this kind of approach. Although they're not saying it here, this implies that if women would just suck it up and not obsess about "little" things like this, their insurance companies wouldn't have to cover their hrt prescriptions. Everybody wins!

Only really not. Because in addition to furthering the old "it's all in your mind" brush-off that's so disabling for women who can't do so or who dare think that this is a problem for them, this kind of attitude really pathologizes the woman who experiences crippling disruptions. And that's more likely to be us in surgical menopause than women in natural perimenopause, for whom non-hormonal, non-insurance-reimbursible approaches can indeed also be helpful.

This is a trend in research just now, finding reasons not to treat things, and it's a trend that looks suspiciously as though it's driven by insurance companies. In recent years we've been told not to get mammograms because they're too distressing for our delicate sensibilities and my sister's husband, who narrowly survived a very early, very aggressive prostate cancer, is told he shouldn't have bothered getting tested and discovering that because most men outlive their cancers. And on and on, nearly every week I read a recommendation that testing for this or treatment of that isn't "cost effective." This is only one more study, but it's one that grates nonetheless because it undoes so much of what has been done in recent years to set surgical menopause apart as a different entity to natural menopause, permitting different treatment approaches.

Let's each of us hope that our own doctors have failed to catch this latest "news" item. And let's be gentle with each other, all of us in any kind of menopause, and remember that while attitude is very important, we're not a failure if that's not enough. We deserve wellness, each and every one of us, no matter how that wellness is obtained.

State of hrt use in menopause: what we (think we) know today

There have been a lot of changes in our understanding of hrts in the past decade and a half, and it's been a tumultuous time for women trying to hold onto their health as medical opinions seem to veer wildly around them. Let's take a look at a bit of history to lay the foundation for our current understanding.

How we got here

HRT use really came into vogue in the mid-twentieth century with the development and marketing of Premarin. Touted as the key to eternal youth in such popular books as Robert Wilson's 1966 Feminine Forever, Premarin was the fifth highest-selling prescription drug in the US in the final quarter of the century. It wasn't long after its introduction, however, before research began to illuminate some of the perils of unopposed estrogen, such as uterine cancer, and the long effort to reduce the risks of hrts while still enjoying their benefits really got underway.

By the 1990s, researchers were exploring the various endogenous estrogens in search of more natural-seeming and lower-risk alternatives to the mainly synthetic and mostly oral hrts then available. The thinking was that by mimicking the natural distribution of estrogens, risks could be reduced or even blocked. At the same time, Dr. John Lee was publishing his work touting progesterone in books and websites. Women were told that progesterone held the key to every hormonal complaint and it wasn't possible to take too much—in fact, the more the merrier. This even went so far as directions to apply progesterone directly to breast tissue to prevent cancer and fibrocystic breasts. Compounding pharmacists, who could blend these new, noncommercial hormones into multi-hormone blends, began selling saliva tests and advising doctors on prescribing these "bioidentical" hrts, an increasingly popular service despite the refusal of most medical insurance programs to cover them. Women were encouraged to replace all of the hormones they could test, "adrenal insufficiency" became the catchphrase of menopause, and hormone precursors were often thrown into the mix because they were "all safe, all natural."

Research, however, was gradually revealing a different picture and in 2002, everything changed. The huge US research project, the Women's Health Initiative study, was abruptly halted due to the incidence of breast cancer in one arm of the study exceeding the pre-established study limits. Overnight, popular and medical understanding of hrt went from it being a helpful menopausal strategy to it being a rapid and nearly-inevitable death sentence. Scare headlines convinced women that hrts were lethal and doctors that only liabilty lay in the path of prescribing them. Data that indicated that risks rose to an arbitrary line after five years of use were interpreted to mean that hrts that had been acceptable for five years became fatal on the following day, and women were told that there was now a firm time limit for hrt use should they be so weak and foolish as to use it in the first place. The entire message was hrt = breast cancer, and it was a powerful, terrifying message. By the end of that year, prescriptions for hrt had fallen dramatically...and so, according to several studies, had breast cancer. Much less mention was made in the medical or popular press of the widespread misery caused by sudden hrt withdrawl, but it was clear online as forums rang with tearful pleas for anything non-hormonal to stem the awful effects. While we know that breast cancer rates dropped, we don't yet have the full reckoning of the more delayed cardiovascular and metabolic price women paid for this panic.

A few voices were raised amidst the hysteria, questioning the applicability of the study results to all hrts, especially since the arm of the study involving women who had hysterectomies, and thus were taking Premarin alone instead of the PremPro used by the higher-risk participants, showed a reduction in breast and colon cancer below what would have been expected for that population. Others questioned the delivery route and age of study participants, especially with regard to the cardiovascular risks the study found.

Also a matter of concern with the study results: was this risk situation particular to Premarin, the oral delivery route, or all estrogens? While medical practice has long required that all hrts be treated as though identical in practical terms, new research was already questioning the impact delivery route was having on inflammatory factors, agents known to contribute to cardiovascular and cancer risks.

And, finally, were the study participants, mostly a decade or more post-menopause and who had not used hrt in the interim, too old to yield meaningful information about younger women using hrt from the time of menopause?

As time has passed, the study data has been re-analyzed and re-examined in the light of other current research and although this reappraisal has not engendered headlines on the scale of the study cancellation panic, the effects are in fact slowly propagating through the medical world. Where 5-8 years ago doctors advised against hrt and if used, used for only a limited time (that five years of safety/five years + 1 day = death proved remarkably sticky as a guideline), today many of the major medical groups are revising their standards back to a judicious endorsement of hrt.

The major focus of research today continues to center around risk reduction. The new understanding of route-related effects has boosted development and marketing of more transdermal, human-identical hrts, with many of the older oral and synthetic hrts fading away off the market. Greater understanding of the cancer risks associated with progestogens (progesterone and its synthetic versions) has reduced the routine inclusion of progesterone in hrt for women without a uterus and driven attempts to develop SERMS that don't stimulate uterine tissue so that women who do have a uterus aren't forced to rely upon progestogens to mitigate that risk. The question of age-related risks has focused research on the "critical timing" (also called "window of opportunity") hypothesis, supporting the notion that women best reap the health maintenance benefits of hrts when they are taken immediately upon menopause, without allowing hormone levels to drop catastrophically. And a greater appreciation of what hrt means to the quality of a woman's life and health, disastrously demonstrated by the widespread misery left in the wake of post-WHI hrt prohibition, has even led to a softening on the stance that women may take an hrt only so long.

Current understandings

Today, the standard offered by most medical groups is "the least amount of hrt for the shortest time." That's a risk-focused strategy and on its surface, sounds rather grudging. But that's not actually what its intent is and that's not how we, in surgical menopause especially, need to take it.

The "smallest dose" is only a sensible precaution that many of us have been advocating for and practicing ourselves for some time: risks accrue with lifetime estrogen exposure, so taking only as much as is required to meet our personal menopausal health goals is simply reasonable. That doesn't mean we all need the smallest retail dose, but rather, we need only as much as provides the effects we've selected as important to us. More hrt (beyond our level of needs) doesn't improve its action; it only raises its risks.

Similarly, the "shortest time" is, once again, determined by a woman's own judgement of her needs and how they're being fulfilled. We have long known that our hormone needs decline with age. In keeping with the smallest dose precaution, we should reduce our hrt dose, then, at intervals as we age. At some point, sooner in natural than surgical menopause, our declining needs curve intersects the zero dose point. And that's when we don't need to supplement any longer. That, then, defines the "shortest time," after which ongoing exposure, again, accrues risks rather than benefits.

Now, if you're reading carefully, you'll see that both parts of that standard, then, are in fact pretty subjective: it's about how our hrt meets our own goals. A doctor's role is to help us explore risks and ongoing need, but the bottom line, in guidelines document after guidelines document, is a woman's own sense of her goals and how they are being met. Everyone from the British Menopause Society, which is currently a stakeholder in the National Institute for Health and Care Excellence (NICE) developing new guidelines for menopause treatment for the NHS to help remedy some of the damages done by ten years of post-WHI hormone avoidance, to the American Association of Clinical Endocrinologists is re-evaluating the lessons of the past decade-plus and forming a more flexible and woman-centric stance on the use of hrt. And this is very good news for us.

Below, we've listed of some of the major medical groups' current menopause treatment guidelines Why? Because reading them helps us understand how our doctors are seeing the situation. And if they're not telling us things that are in accordance with these updated guidelines, we can share these with them as authoritative statements, not just the easily-dismissed "something you read on the internet."

Research and trends

Additionally, there are a few interesting trends that are forward-looking.

We are slowly starting to see women post-cancer-treatment electing to use hrt for quality of life, balancing this against the risks and discomforts of hormone deprivation treatment. This is typically not a measure endorsed by their oncologists, who tend to focus on preserving life at all other cost, but rather one they often work on with their general doctors. Further, the general prohibition of "you had cancer once so you can never take hrt" even when risk of recurrence is low is coming more frequently under examination as the "hrt = cancer" heritage of WHI abates.

Still, there's so much we don't yet know. The whole issue of mental function, Alzheimer's, dementia, "brain fog," loss of multi-tasking capability: this remains an area of research in which study results remain in disagreement or inconclusive. Usually in research this means that the proper situation isn't yet defined, so we can only wait while research slowly rolls on.

Exploration of the "critical timing" or "window of opportunity" issue continues, despite the problematic nature of trying to distinguish between fostering protection and preventing or treating disease. (bookmarked articles on this topic) While this is generally still referred to as a hypothesis, meaning it's not considered proven, the British Menopause Society has recently made the leap to "confirmed," giving it a truly arguable weight as a health strategy.

As use of progestogens comes under greater scrutiny and, in general, wanes, testosterone continues to enjoy considerable chic. Research on its risks, however, is building up and the US FDA in fact recently turned down a testosterone hrt for women on the grounds that it was not universally effective enough to balance its risk profile. As we've discussed elsewhere in our troubleshooting libido section, testosterone seems to be helpful only in women who actually have an actual shortfall of that hormone; in other women, for whom the issues with libido are not related to testosterone levels, it's ineffective in boosting sexual desire or responsiveness and, yes, represents an unjustifiable risk burden.

Finally, SERMS (modified estrogens) continue to receive development attention as a way to capture estrogen's benefits while reducing risks. To date, these have not provided as "full featured" hormone coverage as estrogen itself, but research remains active in this potentially lucrative niche.

HRTs in practice

There are a lot of fine points to using hrts once we've got a doctor willing to prescribe them. Many of these aren't things we'll learn from research, but rather from the discussions women have about their hrts and how they've worked best for them. A lot of this body of knowledge is incorporated into the various articles on this site, but since we're often asked which is the "best" hrt, let's look at some of what we as the community of hrt-using women have learned in the past decade and a half.

There is actually no "best" hrt. The "best" hrt is the one that works for any given women. All hrts work for some women, but no hrt works for all women. That's why the question "what works best for you?" is so frustrating, because that's not going to answer "what will work best for me?" The process of identifying the best hrt for our own selves remains a journey of personal experimentation. Still, there are certain understandings that can help point us in useful directions.

  • Troubleshooting patch techniques and placement, including brand change, solves many of the problems women have with this hrt;
  • Switching from oral to transdermal solves many of the problems women have with poor response to orals;
  • Women who do best on trickle-dosing are a distinct subset, as are those who do best on daily dosing: this seems to be an either/or situation for many;
  • Women who have really worked the estradiol hrts without success often find that CEEs hold the key to a more comfortable fit;
  • CEEs and part/all-estrone hrts can help with with migraine issues where estradiol hrts have proven problematic, and vice-versa;
  • Gel delivery remains the most problematic, in part because we don't yet have good technique troubleshooting information (we think)(it may just be that it's a finicky delivery that we can't make better), even though some women do spectacularly well with it;
  • Low, slow, and estrogen-alone all seem to be the most straightforward and most comfortable ways for adjusting/troubleshooting hrts;
  • Contrary to what we thought a decade ago, most women in surgical menopause do just fine without supplementing progesterone when their estrogen is well-balanced;
  • A well-functioning, well-delivered hrt works for most women at the usual doses, with a predictable age/dose inverse correlation; and
  • The best determinant of "enough" is achievement of a woman's own health goals.

For discussions on new research, guidelines content, or hrt troubleshooting, please join us in our discussion forums.

Tuning our hrt support as we age

After all of the work we have gone through to find our best hrt and correct dose, it would be understandable if we thought our job were done. Unfortunately, that's not the case. Sooner or later, we'll need to re-evaluate where we are with our dose and whether it's still appropriate for us.

Sometimes it's a matter of our doctors freaking out and going "You've been taking hrt for HOW long? OMG you have to quit immediately!" That's not a response guided by the major specialist practice guidelines, but it is a response to popular media coverage of hrt issues, especially the cancellation of the Women's Health Initiative Study, and their sense of legal liability.

What happened was that after five years of studying several kinds of hrt use, the WHI found that in (only) one arm of the study breast cancer incidence rose a small amount that was nonetheless enough to trip the study limit guidelines and force shutdown of the program after it had gone on for five years. In the popular media, of course, the headline was "HRT kills!" And in medical literature, doctors solemnly agreed that they could prescribe hrts for five years of safe use, but one day after that five years, it was unacceptably deadly.

That's a nearly nonsensical reading of the study results. And in fact, over time and re-analysis of the results of the WHI, recommendations have come to reflect this. Most current guidelines repeat the mantra: as little as possible for as short a time as possible. Which, to phrase it more constructively, can be construed as the minimum amount that meets our needs for no longer than we require it to meet our needs.

See what they've done there? There is no calendar attached to that statement other than that provided by our own bodies and our own health goals. Aside from major and incompatible health problems, our doctors have no justification for demanding we quit and we should feel no obligation to stop using hrt at some arbitrary deadline.

Why we do need to revisit our hrt dose

Nonetheless, we do need to be sure we're paying attention to the least/shortest guideline because that does speak to our best current understanding of the risks of hrt use.

Here's the thing: as we age, our hormone needs decline. We can't freeze ourselves at one age by thinking we're supporting that by our hrt. That's an old fallacy and a dangerous one. Instead, our goal is to support our needs as they are in each moment with just enough hrt to feel right.

The problem is that we tend to go along unquestioning and tiny bit by tiny bit our hrt fits us less well. We don't really notice, even, because excess tends to be a lot less dramatic than deficiency. But we may have fewer hot flashes (especially those lingering ones at 5 am) or our breasts may feel fuller or we don't seem to need our local vaginal hrt quite as frequently. It's nothing we might notice as a trend, but that's what it is.

Because of its subtlety, though, waiting until we notice it isn't the best of strategies. Instead, we will more accurately shave that important line of least risk by regularly challenging our dose. How regularly? Oh, every three to five years seems to be the sort of interval that produces useful results, although a case could be made for deliberately asking this question about a year after our surgeries as well.

So how does this work? 

We're glad you asked.

When it comes time for a dose challenge, we need to look at our hrt and determine a reasonable amount to try as a decrease. For some hrts, we're limited by the doses it's sold in because we can't break the delivery form. For others, it's very easy to make a tweak.

We're looking to decrease our dose by no more than 10-15%. That amount is enough to notice but shouldn't be enough to really ignite transitional fireworks. If we have no other choice, a 25% reduction is something we might pull off without too much uproar, but beyond that it's unlikely we'll not experience some deficiency if we weren't in significant excess earlier. In other words: we're looking to eliminate that invisible creep of dose above needs, and if it were more than about 25%, we'd probably have already felt the need for change. On the other hand, if you've been taking hrt for 20 years without ever adjusting your dose, you might be there.

So we try out our new reduced dose. We can do this at any time, although it may be more successfully done in the summer (which of course means winter if you're in the southern hemisphere). That's because the withdrawal of that amount of support from our brain chemistry in particular is most smoothly adjusted to when we have other things to help out with it, things like outdoor exercise and sunshine. Women who reduce their dose in the winter (by which we mean the dark time of year), particularly when they live in higher latitudes, may find seasonal blues too overwhelming when they are decreasing their hormonal support at the same time. Remember: even when we're moving toward a better dose, we're still going to need to make adjustments to that new dose.

If we are going to be dramatically unsuccessful in our challenge, we're likely to know this within a week or two. Transitional symptoms, in which our bodies respond to any change, generally settle within three to seven days, and only after that is the adequacy of the background dose revealed. Journaling through this period, even if we haven't done it for years, can be very helpful in revealing things in retrospect that were too slight to recognize at the time.

If we are experiencing unpleasant symptoms of deficiency, then, we can determine that our dose most likely needed to be where it was. We resume our previous dose and figure okay, good for another few years.

If things seem to be going okay once the transitional symptoms taper off, however, we might as well carry on with the new dose. Which doesn't yet mean our challenge is a total success. Sometimes a dose drop can leave us with such a very tiny deficiency that it takes a long time, months even, to decide that nope, this isn't really meeting our needs the way we want. Symptoms may be very subtle with this kind of a mismatch: maybe we notice one day that we're getting creakier or we just don't feel the joy in life the way we did last year. We make these kinds of evaluations based upon what we have previously learned about how our own body demonstrates deficiency; if we develop new problems, we cannot automatically assume they're about the hrt because we are getting older all the time.

If we experience this kind of slow deficit, the answer is still to go back up a bit in dose: there's no time limit on this. If we have the option, going up less than the full increment we decreased by would make sense; if not, we can go back to the old dose with the assurance that we're as closely tuned as that particular hrt makes possible to our present level of need.

And when our doctors ask at our annual checkup about whether we've thought about still needing hrt? Being able to say "yeah, last year I tried cutting back a bit and found that within a month I was running noticeably low and I feel a lot better now that I'm back on my current dose" is going to go a long way toward convincing them that we're using hrt responsibly in accordance with the current medical practice guidelines.

So in summary:
  • there is no calendar date that defines safe vs unsafe duration of hrt use;
  • our needs for hormone supplementation do decline slowly with age;
  • we should challenge our dose every 3-5 years to make sure we're using the least dose that meets our needs; and
  • our doctors should be impressed that we're taking care of this for ourselves.