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.

What we can agree on about hrts and what we still don't have any idea about

Two interesting documents have recently been released that can make a difference to how we, and our doctors, think about and use hrts.

First is the Revised Global Consensus Statement on Menopausal Hormone Therapy. You can read the full version online here and here, and it's worth doing so because the language is clear and to the point, the article itself brief.

What this represents, as the article clearly states, is what a whole whack of international expert societies on menopause can all agree on. It may not cover everything each one specifically states, but it's the fundamentals they all accept as proven today. And that's important: these are proven points, not things still up for discussion or demonstration. And so if your doctor doesn't know these things or disagrees with them, he's disagreeing with what the specialists in the field accept as proven. There's always room for personalization, but if he's still arguing about this stuff and can't explain why it doesn't apply to you, you may be receiving outmoded care.

What's exciting for us in this? Mostly, that this includes a number of points we've been making for years.
The type and route of administration of MHT [Menopausal Hormone Therapy] should be consistent with treatment goals, patient preference and safety issues and should be individualized. The dosage should be titrated to the lowest appropriate and most effective dose.
Note the "patient preference" part in there. As well as the "most effective" in with the "lowest" point.
Duration of treatment should be consistent with the treatment goals of the individual, and the benefit/risk profile needs to be individually reassessed annually. This is important in view of new data indicating longer duration of VMS [hot flashes] in some women.
See what the main standard is there? the "treatment goals of the individual." That means that if we say we need it, we do. Yes, it's right to check this every year and try out a lower dose from time to time, but no longer is there any excuse for an arbitrary age or cumulative time cut-off.

And, finally:
The risk of breast cancer in women over 50 years of age associated with MHT is a complex issue with decreased risk reported from RCTs [clinical trials] for estrogen alone (CE [Premarin] in the Women’s Health Initiative (WHI)) in women with hysterectomy and a possible increased risk when combined with a progestin (medroxyprogesterone acetate in the WHI) in women without hysterectomy. The increased risk of breast cancer thus seems to be primarily, but not exclusively, associated with the use of a progestin with estrogen therapy in women without hysterectomy and may be related to the duration of use.
Note that although they identify the one progestin that there's solid clinical data for, they leave the question somewhat open. Thus we begin to see that the risk of all progestogens is gaining in credibility. "Just because" is no longer sustainable in hrt prescribing, especially for women who have had a hysterectomy.

Here's the full citation and doi number if you want to share this and it's not convenient to download one of the pdf versions linked above:
ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20
Revised Global Consensus Statement on Menopausal Hormone Therapy
T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang & D. D. Pierroz
To cite this article: T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang &
D. D. Pierroz (2016): Revised Global Consensus Statement on Menopausal Hormone Therapy,
Climacteric, DOI: 10.1080/13697137.2016.1196047
To link to this article: http://dx.doi.org/10.1080/13697137.2016.1196047

Could precision prescribing of estrogen be achieved?

This is the second interesting article, one that one of the members of our discussion group just shared with us all: Post NICE Guidelines: could precision prescribing of estrogen be achieved?

In a way, this article also says the things we've been saying for years about the fact that while the drug information data for hrts suggests that they are drugs of a "one size fits all" sort, personal experience of women is varied and confusingly individualized. In short, it basically says that different women have different needs and to best meet them, you need to give them different things. And by the way, lab tests are rubbish at figuring all of this out.

Groundbreaking stuff, this.

Okay, while we'd like to just be snotty along the lines of it being about time doctors were catching on to what women have been trying to tell them for so long, it's actually good, in the ponderous, over-proven way that medical consensus moves, that these things are being said. Again. Because if we say it, we're just poor ignorant deluded women; if doctors say it, it is thought-provoking and reasonable...and may eventually make a difference. And that's the real importance of this article: that doctors are saying that there's more to using or prescribing hrt than thinking of it as an interchangeable drug.

Also, we wanted to throw up our hands and cheer at this paragraph—or, actually groan with the truth of it:
The NICE guidelines have been published at a time when investment in research into women's health has evaporated, not only because of desertion of commercial money but fundamentally because the funding in this area of research is not attractive for voters and, indeed, many opinion leaders in those policy-making circles believe that the menopause and its associated symptoms are women's destiny and they have to cope with it.
We don't entirely like his conclusion that women should fund this needed research, but we have a sneaking suspicion that we're looking, right here, at the future of medical research: if you want it, you have to invest in it. And when haven't we women, in the end, had to do things for ourselves?

The "problem" of bioidentical HRTs

Medical news services are full, lately, of articles decrying recent surveys indicating the popularity of compounded HRTs (one, two). With figures showing use statistics varying from 28-68% of HRT users choosing compounded (so-called "bioidentical") HRTs, this represents a significant loss of income to physicians. Dismay over this loss is cloaked in a variety of concerns, typically that these HRTs are not FDA-approved and that they come without boxed warnings, but the subtext is very clearly "but they didn't get them from US" or even more blatantly "but they didn't do this OUR way." And the tactics suggested in the more instructional of these articles focus primarily upon creating fear and shame in these straying patients.

What seems to be substantially missing from the medical professionals' side of the discussion is any attentiveness to why women have made this decision and how medical practice could address those concerns better. "Personalized" is what a lot of the comments come down to, but that's not the full picture we see in our discussions with women.

Women talk about things like how they're seen as noncompliant when the stock HRT their doctor offers them doesn't suit their needs or even their lifestyle. Women talk about being rebuffed with "I can't help you" or "I don't do that" when they ask for a different HRT brand or route or dose as they struggle to find their way in an opaque and guideless wilderness of choices. Women take articles they've found from medical journals or medical specialty group consensus documents to appointments to discuss latest findings and guidelines and are waved off with "I know everything I need to about HRTs." Women who have had cancers find discussions of their hormone needs flatly dismissed with the notion that it is ungrateful, their lives having been saved from cancer, to want to enjoy those lives with some quality of comfort. Women disabled by symptoms are frightened when those symptoms are waved off with an "I gave you HRT so it can't be your hormones" and the blame turned back on them. Women in surgical menopause, who understand that this is a different entity to natural menopause, are unable to establish trust with health professionals who insist that their symptoms are simply self-indulgence and that "a few warms spells and it'll all be over." And women who have been taught that medicine is evidence-based are dumbfounded to find that there are no tests to guide their way and no objective standards that can be applied beyond "the FDA says this drug works" when a particular HRT manifestly doesn't for them.

There is a vast gulf between what doctors want—customers—and what women in menopause want—health—and everything in the current discussions seems to indicate that doctors are not willing to bridge that gap. Is it any wonder, then, that advertising claims of customization, personalized care, attentive adjustment of HRTs, "natural" treatments, and safety—no matter whether justified or not—are winning out with these customers in the face of the "do it our way or no way" approach they feel they are receiving from their medical caregivers?

It can be argued that menopause is really a poor fit for allopathic medicine in the first place, that being, by definition, the diagnosis and treatment of disease. What women in menopause want is not to be labeled with a disease requiring treatment but rather a way to maintain their health in the face of a lifestage change that alters their health, comfort, and risks profile. For all that is good and bad in the compounded HRTs industry (and we have many thoughts on that), that's what is, in the end, the perception of the product being sold. Women are no longer the dependent, easily-influenced, uninformed 50s-era housewives who hang upon their doctors' guidance: they're smart, educated, doing their research, and willing to shop for what they feel they need. And until doctors and other prescribing professionals can address this opportunity in a constructive manner that actually addresses these women's needs, this situation isn't likely to turn around.

In the end, it doesn't matter which HRTs are fully licensed or which of the compounders' claims are bogus. What matters is that those practitioners are saying to women: we hear you; we believe you; we'll work with you. And until medicine can do that, can meet menopausal women from a point of respect, it is likely to continue to hemorrhage patients to more receptive practices.

Stopping Hormone Therapy Linked to Cardiovascular Death

News article (free signup required)
Full article

Okay, this is big. This is the biggest news in hrt/menopause since the WHI cancellation. And, as the news article notes, it's gonna be controversial and an uphill battle, but so far the results look really really impressivee. Short form (quotes taken from the Medscape article linked above):
In the first year after a postmenopausal women discontinues hormone therapy, her risk for cardiovascular mortality is higher than if she had continued the therapy.
Or to put it in more quantitative terms:
In the first post-treatment year the discontinuation of HT use was accompanied with 26%– 66% elevations in the risk for cardiac or stroke death. This risk elevation was markedly higher in women who were younger than 60 years at the initiation or discontinuation of HT use.
So much for quitting hrt to a timeline. We already have data that the post-WHI hrt-cutting cost the world economy billions of dollars in lost productivity, that being a more important (*sigh*) measure to many than the level of misery experienced by those women, which was astronomical. Since that study cancellation the major medical consensus guidelines have been backing away from established timelines, defaulting to a woman's own evaluation of her needs while still emphasizing the risk-limiting "shortest possible time." Those guidelines have, however, escaped either the notice or the endorsement of many, many doctors, and the practice of time-based hrt prescribing continues on a very large scale.

But now we have a lot of pretty compelling data that arbitrary discontinuation of hrt to a schedule, absent other health considerations, is not just miserable but fatal. Oops.
In women 50 to 60 years of age, "we clearly see" that this "is doing more harm than benefit," he reported. "If women are otherwise healthy, they could continue hormone therapy as long as they wish."
Now this immediately raises two questions with respect to surgical menopause. First is of course the woman who is left post-op without hrt support, effectively the same thing as taking then stopping hrt when we're talking hormone levels. This makes "let's wait and see if you need it," a witless approach with surgical meno, not just cruel but potentially fatal. Let's take a moment and think about that. Yeah, not easy to come up with a lot of gratitude for that, is it?

We do have to raise the question: what about women with cancer risks or who have had cancer? And here it's obvious, really, that we need to individualize a great deal more than has been done with the current default policy: cancer of any kind = no hrt. That's going to be a challenge for women and their oncologists, and we probably can't expect that issue to be resolved in any useful way very soon. But that doesn't mean that women shouldn't ask and shouldn't press for a very clear evaluation of their relative risks beyond the kneejerk one that prevails right now.

The other issue is at the other end of the timeline. Does this mean that we need to continue hrt forever? That's not actually what this research is saying. The underlying action here likely will be seen not to be some magical property with which hrt is imbued but rather one of meeting current hormone needs. We've well established that our needs do decline with age, such that lower and lower doses of hrt make up coverage for that decreasing level of need. So there's no reason at this point to doubt that we can and should continue to step down, meeting our needs at their current level, until we are covering them on our own without an increment of supplementation. There's nothing to indicate that easing off of hrt in this fashion would present the same problems as discontinuing hrt when it was still needed, although that may change as this continues to be researched.

We've linked above to the full journal article, which can be downloaded in pdf format and also be found in our bookmarks account. It has some good examinations of the solid and the more questionable aspects of the study, which will come into play in the quibbling over it that has undoubtedly already begun. This is going to complicate the practice of prescribing hrt for doctors, but in a manner that brings it in a direction that women have always espoused: normalizing health rather than treating menopause like a disease, like something that only involves fertility. And that's good news for us.

Too old for hrt?

Despite the loosening of medical stance about hrt in general as the early panic over the Women's Health Initiative Study has waned, many women have encountered the seemingly hard stop-date of 65 on their HRT prescriptions despite being in surgical menopause and still experiencing considerable hormone supplementation need.

Recent research has, however, begun to validate (because goodness knows they couldn't believe us about it) the persistence of hot flashes well beyond the conventional "just a few months" and in fact into years if not decades post-menopause. This has, in turn, led to reappraisal of that upper limit for treatment.

The North American Menopause Society (NAMS) has taken this research into account in their latest position statement, NAMS Supports Judicious Use of Systemic Hormone Therapy Even After Age 65. Here are the money quotes from that release:
“The official position of NAMS is that there shouldn’t be hard and fast rules against hormones after age 65,” said Wulf Utian, MD, medical director for NAMS. “Yes, there may be safety concerns, and the Society does recommend that a woman use the lowest dose of hormones for the time appropriate to meet her needs. But we know that, under some circumstances, hormone therapy can be appropriate for women over age 65, such as those instances when the benefits of treating hot flashes outweigh the risks or when a woman has a high risk of bone fractures and can’t take other bone drugs or can’t withstand their side effects.”
“The use of hormone therapy should be individualized and not discontinued solely based on a woman’s age,” said Dr. Utian. “NAMS encourages all women bothered by their menopause symptoms to seek the help they need and consider all of their options with the guidance of their clinician.”
What does this do for us? If our doctor suddenly decides to cut us off despite our work to keep our HRT dose reduced to reflect our decreasing needs as we age, providing them with a copy of this statement may help them find their way to updating their understanding of the current standards for HRT use. And if we're interviewing a new doctor, asking if they are familiar with this new recommendation and are willing to prescribe accordingly can help us make sure we're working with a doctor who shares our interest in maintaining our menopausal health. While not all of us in surgical meno will need to supplement our estrogen past the age of 65, it's wonderful to finally have explicit medical guidance that we may do so if we need it.