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.

The Cenestin-Enjuvia discontinuation quandary

With the recent reports that these two HRTS have been taken off the market, we've had an influx of women joining our discussion group asking what they can take to replace them.

That's not an easy question to answer. In part, the answer depends upon just why each woman chose that HRT and continued to take it. So let's look at some of the ways we might end up with this particular blend of conjugated estrogens and consider where we might go from there.

The first one they tried

For women who took one of those brands simply because that's the first one their doctors gave them and it seemed to work okay, this presents an important opportunity to actively choose and try out other hrts. We've put up a simple framework and supporting aids for working through this process based upon each woman's own priorities, not whichever drug rep most recently pitched their product to our doctor. If we work though the selection process, choosing an HRT that meets our own preferences and lifestyle, our doctors should honor that request. And because we've done our homework beforehand, we're prepared to state just why we're making that request, which factors are important to us. We may not have success with our first try or our first try may need a bit of tweaking, but we have to start somewhere. The good news is that this process is easier moving from the stability of a good solid HRT foundation than if we've just had surgery or have been in a state of hormonal uproar.

Alternative to Premarin

If a woman chose this HRT as an alternative to the Premarin that their doctors were urging on them, no, there is not another alternative. There is no other vegetable-source HRT on the market that provides conjugated estrogens. If your doctor is Premarin-or-nothing and will not countenance your using a different type of HRT, the other option is to find a more reasonable doctor who is willing to let you make the critical decisions about your own body and health. Or take Premarin. Even though Premarin is likely to provide for a somewhat different experience, it may work acceptably if one of the others previously did. That assumes, of course, that one is not a vegan or does not have ethical objections to its manufacture.

Tried everything

If women came to this HRT after hopping from one brand and type to another, taking each one at one dose for a short period of time and then, because that one didn't fit, moving on to another, it may be time to reflect upon that process. It often happens that the first dose of an HRT we take doesn't thrill us, but if it does demonstrably deliver to our bodies, we can often tweak the dose or application mode to provide a better fit. When we instead simply jump to another HRT and then another, we pile up the stress of all of those imbalances on top of an already stressful lack of estrogen, leaving us in a deeper and deeper hole we've got to dig back out of.

We've written elsewhere about the process of choosing and tuning an HRT, and while it's not instant gratification, we're all capable of the self-observation skills to carry this out. This may be a good time to revisit this basic selection process, think about which formerly-tried HRT really seemed as though it might have been a good fit for our lifestyle, and revisit it for another attempt. It's very important to remember that if we did this hopping in the first few months after a hyst, we were adding the hugely stressful burden of the menopausal transition to all of the things going on in our bodies, and in a changed setting, months or years later, our overall response might be changed as well.

Prefer oral

If a woman came to this HRT simply because they wanted an oral HRT, a pill they could pop and not worry about it, then reviewing the list of HRTS available in the US (this issue does not affect those using UK HRTs since there was not a non-Premarin conjugated estrogen sold in this market) will show you your options. While this delivery has been less popular in recent years because of its greater risks for cardiovascular disease and cancer, it remains a valid choice for women who are willing to accept that risk profile or who have found that most transdermal deliveries don't work effectively for their bodies.

Uncomfortable with estradiol

While the majority of women today use estradiol HRTs, that contain this active form of estrogen, there is a body of women who find this much activity in a dose excessively stimulating. While we can speculate about genetic variants in metabolism, we don't really have any good explanation why this affects some women but not most others. Nonetheless, after giving more than one estradiol at more than one dose a try, these women just can't settle in. In the end, an HRT that is more estrone-based (the less active, storage form of estrogen) seems to be more comfortable for them.

Unfortunately, there are not a lot of options for these women. Some of the estrone options will be sold as "piperazine estrone sulfate" (formerly known as estropipate), sold as brand names Ortho-Est and Ogen, or "esterified estrogens", sold as the brand name Menest. It's not clear how many of these remain on the market, but women are successful in finding them from time to time. Probably the best tactic, since this availability is not something your doctor will be able to advise you on, is to call around to pharmacies to see if any of them carry or can order it, and if you find one, then ask your doctor to prescribe it for you.

The other option for an estrone-based HRT would be to have one compounded. While compounding pharmacies can make up all-estrone or an estrone-estradiol blend of any proportion for use by a variety of routes (oral, transdermal, transbuccal), women should be aware that the typical "bioidentical" prescription is a generic blend that is more appropriate for a woman in natural perimenopause and contains mostly estriol, a weak estrogen breakdown product effective only in urogenital tissues, plus a small amount of estradiol. This particular type of HRT is not likely to meet a woman's needs in surgical menopause. Instead, one needs to have a doctor prescribe either all estrone or a proportional estradiol/estrone blend to come closer to replicating something more like the conjugated estrogens that have been discontinued. Compounding pharmacies cannot make up a conjugated estrogen blend to match the discontinued HRTs because they do not have access to the components.

Prefer a synthetic estrogen

There are many factors that go into selection of HRTs, and some women may for one reason or another choose a non-human-identical estrogen. There is not another synthetic estrogen blend on the market, however. The most popular synthetics that are not Premarin are ethinylestradiol, a potent synthetic used in oral contraceptives, and tibolone, sold as Livial or Tibofem, that is a synthetic steroid drug with some estrogenic, progestogenic and androgenic activity. It is unlikely that either of these will provide for the same experience as the conjugated estrogens.

How to switch

Once you've made your choice, have your new HRT and are about to run out of the last of your Enjuvia or Cenestin, you might be wondering what the best tactic is for changing over. Luckily, it's pretty easy:

  1. Take your last conjugated estrogen pill.
  2. Wait 24 hours.
  3. Begin your new HRT.

It's as easy as that.

Now, because the conjugated estrogens aren't actually human-identical estrogens, it may take your body a while to fully metabolise them, especially if you've been taking them for years. So you may find that after a few days to a few weeks or even possibly a month or two, your new hrt, even if it felt great at the beginning, now doesn't feel as though it's quite such a good fit. Don't panic! This doesn't mean it's stopped working. It just means that you were still cruising on some leftover conjugated estrogens and now they're gone so they're not contributing to your total coverage any longer. And that means that you need to make a small bump in the dose of your new HRT. In this context, "small" generally seems to mean no more than about 10-15% of your dose, not doubling it. Too big a jump is not only uncomfortable in itself, but it risks taking us right past our best dose and into the risky and unpleasant territory of excess. So this is a case where being gentle with ourselves really pays off better in the long run.

One other question we often see has to do with how much of a dose we will need of our new HRT. In general, wherever we were in the range of available doses of our old HRT (highest, lowest, middle), that's where we start in the range of doses of our new HRT. That's just a guess and it won't be perfect, but a guess is as good as we can get when changing from one type of HRT to another. So we start there and then tune. If in doubt, it's almost always better to underestimate than overestimate, just because it's easier to identify and quicker and safer to play catch-up from.

The bottom line

Cenestin and Enjuvia are gone. There is no secret illegal internet pharmacy that can provide non-counterfeit versions of it. There is no immediate replacement that we can expect to work exactly the same way. This means that, one way or another, you're changing HRT.

In order to best do this, you need to identify your own situation and goals, pick a new option, and test it, including tweaking it if needed.

We can help you with this. Here are the links again for some of the specific resources we can provide:

And of course you're always welcome to come to our discussion group to talk through your own process. We can't tell you what will work best for your own body, but we can help you and keep you company as you explore the various options you have.

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.