Special situations: no HRT

There are a number of reasons why some women are unable to take hormones in surgical menopause. A blood clotting disorder or cancer are the most common reasons for this, but occasionally we hear of doctors recommending against hormones for other reasons such as blood pressure, smoking, or fear of the other risks they can carry. Whatever the reasoning, this is a difficult road to follow. While women in natural menopause can often get by with symptomatic relief to augment their own lingering ovarian output, a woman in surgical menopause is most likely going to have to face life in some degree of hormonal deficiency.

Of course there are also women who wish to refrain from taking HRTs or supplementing their hormones (these may not be considered the same thing by some women). We've read comments from many women who are afraid of hormones or HRTs because of some family history of cancer or because they had their hysts for cancer. But not all cancers are the same in the effects hormones may have on them, and if you don't know, for sure and in detail, that your specific cancer or family risk is specifically estrogen-mediated, you may want to discuss your own particular risk factors with an oncologist. Just because cousin Mabel thinks she recalls that Great-aunt Violet died of some sort of cancer doesn't mean that HRT may pose an unacceptable level of risk for you.

By the same token, if you cannot safely take HRTs, please understand that alternative HRTs like nutraceuticals and high-phytoestrogen foods do contain functional hormones and carry those same risks you're avoiding with prescription HRTs. And consider further that if you deem a family or personal cancer risk too high to supplement your hormones, you may want to discuss with an oncologist whether your own hormones also present that level of risk. Remember: your body doesn't stop producing hormones entirely when you lose your ovaries: you are still producing enough for the majority of your needs via body fat and adrenal conversion. If the small increment that HRT use adds is too dangerous, so too might your own production pose an unacceptable risk. An oncologist can help you explore whether you need to take drugs to block all hormone production or use in the body, and this may be every bit as important for you as not adding more to your system.

We also hear from many women who don't want to take "artificial medicines" that "make menopause a disease." Well, neither do we. Alas but HRT has been demonized plenty, both in the popular media and by crusaders who view it as nothing more than an evil plot by doctors/pharmaceutical companies/aliens to enslave women. That ignores, sadly, the real situation of surgical menopause as characterised by a shortage of something normal to the body's functioning and replaceable with equivalent chemically-structured supplements. We're not proselytizing for the use of HRT, but we are, strongly, urging women to research and understand the physiology behind their hormone needs and how they can be met. It's not a case where taking HRT is the only side of the question that has potentially negative impacts on health: not taking it can be just as devastating, can raise mortality risks just as high. And sadder yet are those who try to meet their hormone needs with alternative HRTs all the while denying that they are taking HRT and failing to monitor for those hormone risks. Whatever you do, please understand both the risks and benefits; don't just be swayed by fearmongers and salesmen.

For those, then, who cannot or choose not to supplement their hormones beyond what their own body can produce, there are a number of coping strategies that may be of use in dealing, one by one, with the aspects of hormonal deficiency that most plague you. The big question for women in this situation is well, what can I do? We'll do a rundown here of the most common problems.

Bone density


Weight bearing/strength/balance exercise is the biggest component of bone maintenance, whether or not we take HRT. No matter what raw materials we take in, we need to use our bones daily to produce the stimulus for our body to maintain bone strength. All women, irrespective of hormonal status, are recommended to get a hour's weight-bearing exercise daily. Yes, we realize that this is dull and unappealing for many women, but for women not taking hrt, this is akin to a drug that is required to replace it.

In addition to that, we need to provide our bone-building cells with the raw materials to construct those bones. This means about 1200-1500 mg calcium and 600-750 mg of magnesium, 15-30mg of zinc, and 800 mg of folic acid. We also need to make sure our vitamin D intake is adequate; while the US government standard has been raised from 400 IU daily to 600- 800 IU, the latest numbers we're seeing call for 1000 IU daily (free signup required to read) and many physicians, especially in higher latitudes, are recommending 2000 IU to their patients. It is widely believed that caffeine is a bone-robbing culprit, but that has recently been demonstrated not to be the case (it does boost circulating estrone, an estrogen, and for that reason is not something to binge on if you can't use HRT).

Bone scans are even more important for those who cannot use HRT, and getting a baseline density measurement soon after your hyst may be wise to track changes. There are a number of different drugs doctors can prescribe if we develop osteoporosis, but each of them carries fairly significant and not necessarily reversible risks of their own, and they are all rather expensive for lifelong maintenance.

Cardiovascular system


Taking a daily aspirin can reduce your CV risk by 33%, achieving your ideal body weight counts as a 45% risk reduction, regular exercise contributes a 45% reduction, you reduce your risk 2% for every mmHg of hypertension (blood pressure above 140/90) you reduce, quitting smoking is another 50% reduction of risk, and you get a 2% reduction for every 1% you reduce an elevated cholesterol. Sources also attribute a 35% risk reduction to "modest use" of alcohol, but because alcohol ingestion boosts circulating estrogens, we can't recommend it as a strategy in those avoiding estrogen exposure. Needless to say, monitoring blood pressure and lipids should be a part of a menopausal woman's annual physical and this is especially true of women raising their CV risks by practicing estrogen deficiency.

Dry skin, eyes and hair


Make sure you drink plenty (that's at least a quart and a half) of water every day (this doesn't mean sweetened drinks, which don't hydrate you very well). Put on a good moisturizer while you are still wet from your shower, and don't shower in excessively hot water or more than once a day. You may find that a moisturizer that contains urea will help hold moisture in your skin. Taking evening primrose oil may help with your hair, but you need to eat oily fish (salmon, mackerel, sardines, etc) twice a week to make sure that the whole process works right. Ask your eye doctor for a recommendation of moisturizing eye drops (the single-dose packets are great for avoiding contamination). You may not be able to wear contacts, but if you have your heart set on them, look into some of the newest, high-moisture brands. Limit the number of hours you spend staring at a computer monitor (and remind yourself to blink regularly). If eye dryness begins to damage your eyes, your ophthalmologist can insert tiny plugs in your tear ducts to help maximize the use you get out of what moisture you do produce.

Urinary incontinence


Kegel exercises are the best remedy for this. Antispasmodics such as oxybutynin or hyoscyamine may help. At night, some women get relief using a low dose of the tricyclic antidepressant imipramine (25 mg). A pessary may help support weak pelvic tissues. Simple tricks like emptying the bladder more often, planning for bathroom availability on long outings, and moderating fluid intake when bathrooms are not convenient can help get you through awkward moments during the day.

Vaginal atrophy


Avoid using scented soaps and rinse thoroughly when washing the genitalia. Avoid the use of antihistamines, decongestants or other drying medications. The use of vitamin E as a vaginal lubricant/moisturizer is well-documented as effective (insert a gel-cap of the regular vitamin into the vagina and let it dissolve and absorb—best done at night). External use of soothing creams made with calendula, comfrey or other soothing herbals may help…if you are not allergic to them (test a tiny bit first, please). Oatmeal baths are a classic for soothing skin complaints of all sorts. Commercial lubricants like K-Y or Replens will help during sex, but may not do as much as vitamin E for general moisturizing. Vaginal tissue health is a use-it-or-lose thing, in which regular intercourse or masturbation can greatly combat atrophy. Zinc and evening primrose oil are said to contribute to vaginal tissue health.

Insomnia


The primary problem with sleep is often being awakened by either hot flashes or their aftermath, soaking sweats. We discussed some measures related to hot flashes at night in our overall discussion of flashing, and there are more under a separate section below. For other sleep help, the use of soothing bedtime drinks is preferable to the use of sedative drugs. Try valerian or chamomile (or both combined in a "sleepytime" tea) or non-chocolate Ovaltine as bedtime relaxers. A traditional remedy is to sleep with a pillow stuffed with dried female hops flowers—which sounds rather nice. Finally, consider what your expectations are. It is better to get up and do something than to flop around in bed being furious that you aren't sleeping. Don't go to bed till you are tired, even if that's not till 4 am, as you'll just train yourself to be frustrated. These tips and many more, both medical and non-medical, are available from the National Sleep Foundation's insomnia portal.

Hot flashes


Black cohosh and red clover are about the only two herbals that have actually tested out as effective, but only in a limited way and with some notable risks. Red clover can affect clotting time, thus impacting those on anticoagulants as well as anyone facing surgery, and some of the recent tests proving its efficacy for hot flashes are now being questioned. Black cohosh, as studied in animal tissue, may stimulate metasteses of existing cancers (not cause new ones). This essentially moves it out of the "herbal-alternative" column and into the "estrogen" column as far as level and type of risks go, although it may retain some utility for those whose objections to pharmaceutical hormone preparations are philosophical rather than health-related. There is also a body of research that suggests that black cohosh does not stimulate new cancers, so its use in women who are convinced they are cancer-free may be less objectionable.

Soy, while considered by many naturally-menopaused women to be useful for hot flashes and other estrogenic effects, is shown to be too estrogenic in the biochemistry of its action to be safe for those avoiding estrogen. Soy isoflavones have not been demonstrated as effective as whole soy, although combination products of the two may be a little more potent (or may not).

The other potentially-useful agent is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Because these drugs boost serotonin, which can occupy estrogen receptors in the brain, SSRIs can be very effective in combating both the hot flashes and the depression that can result from lack of estrogen. They are not totally benign drugs and must be used under a doctor's supervision, but they can be true lifesavers. An older drug that was used to treat hot flashes, bellergal, is a less-attractive choice because of its sedative and drying properties. Clonidine, a blood pressure drug, and Gabapentin, an anti-seizure drug, are other non-hormonal drugs used to treat flashes but also have significant side effects. All of these agents may decrease the frequency and intensity of flashes but probably will not eliminate them entirely.

Depression, mood swings, crying, lethargy


In some ways, this can be one of the most extreme and destructive problems a woman in surgical menopause must wrestle with. While doctors are sometimes too quick to offer the easy fix of antidepressants as a bandaid to cover up hormonal balance problems, we have to endorse the validity of this approach when HRTs cannot be used to correct the underlying chemical disruption lack of estrogen causes in the brain. Depression is a life-sapping disorder and one difficult to admit to or to be effective in combating while in its throes. There are lots of useful non-drug interventions available to help with depression but perhaps the best is exercise. Exercise releases endorphins, a feel-good chemical that can improve your mood for a considerable amount of time. Unfortunately, depression can make it difficult to motivate yourself to exercise or use many of the other useful techniques.

Stepping up in intervention is use of an antidepressant. St. John's Wort continues to be well-regarded by some practitioners as a safe and effective antidepressant. For some women, it's all they need; for others, it's not just strong enough. In those cases, treatment with an SSRI antidepressant would seem to us to be a desirable approach. Some of us who cannot use hormones are now using an SSRI, and the rest of us would like you to know, it's making a vast difference that both they and we can see. An article published by CNN in Dec. 2000 cited a Mayo Clinic researcher, Dr. Charles Loprinzi, who reported that "a four-week trial involving 229 women, most of whom had a history of breast cancer, revealed that venlafaxine was 60 percent effective against hot flashes. The optimum dosage was 75 milligrams daily," Loprinzi said. "And the effects we saw were within a week." The report is the end result of ten years of studies looking for the best solution for breast cancer patients, and finds that venlafaxine (Effexor) to be expensive, but far more effective than any other of the traditional medical, herbal or vitamin remedies. This has been further supported by research since then, and an SSRI is now considered a standard of treatment. As with hormones, different women respond differently to each SSRI, so some experimentation may be necessary to find the best, most effective one for any given woman.

Depression in menopause is both over-dramatized and under-appreciated. Women tend to blame themselves (and doctors may help them do it) for not "getting a grip" and "having a positive attitude." Sure, it's a rough adjustment, especially when we're limited in our choices and the transition is traumatic. But there are also real, physiological issues here. For the best explanation we've seen, we highly recommend the book Women's Moods by Deborah Sichel and Jeanne Watson Driscoll for a scientifically-sound but not incomprehensible discussion of the topic, including a number of self-help steps any woman can take to help cushion her brain from the effects of menopause. The link in the book title above takes you to a more in-depth report on this book here, but you can also check your favorite used book store or library for a copy.