We are (broadly speaking) either fertile or we have stopped cycling/ovulating. The moment in time when ovarian output, which is in a long, slow decline from peak fertile years in our early twenties till our 80s, dips below that required for cycling, is called menopause. The portion of life after experiencing that critical hormone output dip is properly called postmenopause. Menopause, then, is defined as that moment when we have not had a period for 12 months, and it is only a named milestone, a convenience of terminology, not a particular physical event.
Our normal decline in ovarian output is not smooth, and beginning about a decade before we reach the point of menopause, the rate of decline typically speeds up and becomes very erratic in terms of the amount of hormones produced by our ovaries. It's also typical for the balance of ovarian hormones to grow more erratic as the decline in output of each one fails to sync with the output of the others. This period is called perimenopause and it is fraught with the symptoms caused by this hormonal uproar that we normally refer to as "menopausal symptoms."
But—and this is critical to making sense of this—these symptoms continue around the time of menopause and mark the entire transition, not just the time before menopause occurs. These symptoms gradually abate as the fluctuations that created them abate and the we settle into some degree of hormonal stability again. The extent to which our hormone needs are met by our postmenopausal ovarian output will determine the extent to which we may experience hormonal deficiency symptoms that persist beyond this transitional time. But it's this settling down that is the key to the end of this perimenopausal period, not that we have "gotten over" our need for non-fertile hormone functions.
This diagram, which is conceptual rather than a strict numerical representation, shows how these periods and events intersect in natural menopause.
For us in surgical menopause, however, there is a bit of a difference. Instead of following the normal decline in hormonal output, at some point we undergo surgery and cut off the ovarian contribution to our total hormone supply entirely. When we have our surgery, the precise time the surgeon snips our ovaries free from our bodies is our time of menopause. Wherever we may have been on the natural menopausal timeline of ovarian decline before surgery, we depart from it dramatically and totally at the moment of surgery.
Following surgery, we are postmenopausal. We also typically undergo a period of transition during which our body adjusts to the sharp hormone decline plus whatever fluctuations we induce by our recovery from surgery and our menopausal strategies and lifestyle measures, including hrts. While not strictly fitting the definition of perimenopause because this time of transition is non-ovarian in nature, the symptoms we may experience will have much in common with those in the natural menopausal progression undergo in perimenopause.
And, just as those in natural postmenopause will experience hormonal symptoms reflective of the way their postmenopausal strategies meet their remaining hormone needs, so we in surgical postmenopause will experience symptoms that reflect the overall adequacy of our strategies in meeting those needs. We don't "get over" our need for hormones but we may (we surely hope that we do) get over that chaotic time of transition.
So, again, a little sketch chart of how our hormone levels in surgical menopause map out against time and the named milestones:
This then ties into one of the very confusing concepts that is pretty important in balancing hrts in surgical postmenopause: the difference between transitional symptoms and background hormone level adequacy.
Any hormone fluctuation can cause symptoms. Our bodies work very hard, constantly, to keep us on an even hormonal footing in a very dynamic world. We obviously throw a huge monkey wrench into this system when we dispose of one major component, our ovaries. Our bodies respond to this catastrophic change with symptoms due to the fluctuation. So too when we change our hrt dosage, even if by a relatively small increment, our bodies notice, and respond to, this fluctuation. Once our bodies have had some time to adjust to the transition, the magnitude of these symptoms diminishes. This can actually be a useful thing, by the way, when adjusting our hrts, since these symptoms signal to us that we have, in fact, done something effective to change our hormone levels. In that way, then, transitional symptoms play a positive role in confirming that change is occurring.
The other aspect of our hormonal situation at any given moment has to do with our background level of hormone adequacy. We have hormone needs. If the total quantity of hormones in our system at any given moment meets those needs, we're balanced and probably feel pretty good. If our background level of hormones fails to meet our needs or exceeds them, the extent to which it does so will produce symptoms that reflect both the magnitude and extent of that mismatch between supply and demand.
Where the interplay between these two become tricky and an understanding of them becomes most needed is when we are adjusting hrts. When, for example, we adjust our dose in the correct direction (towards better meeting our needs), we may still expect to experience symptoms due to that hormonal fluctuation. Only once the transition is over and we settle down (a matter of a week to a couple months, depending upon the hormone and situation) can we properly determine the background adequacy of the new dose. While the transition may be shorter with smaller changes or less dramatic when it goes in a supportive direction, we cannot read its symptoms as answers to the question of background adequacy. We have to wait out the transition before that question is answered. Users who make hrt changes too rapidly risk becoming mired in continuous transition and may never be able to actually determine background adequacy until they slow down and allow their bodies to settle down.
Does that mean we cannot effectively adjust our hrts when we are in that pseudo-perimenopausal period after our surgeries? No, not at all: that is a time, as we've explained elsewhere on this site, when we have to accept the hormonal turmoil of this very major transition and just do the best we can on an ongoing basis while waiting for recovery to carry us through into healing and greater stability. But understanding that a component of that turmoil is only due to the transition and doesn't reflect our chances of attaining the hormonal balance we're working for is important. And understanding what's going on in our bodies, even in this simplified way, can go a long way towards helping us put up with the aggravations with such grace as we can muster and keep us working in a productive direction towards better postmenopausal wellness. And that's what we're all here for, right?
