Natural vs surgical menopause: what is the difference?

It seems as though a lot of folks (and some doctors) find the differences between natural and surgical menopause confusing, especially in the light of the popular misconception that a woman can "get over" a certain period of menopause and then be fine with no further need for ovarian hormones. That's not how it goes at all, as we've explained elsewhere on this site, but we're probably not helping things by going along with everyone else in misusing the terminology. Let's see if we can redeem ourselves by clearing up a little of this confusion.

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?

Troubleshooting patches: Adjusting patch dose

While the obvious answer in customizing patch dose is to have your prescription rewritten for another of the doses in the range offered by the manufacturer of the particular patch brand you are using, it can be difficult to guess which new dose might offer the improvement you are looking for. It's a good idea, when your doctor suggests altering your dose, to ask for a few samples so you can try out a new one before paying for a whole prescription's worth of them.

But what if your doctor is unreceptive to the idea that your dose isn't exactly right, or there are other considerations that make the most obvious course less of an option for you? There may be times when, in order to clarify your own thinking, you want to try a very small iteration of change, not a whole different prescription. There may be times when you're not sure of the direction you need to go, or you may feel that the next regular dose increment is too much of a change and you'd like some smaller degree of adjustment. The available dose range is not sacred; it's simply a marketing decision made both to cover the range in terms of something-for-the-majority and to match the offerings of their closest competitor. It doesn't mean that other doses might not work—and might not work better—for you.

You can change your dose by moving the patch

In the discussion of location, we looked at how repositioning your patch allows for one sort of dose adjustment: where the patch is placed may affect the amount of hormone you take up from it.

Depending upon where you're placing your patch right now, you may be able to increase or decrease your dose just by moving it. That only works if the right direction is available to you, of course, but it's a quick and easy way to tweak your dose when it does work.

You can change your dose by adding and subtracting from your patch

When you need something different than just location can provide, your next option is directly acting upon the amount of patch available to deliver the dose. If you decide, for example, that you want to double your dose, then you can slap an extra patch of the same size on and, just as simply as that, you are getting that doubled dose. This works with any type of patch.

But what if you want less than a doubling of dose or some form of decrease? That can still be done, but now you are into the trickier realm of cutting patches. There are some very important considerations that govern patch cutting, so pay close attention here.

To begin with, not all patches can be cut. All of the reservoir patches, which contain a glob of hormone gel between two membranes, cannot be cut. To cut a reservoir patch would simply allow the contents to leak out onto the skin in an unmetered way. So if you're using a reservoir patch (and this is part of the information we cover for each patch on our estrogen HRTs page), stop reading here: this isn't an option for you. Your options are either changing prescription dose or changing prescription.

If, however, you are using a matrix patch, in which the hormones are distributed through the adhesive, you do have some additional options. Again, be sure to check that your patch does fall into this category before you try this.

The important thing to understand about matrix patches is that the dose of hormone delivered is proportional to the area of the patch. That means that half of your patch will deliver roughly half of your dose, one quarter of your patch will deliver one quarter of your dose, all the way down to 1% of your patch delivering 1% of the dose. Because of that, if we cut our patch in half, we now have two smaller patches, each of which delivers roughly half of what the original patch did. And so forth.

Obviously, there are limits to where we can go with this--a 1% patch slice is going to be laughably difficult to cut accurately. And we must make our cuts accurate if we are to have any hope of reproducing our dose adequately from one patch change to the next. Depending upon the original patch's physical size, you may be able to accurately make a 1/4 or 1/8 cut, but beyond that, it's not likely that the cut will be accurate. Still, that's a finer degree of adjustment than may be available with the regularly prescribed dose range, and is probably about as fine a distinction between one dose and the next as we'll be able to feel. Remember about making hormone dose changes: the greater the degree of change, the greater the symptoms likely to be caused by the fluctuation of the transition. So a 1/4 or 1/8 or 1/6 patch change is plenty for one change cycle and about as small as is practical.

How do you do this? It's a good idea, when you first are working this out, to trace a patch on paper and use a ruler to evenly mark off whatever grid will produce the size block you'll be cutting out. Trimming off an edge makes the most sense from a functional standpoint, since it doesn't leave corners that will be more likely to peel up, but in fact a small change may mean taking out a squared chunk. Do the best you can within the limits of being as accurate as you can. From your paper template, cut out the piece you'll be working with. That becomes a stencil you can use from one patch to the next, tracing it on the patch backing, to make sure each patch is cut the same way.

Use sharp, pointed scissors to make your cuts. You may need to clean the blades afterwards with something like acetone or alcohol to remove patch "sticky" from them so they will cut sharply the next time and not contaminate other things/people with the hormones that adhesive contains. Make the cut with the backing paper still on the patch. If possible, align your cuts across the division in the backing, not parallel to it. That way, you can still grab the two backing halves easily to remove them.

Can you save the unused portion to use next time, as you might if you were cutting your patch in half? Yes, if you don't remove the backing from it and you fold it back into its container so it doesn't dry out. It's probably not good to save cut patches longer than until the next change, just because they will indeed be drying out, no matter how tightly you've resealed them. Take a marker and write on the package when it was cut and how much you cut it--don't rely on remembering this.

Once you have your modified patch, you apply it as normal at the usual interval for that patch brand and type. That modified dose may be a patch cut down or a part of a patch worn in addition to a whole patch--it depends upon which way you're going with your dose modification. If you're in doubt about your math or that you've done this correctly, have someone else check your figures. Don't be embarrassed—nurses routinely and by policy often ask another nurse to check their work, even if it's just drawing up a particular dose in a clearly-labeled syringe, if the medication has important and potentially negative effects. It's always, especially, when you may not be thinking as clearly as you'd like due to hormonal upheavals, fine to ask another person to check your work. This is, for example, a perfect real-world teaching opportunity for those high school math students.

One thing that those using partial patches have discovered is that the fresh cuts tend to be very sticky, and the patches may adhere to their clothing and lift once they've been cut. You can get around this by powdering over the patch edges once the patch has been firmly applied. And keep an eye on the edge--you may need to repeat the powdering if it's quite hot/sweaty or especially being abraded by your clothing.

The great big disclaimer

You may ask your doctor or pharmacist whether you can cut a patch to modify the dose and be told no.

In the case of a reservoir patch, they are completely correct: you'll destroy the patch if you do so. Don't do this.

If you are using a matrix patch, however, the reason for their answer is different. Each patch is licensed by the FDA to deliver a specific dose. When you alter the size of the patch, you alter the dose. That new dose is not licensed, so it's not "proven" to work. The manufacturer, the pharmacist and the doctor all are legally unable to assure you that it will work because it's neither tested nor licensed at that dose. You are, by modifying your patch, creating an "off label" use, and they are forbidden to participate in this if they interpret their responsibilities to you literally.

You may also be told that the dose, from a modified patch, will not be accurate. This is kind of obvious: you'll be using scissors and pens, not accurately-calibrated cutting lasers, so, no, your accuracy won't be precise. You may be told that the hormones will seep out along the edges and you'll lose some that way, or that the hormones may not be distributed exactly through the adhesive, so that your cut won't accurately remove that exact percentage of them even if you are pretty close on the area.

Again, these are valid points. But the magnitude of this inaccuracy is probably not going to be functionally significant enough to be noticeable, given the other factors that render our hormone supplies constantly in flux. That cut edge will expose a tiny increment more hormone, sure--but if you powder that edge, you're decreasing that exposure again. When you look at the total hormone-releasing surface, what increment increase in area is that fresh edge? Not much, right?

As for the failure of the hormone to be evenly dispersed, again, that's literally true but we're not sure how important that is in practical terms. We haven't witnessed the manufacturing process for patches, but we strongly suspect that each patch isn't individually crafted but rather cut from larger stock to specific size. In order, then, to have dose accuracy from one patch to the next, mixing must be adequate on that scale to distribute it fairly evenly. users who have cut their patches have not reported wide dose fluctuations apparent from one patch to the next. This, then, does not appear to have functional significance for users who report their experiences with this process.

Remember, then, that the answers you get to this question are based on legality and strict uniformity of provided dose. But our practical experience of HRT is more variable: we will take a little bit more up when we're warm than when we're cold; we'll take a little bit more up when we exercise than when we're asleep; our hormone levels once in our system will be affected by diet and stress and metabolic cofactor availability and a whole host of other things that do vary from moment to moment and day to day.

The added increment of potential variation from careful cutting and and use of partial matrix patches is not likely to be of functional significance to many users. It may be to you—just as any other element of HRT use may make a difference to any one individual. But there is nothing inherent to the process of cutting a patch that would rule out adequate dose stability in functional terms. Many of us have successfully tried out dose alterations through this method and some have continued to use doses modified in this way for long term HRT because the commercially-available dose sizes do not meet their exact needs.

You probably shouldn't try to change your dose by these other methods

We're everlastingly impressed by the endless creativity users have shown in trying to modify their patch delivery characteristics. Unfortunately, some of these techniques don't work, and so to save you time and turmoil, we'll look at them right now.

One obvious one is to alter the patch change frequency. It kind of seems as though putting a patch on more often should increase exposure, and hence dose, while changing it less frequently might decrease dose. Nice idea, but it doesn't work that way.

It's your body that draws the hormones out from the patch (more on this if you're not clear on why that is the case), and the patch is designed to meter the rate of that process. We can and do speed that up a bit when our deficit is extreme, but there are limits to how fast it can go. Changing the patch more often more often does not equate to delivering more estrogen; all it does is waste patches by discarding them when they still contain part of the dose.

So too does changing them less frequently not slow down the dispensation of the hormones. The hormones will travel into the body at the same rate as ever and the patch will be exhausted at the usual time. The extra time that patch subsequently spends on skin will be as an empty patch, not a functional delivering patch. This means that leaving a patch on past its depletion risks causing significant fluctuations in hormone levels from, first, normal dispensation and then, no hormones at all. Since someone using a patch is not likely to have many hormones stored, they rely on that continuous trickle and aren't likely to keep themself supplied when the patch isn't providing more. Unless you're really really fond of roller coasters, this is just not likely to be an effective strategy.

Another good-idea-but-no-cigar attempt is trying to leave some of the backing paper on the patch, with the idea of preventing that part from dispensing. Unfortunately, this seems to interfere with adhesion, resulting in premature patch loss or interrupted delivery. Even, yes, leaving the backing piece in the middle. It just doesn't work out in real life. Go ahead and try it if you don't believe us, of course, but it's not likely to make you happy.

So those are your options for altering the dose you'll get from patches. The fact that it may or may not be possible doesn't say anything about whether altering the dose is the right thing for you to do—that's still something you must work out for yourself.