Assuming we're all in this for the long haul, there are some regular maintenance things we've got to take care of now that maybe we were sloughing off on before.
Although it hardly seems fair, we do still need to have regular pap smears. They may not need to be annual (discuss this with your doctor and set up a schedule), but they should be regular. Even if you no longer have a cervix, remnant cervical cells could conceivably still turn malignant. A pap also screens for vaginal cancer, a lower but still present risk. So it's still a good idea.
Mammograms are a necessary adjunct of HRT. While the risks of dying of breast cancer are way lower than those of heart disease or osteoporosis, the fact remains that your risk of breast cancer is related to your lifetime hormone exposure. Regular self-exams are a must, but with the denser breast tissue estrogen promotes, mammography is necessary for a thorough exam. Nobody likes getting their tits smashed, but the alternative is way more wretched. Take heart—as the demographic bulge gets into the menopause years, better and gentler screening methods are being developed.
Bone density measurement is something to think about having done at surgical menopause and every few years thereafter, just to make sure you are holding your own on (or off, as the case may be) your HRT. Since the worst rate of bone loss is in that first year post menopause and that is the time when you are least likely to be well-balanced on HRT, you may need to keep a closer eye on things for the first few years till you stabilize.
Although many insurance plans will cover bone density testing, if you don't have insurance or are otherwise burdened by the cost of the scan (it runs a couple hundred dollars, on average), a less precise but nonetheless useful method is also available. This uses ultrasound or xray (there are several varieties of specialty measuring devices) to measure the density of one single bone, and is performed using a small machine that is often located in doctors' offices. While its results are limited to that one bone (and density loss can vary from bone to bone), it at least is valid as a monitor of change over time and costs well under $100 in most offices. If your doctor doesn't have one, call around to the larger area OB-GYN practices or private radiology practices and you may locate one. They are usually willing to do the test for a non-patient if you have a referral from your doctor.
Another recent arrival on the scene is the mobile "health fair" that comes into a community once or twice a year to provide educational booths and low-cost testing to walk-ins. These are increasingly offering single-bone screenings in addition to a broad range of basic blood tests, and provide excellent value for those who are uninsured or juggling insurance deductibles.
We've already talked about the usefulness (or not) of getting ovarian hormone levels done. So long as you feel good, there is probably no particular reason to check them on any regular basis.
Some lab work you might find worthwhile is a check for diabetes. The changes in insulin and metabolism that come with menopause can push those who were marginally under control over the line into "adult-onset" or "Type II" diabetes. This should certainly be part of your workup if you are having long-standing difficulty finding hormonal balance, since many of the symptoms can overlap with hormonal ones.
Thyroid problems are so common after a hyst that checking thyroid hormone levels should almost be considered a routine measure. It is very difficult to distinguish one imbalance from the other, and in fact there is often overlap. When checking, it is appropriate to ask for free T3 and T4 levels in addition to TSH, since it is very common for menopausal women to show a normal TSH but low circulating T3 or T4 levels. If you are at the bottom range of normal, some practitioners feel it may be worthwhile supplementing with just a little thyroid—it may bring your whole system into better balance, even though you were not hypothyroid in the strictest sense.
And then there's good nutrition (remember those essential nutrients we talked about?), a diet that doesn't aggravate that middle-age tendency to pork up around the middle, and plenty of weight-bearing exercise. May we repeat that about exercise? One of the most important adjuncts to HRT is regular (several times a week) weight-bearing exercise. It doesn't even have to be that strenuous or prolonged: results from a large study released not long ago indicated that as little as an hour a week could halve some cardiac risk measurements. Exercise strengthens your bones, maintains your flexibility and counters depression. All you have to do is get off your butt and do it. And don't bother with the excuses—we've already thought of them all for ourselves.
You've taken a big step to reach for better health when you had your hyst and began working on hormone balance. Now you are entitled to enjoy your new, healthier life…by keeping that body healthy. Go for it.
Life with HRT: Other hints and tips
Remember to take them
The most useful approach we've found is to try to link taking your hormones with some other, already established habit. If the very first thing you do every morning, without fail, is to go start the coffeemaker, keep your estrogen pill bottle on top of the coffee canister or in the box with the filters or somewhere you have to move it to make that coffee. If every night before you go to bed you rub in that certain hand cream, rubberband your progesterone cream to it. Tie a note to your toothbrush. Tape it to the handle of your underwear drawer. Hide your deoderant behind it. Unplug the hairdryer and tie the cord in a loop around it. Somewhere in the right part of your day is a habit already established, and that's where you need to look. That doesn't mean you can't ever change, but just that linking to something already established helps you establish the new habit. Once your day is incomplete without your hormones, believe us, you'll remember.
For those on patches, we don't have any great ideas unless there's something you're already doing twice a week or once a week to link with. The once-a-week patches can at least be changed on the same day. For the twice a week crowd, best results and mileage are found changing at 3 1/2 days, meaning you need to find one morning habit and one evening habit. That's not impossible, and messing your timing up once or twice will help motivate your search for the right memory aid. A calendar can help, but only if it's unavoidably unmissable and you get in the habit of checking it. Some women report success with taping a small checkbook register-size calendar to the medicine cabinet door or their deoderant container or someplace else that's a part of their life. Some write reminders on the bathroom mirror with dry-erase markers or soap. Some write the date their patch gets changed on the patch itself, although if you don't spend a lot of time looking at your butt, that might be less helpful. We even know of one woman who uses a multi-day pill keeper for her vitamins (already established habit) and drops her patch in there in the correct day's slot with the pills. Don't be afraid to be creative with these, because the wackier they are, the more their amusement value will go on attracting your attention.
Refill your prescription
Okay, enough drama: the point is, for something like this, it's always good to pick up a refill before you're out. If you take pills, take a week's worth, put them in a bottle in the fridge, and when you get to the bottom of the bottle on the dresser, it's time to reorder. You can do the same thing with creams by decanting a week's worth into an old jar and using the switch to that supply to trigger a reorder. If you use patches, stick a note in the box two patches up from the bottom. If you use an online calendar service or a scheduler that provides auto-warnings, fill in the correct dates and have it email/popup you a reminder. And then another one the next day in case you got busy and forgot. In time, you won't need this help, but it's a good idea to use for the first year or two until it becomes totally second nature. Some women should always do this (you know who you are). Make it easy for yourself: use tools.
Carry your HRT
Traveling with HRT
If you travel a lot, especially without much warning, you may want to make certain that you always have on hand enough of a supply to cover a trip. Of course, a surprise trip can catch anyone short. Still, if you have your prescription refill reminder stash, you have enough of a cushion to at least arrive at your destination with enough. As soon as you get there, find a major pharmacy (or a compounder, depending on what you use at home) and explain your problem to the pharmacist. They should be able to call your home pharmacy (you carry their phone number with you, right?) and get an okay to dispense a small amount of your prescription to tide you over till when you expect to return home. If you run out while on your trip, you can do the same thing. A reputable pharmacist understands the importance of continuing your hormones, and should be willing to help you out.
When you cross a lot of time zones, it can be difficult to guess how to handle your dose times so as not to get too low or take it so soon you have an excess (no one enjoys a guest or business associate in hormonal meltdown). For a short trip of a day or two, it may be simplest to just count off the number of hours between doses and maintain that spacing, no matter when in the day it falls, knowing that you'll backtrack again to your usual time when you return home.
If you are going to be there long enough that you want to acclimate to the local clock (and back again on your return, don't forget), the gentlest approach is to slide by just an hour or two a day. You'll have to decide whether you feel best increasing or decreasing the time span, and you'll need to take into account the amount and direction of the time difference. The hardest changes are those of half a day or so. In those cases, the easiest thing may just be to pick a halfway point in the next day and a half, take part of your dose, and then take another partial dose at the end of the day and a half. Then you should be set up to go back to the full dose on the new schedule. It gets complicated to reason this out, but it's usually better than just skipping it for a day.
If your trip is unexpectedly extended and you run out in another country, take your bottle/container to a local pharmacist. Your hotel or business associates or embassy/consulate may be able to steer you to one that has more expertise in dealing with foreigners. When you can speak with a pharmacist (not an aide), explain the situation. Many times there is a local equivalent that they can sell you enough of to tide you over. If your bottle label just has a brand name, like "Estrace" or "Premarin," you may need to print out on a piece of paper the generic name for the drug ("estradiol" or "conjugated equine estrogens") so that a pharmacist can find a local equivalent. Obviously, you'll need to know this before you go. Our experience has been that writing drug names communicates much more easily than trying to say them and have the pharmacist understand/recognize them across the barrier of accents (even when you both think you are speaking the same language). If you are taking compounded hormones, you will have more difficulty. The best bet, if you need to switch hormones from compounded to commercial in a pinch, is to ask for estradiol (or oestradiol if you are in a UK-English-speaking country). If you are taking progesterone, you should know that it can be very difficult if not impossible to find in many places, such as Australia and the UK. It may also be impossible to obtain testosterone in a female-suitable dose or without a prescription, given how tightly it is controlled many places.
When you are traveling internationally with prescription drugs, it is important to carry them only in labeled containers—that is, containers with the original pharmacy label on them. It doesn't hurt to carry a photocopy of your prescription for each drug with you when you travel places where scrutiny by customs may be intense and…um…uninformed. That also makes it easier to get an emergency refill on the trip as well. It's a good practice to copy your prescription before handing it over to the pharmacist just so you have it on hand for this sort of eventuality. If your pharmacist normally dispenses your hormones in the handy gallon jar and you need something more petit for a trip, ask if they can make up a small travel container, with label, for you to use on these occasions. We would also advise against traveling with your creams in syringes, or, even worse, carrying an empty syringe to measure creams if you are going to places where customs scrutiny is intense. If you must, make sure the syringe has a pharmacist's label on it.
One last caution: carry your hormones in your carryon when you fly or check your baggage on a public carrier. If the containers are too large, carry enough to get you through 2 days and carry copies of your prescriptions, so that when your hormones are sitting in your checked bag in one hemisphere and you are in another, you have a little room to recoup. It's a lot easier to buy a new toothbrush or go without clean underwear than it can be to replace lost hormones.
Sadly, not all TSA agents working in US airport security have the math background to convert units. One of our members was actually turned away with a 3.5 ml prescription bottle by an agent who kept chanting "3 ounces, only 3 ounces, no more" and trying to take her prescription away. Despite polite attempts to explain that this was a different scale of measurement and demonstrating the size difference compared to items containing 3 ounces, the agent was unpersuaded. Finally, she had to demand to see a supervisor, which resulted in considerable delay, body searches, and hostility before the supervisor, rather than admitting any error, agreed to "make an exception" for her. There's not necessarily any way to prepare for this sort of encounter other than to remember to leave time to deal with the kind of issue where formalities can go awry. Or ask your pharmacist to label your bottle in decimal ounces.
Do you have any other tips or hormone-management-challenging situations you've solved with particular brilliance that you'd like to share with us? If so, email Framboise and she'll take a look at adding them to this collection.
Looking for a new doctor
Many women find that once their surgery is over, their surgeon may no longer be their best resource, especially for balancing HRT. Some OB/GYNs focus so much on the OB part of their practice that they are unfamiliar with hormone needs in menopause. Some doctors have such a limited interest and knowledge of hormones that if the one brand they know of doesn't work, they blame you (here: have an antidepressant and stop whining). Many surgeons are just that: doctors who perform surgeries, not long term health management practitioners.
For whatever reason, if you don't feel your doctor is open to your needs and desires for menopausal health management, you have two choices. You can re-educate your doctor or you can find another one who suits you better. Many women have found that returning to a GP or family doc is all they need to do.
There is no clinical specialty in surgical menopause, or even menopause in general. Nonetheless, it is a growing field and practitioners are gradually carving out a new interest in menopausal issues. They don't necessarily all come from the same original field, however. Some are GYNs, some are endocrinologists (specialists in glandular disorders), some may even be internists or general family doctors. What unites them is that they are interested and willing to educate themselves in this growing field. These specialists can be especially helpful if you have other needs that affect your hormone balance, or you are having particular difficulty finding balance.
But there's no reason why you must go to a specialist. Hormone-prescribing and the necessary followup are certainly well within the capabilities of a willing family doc—but the crucial part of that is the "willing." To some extent, having one doctor manage all of your medical care does provide a greater continuity in making sure that the person who is prescribing your HRT is also aware of all of the other health-related things you're facing. Additionally, you may find that your family doctor is willing to be less dogmatic about a single "right" answer as some specialty clinics or practitioners are. So there's no correct answer here, other than finding someone who has enough interest to work with you.
But if you've gone through all the doctors you already know, how do you find a new one who is knowledgeable and willing to work with you? Well, one good way is the old word of mouth trick: ask around. Got any friends on hormones? How about asking your hairdresser who's on hormones and happy with their doc—believe us, hairdressers hear it all. Another knowledgeable group is hospital nurses, especially ones who work with GYNs. Sometimes your local pharmacist can tell you who's writing a lot of hrt prescriptions. Of course, you'll want to interview the staff (not the receptionist—tell them what you are doing and ask to speak with the nurse) of any recommended doctor to make sure their practice really is open to what it is you want.
A number of websites offer lists of doctors. Everyone from the North American Menopause Society to Menopause Matters (UK) to the smallest personal website is making recommendations these days. Of course, you want to consider carefully the philosophical bias that drives each list provider and it's a good idea to check out any referrals with a your state licensing agency (don't be complacent: one of us was referred by a very reputable group to a great-sounding doc…who had just lost his practice privileges for something rather unsavory) as well as interviewing them before you actually spend money for a new-patient appointment.
For whatever reason, if you don't feel your doctor is open to your needs and desires for menopausal health management, you have two choices. You can re-educate your doctor or you can find another one who suits you better. Many women have found that returning to a GP or family doc is all they need to do.
What kind of doctor do I need?
But there's no reason why you must go to a specialist. Hormone-prescribing and the necessary followup are certainly well within the capabilities of a willing family doc—but the crucial part of that is the "willing." To some extent, having one doctor manage all of your medical care does provide a greater continuity in making sure that the person who is prescribing your HRT is also aware of all of the other health-related things you're facing. Additionally, you may find that your family doctor is willing to be less dogmatic about a single "right" answer as some specialty clinics or practitioners are. So there's no correct answer here, other than finding someone who has enough interest to work with you.
Ways to find a new doctor
A number of websites offer lists of doctors. Everyone from the North American Menopause Society to Menopause Matters (UK) to the smallest personal website is making recommendations these days. Of course, you want to consider carefully the philosophical bias that drives each list provider and it's a good idea to check out any referrals with a your state licensing agency (don't be complacent: one of us was referred by a very reputable group to a great-sounding doc…who had just lost his practice privileges for something rather unsavory) as well as interviewing them before you actually spend money for a new-patient appointment.
Special situations: Polycystic Ovary Syndrome (PCOS)
This is a metabolic disorder characterized by high androgen levels, insulin resistance and infertility that is believed to affect perhaps 6-10% of the female population. The Polycystic Ovarian Syndrome Association has an extensive website with information, referrals, and discussion forums.
For women with the disease who are entering surgical menopause, balancing hormones can present a special challenge. This is a whole special realm in itself, and we can simply caution PCOS women to work closely with their endocrinologists in the balance process. Reading as much as you can about the hormones and their roles is still important, but you need to understand that normal doses and protocols may not be right for you because your body is so accustomed to the abnormal levels you've had for so long. In fact, there seems to be some evidence that even without ovaries, even despite careful HRT balancing, women with PCOS may still use those hormones in atypical ways.
Because most GYN doctors focus on the fertility aspects of PCOS, they may not be your best caregivers once you are in surgical meno. Some women have told us that their doctors have told them that removing their overies has cured their disease—which is in fact not the case, even though it may get rid of one of the more troubling symptoms. Most women with the disorder find that because of the multi-system involvement of PCOS and the fact that having a total hyst does not cure it, their long term needs are better served by an endocrinologist (a hormone specialist) who can treat all aspects of their problems.
For women who seem to always have had an excess of testosterone or seem to have recalcitrant testosterone in surgical menopause, we encourage you to read up on this disorder. It is very underdiagnosed, yet it carries significant health consequences, especially as we age. A proactive approach to surgical menopause survival requires identifying your personal risks, and it may have important impacts on your health for the rest of your life to be aware of this one.
For women with the disease who are entering surgical menopause, balancing hormones can present a special challenge. This is a whole special realm in itself, and we can simply caution PCOS women to work closely with their endocrinologists in the balance process. Reading as much as you can about the hormones and their roles is still important, but you need to understand that normal doses and protocols may not be right for you because your body is so accustomed to the abnormal levels you've had for so long. In fact, there seems to be some evidence that even without ovaries, even despite careful HRT balancing, women with PCOS may still use those hormones in atypical ways.
Because most GYN doctors focus on the fertility aspects of PCOS, they may not be your best caregivers once you are in surgical meno. Some women have told us that their doctors have told them that removing their overies has cured their disease—which is in fact not the case, even though it may get rid of one of the more troubling symptoms. Most women with the disorder find that because of the multi-system involvement of PCOS and the fact that having a total hyst does not cure it, their long term needs are better served by an endocrinologist (a hormone specialist) who can treat all aspects of their problems.
For women who seem to always have had an excess of testosterone or seem to have recalcitrant testosterone in surgical menopause, we encourage you to read up on this disorder. It is very underdiagnosed, yet it carries significant health consequences, especially as we age. A proactive approach to surgical menopause survival requires identifying your personal risks, and it may have important impacts on your health for the rest of your life to be aware of this one.
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.
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. For recent articles on these drugs and other aspects of bone density/osteoporosis, check out the relevant collection in our bookmarks account.
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.
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.
Kegel exercises are the remedy most recommended by physicians 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. It may be helpful to consult a physical therapist who is licensed with the Women's Health Physical Therapy branch of the American Physical Therapy Association (the website includes a service locator). Many physicians aren't aware of this specialty service, but trained therapists can do a lot by teaching simple pelvic floor exercises (more specific than Kegels).
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.
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.
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 (research remains conflicted) 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). Soy also is considered inadvisable for those with thyroid issues.
Another potentially-useful agent is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Because this family of 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. All SSRIs may not be considered suitable for women taking tamoxifen, but citalopram and venlafaxine are considered safe in that situation.
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. In 2018, oxybutynin, an anticholinergic drug developed for bladder spasms, was shown to be more effective than citalopram or venlafaxine and safe for women who need to avoid hormone exposure, but it is not without its own side effects. More on this new option in this separate post on oxybutynin.
All of these agents may decrease the frequency and intensity of flashes but probably will not eliminate them entirely.
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.
[This post last updated: 12/10/18]
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. For recent articles on these drugs and other aspects of bone density/osteoporosis, check out the relevant collection in our bookmarks account.
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 remedy most recommended by physicians 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. It may be helpful to consult a physical therapist who is licensed with the Women's Health Physical Therapy branch of the American Physical Therapy Association (the website includes a service locator). Many physicians aren't aware of this specialty service, but trained therapists can do a lot by teaching simple pelvic floor exercises (more specific than Kegels).
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 (research remains conflicted) 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). Soy also is considered inadvisable for those with thyroid issues.
Another potentially-useful agent is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Because this family of 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. All SSRIs may not be considered suitable for women taking tamoxifen, but citalopram and venlafaxine are considered safe in that situation.
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. In 2018, oxybutynin, an anticholinergic drug developed for bladder spasms, was shown to be more effective than citalopram or venlafaxine and safe for women who need to avoid hormone exposure, but it is not without its own side effects. More on this new option in this separate post on oxybutynin.
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.
[This post last updated: 12/10/18]
Special situations: Thyroid
Thyroid hormone problems are closely linked with ovarian hormones. For many women, starting HRT is the final blow that pushes their thyroid hormones down to symptomatic levels. We've mentioned in the discussion of estrogen that it stimulates higher levels of a protein that binds (inactivates) thyroid hormone and in discussing progesterone that it affects levels of minerals necessary to use thyroid hormone inside the cell. Because of these interrelationships, it's wise to ask for thyroid testing if you are having difficulty with your balance, having some question as to whether what you are experiencing is due to ovarian or thyroid imbalance, or you have a pre-existing thyroid problem or a family history that leads you to suspect you might be at risk to develop one.
Many women feel unjustly picked-upon by discovering that, just as they're trying to sort out having one system go manual (ovarian hormones), suddenly their thyroid packs it in as well. Did their hyst cause this? No, not really. In fact, a lot of women in natural menopause experience the exact same thing and feel just as unfortunate. Menopause just seems to be the time when our thyroids are wearing down and can't cope with the additional burdens placed on them.
We won't go into a lot more detail here, but will instead refer you to the authoritative thyroid.about.com for a full discussion of diagnosis, testing, and treatment options. We will throw in the note that women with a badly out-of-balance thyroid are not likely to be able to balance their ovarian hormones until the thyroid hormones are closer to normal. This means that you may have to treat them sequentially, and in successive small iterations. This can be a long and even more frustrating process than balancing the ovarian hormones alone, and you have our sympathies.
One thing that is becoming clear as we see more women work the ovarian-thyroid connection is that women on a combination of T3 + T4 may do better than those on just synthetic T4 alone if they have trouble converting from one form to the other (this is common, apparently). In fact, this page goes into depth on the premise that people on a combination of the two claim they had "more energy, improved concentration, and just felt better overall" that those taking just T4. Once again, this takes us away from the simple answers to the complex and subjective, but if it's the route to feeling good, hey—we're for it.
For those who are using alternative HRT and hitting the soy heavily, you should know that soy may also interfere with thyroid function. We have actually seen women trying to use high soy intake to replace estrogen use drive their thyroid into depressed function from which it did not recover. That doesn't mean you have to avoid soy altogether, but it does mean that if you already have thyroid problems—or develop them—that soy may not be your best choice for alternative HRT.
One last note on necessary supplements: selenium is necessary to convert T4 to T3 (the active form). A lot of "silver" type multivitamins contain selenium. If yours doesn't, eating just two brazil nuts a day will meet your needs. Now, isn't that refreshingly simple?
Many women feel unjustly picked-upon by discovering that, just as they're trying to sort out having one system go manual (ovarian hormones), suddenly their thyroid packs it in as well. Did their hyst cause this? No, not really. In fact, a lot of women in natural menopause experience the exact same thing and feel just as unfortunate. Menopause just seems to be the time when our thyroids are wearing down and can't cope with the additional burdens placed on them.
We won't go into a lot more detail here, but will instead refer you to the authoritative thyroid.about.com for a full discussion of diagnosis, testing, and treatment options. We will throw in the note that women with a badly out-of-balance thyroid are not likely to be able to balance their ovarian hormones until the thyroid hormones are closer to normal. This means that you may have to treat them sequentially, and in successive small iterations. This can be a long and even more frustrating process than balancing the ovarian hormones alone, and you have our sympathies.
One thing that is becoming clear as we see more women work the ovarian-thyroid connection is that women on a combination of T3 + T4 may do better than those on just synthetic T4 alone if they have trouble converting from one form to the other (this is common, apparently). In fact, this page goes into depth on the premise that people on a combination of the two claim they had "more energy, improved concentration, and just felt better overall" that those taking just T4. Once again, this takes us away from the simple answers to the complex and subjective, but if it's the route to feeling good, hey—we're for it.
For those who are using alternative HRT and hitting the soy heavily, you should know that soy may also interfere with thyroid function. We have actually seen women trying to use high soy intake to replace estrogen use drive their thyroid into depressed function from which it did not recover. That doesn't mean you have to avoid soy altogether, but it does mean that if you already have thyroid problems—or develop them—that soy may not be your best choice for alternative HRT.
One last note on necessary supplements: selenium is necessary to convert T4 to T3 (the active form). A lot of "silver" type multivitamins contain selenium. If yours doesn't, eating just two brazil nuts a day will meet your needs. Now, isn't that refreshingly simple?
Special situations: Endometriosis
It is now becoming accepted that a hysterectomy/oophorectomy does not "cure" endo, although it may reduce the impact of it for a time. While a hyst will certainly remove those symptoms related to uterine discomfort, the most realistic expectation of the long term effects of the surgery is that a hyst and subsequent use of HRT may provide a more stable hormonal environment with less endo stimulation.
Because estrogen stimulates endo growth (just as it stimulates proliferation of the uterine endometrium) and progesterone inhibits it, current post-hyst endo management practice guidelines often calls for the addition of a progestogen to estrogen HRT. This is intended to prevent the stimulation of the endometrial implants, reduce their proliferation and the risk of converting that endo to a cancerous state.
Many endo specialists also call for a post-op period (varying from six weeks to six months to "as long as you can stand it") without HRT, in order to encourage any remaining bits of endo not removed during surgery to shrink away. Some take that a step further and prescribe the use of a progestagen alone to directly squelch that endo growth. This may have the additional benefit of helping ease some of the transitional menopause symptoms experienced during the wait for estrogen.
Doctors are not all in agreement on post-op endo treatment, however. Some surgeons are highly indignant at any suggestion that they might not have cleared all traces of endo; others freely admit that microscopic bits of endo are virtually guaranteed to remain and require ongoing treatment. We're not going to argue with your doctor's take on the situation, other than to suggest that if your doctor insists that all endo is gone and you continue to experience post-op endo-like pains, you might want to research this part of the question further. We aren't endo specialists, but we have a few links in our bookmarks that may be useful in your researches. Use a search engine for many more resources, but search wisely: there's lots of nonsense and profiteering out there too. Endo is a long, grim battle, and it's sadly not one that seems to be over after a hyst.
In addition to progestagens, you may want to look into other measures to help with your estrogen deficit period if that is your treatment choice. You will need to work very hard on maintaining your bone density and keep an eye on your overall cardiac measures such as cholesterol and blood lipids. Both of these risk profiles see their most rapid rate of change in the year after ovarian hormones decline (and if you had pre-op therapy with hormone suppressors, that clock has already been ticking for you). Many of the symptomatic relief measures may also be helpful. In particular, use of an SSRI may be helpful if depression and hot flashes become debilitating.
It's important to bear in mind that most of the herbal/food estrogen-alternatives can totally undermine the point of going without estrogen. As a rule, the estrogenic properties of black cohosh and red clover are considered too high to be safe for use during endo suppression. Soy, which is often used as an estrogen supplement or alternative in natural perimenopause, should also be avoided in endo suppression just because it has some of the same capacity for endometrial stimulation as estrogen. Taking the adrenal precursors (DHEA, pregnenolone) is a little questionable as they can ultimately be converted to estrogen; testosterone supplementation during this period will probably also be hijacked for estrogen production, so also may not be wise. Even caffeine stimulates elevations of circulating estrogen and may be implicated in the exacerbation of endo.
Check all this with your doctor, of course—but remember the bottom line: if any of these do stimulate further endo, you are the one who suffers. And you know what that's like. Since estrogen deprivation treatment only has to go on for about six months, our feeling would be to be as conservative as possible rather than risk more endo. But you have to decide this for yourself.
One of the things that women with endo who choose to use a progestogen on a continuous basis to suppress their endo least like about that practice is that they more or less have to put up with a progestogen-heavy hormone imbalance. Evidence suggests, however, that employing vaginal (or, in the case of women who retained their uterus, intrauterine) delivery of a progestogen enhances its concentration in local pelvic circulation while minimizing its other systemic effects as well as the cancer risks associated with progestogen use. This is becoming a more popular strategy, with a number of available hrts suitable for this use. You can read more about them in the discussion of providing for uterine protection elsewhere on this site.
Because estrogen stimulates endo growth (just as it stimulates proliferation of the uterine endometrium) and progesterone inhibits it, current post-hyst endo management practice guidelines often calls for the addition of a progestogen to estrogen HRT. This is intended to prevent the stimulation of the endometrial implants, reduce their proliferation and the risk of converting that endo to a cancerous state.
Many endo specialists also call for a post-op period (varying from six weeks to six months to "as long as you can stand it") without HRT, in order to encourage any remaining bits of endo not removed during surgery to shrink away. Some take that a step further and prescribe the use of a progestagen alone to directly squelch that endo growth. This may have the additional benefit of helping ease some of the transitional menopause symptoms experienced during the wait for estrogen.
Doctors are not all in agreement on post-op endo treatment, however. Some surgeons are highly indignant at any suggestion that they might not have cleared all traces of endo; others freely admit that microscopic bits of endo are virtually guaranteed to remain and require ongoing treatment. We're not going to argue with your doctor's take on the situation, other than to suggest that if your doctor insists that all endo is gone and you continue to experience post-op endo-like pains, you might want to research this part of the question further. We aren't endo specialists, but we have a few links in our bookmarks that may be useful in your researches. Use a search engine for many more resources, but search wisely: there's lots of nonsense and profiteering out there too. Endo is a long, grim battle, and it's sadly not one that seems to be over after a hyst.
Post-op estrogen deprivation treatment
In addition to progestagens, you may want to look into other measures to help with your estrogen deficit period if that is your treatment choice. You will need to work very hard on maintaining your bone density and keep an eye on your overall cardiac measures such as cholesterol and blood lipids. Both of these risk profiles see their most rapid rate of change in the year after ovarian hormones decline (and if you had pre-op therapy with hormone suppressors, that clock has already been ticking for you). Many of the symptomatic relief measures may also be helpful. In particular, use of an SSRI may be helpful if depression and hot flashes become debilitating.
It's important to bear in mind that most of the herbal/food estrogen-alternatives can totally undermine the point of going without estrogen. As a rule, the estrogenic properties of black cohosh and red clover are considered too high to be safe for use during endo suppression. Soy, which is often used as an estrogen supplement or alternative in natural perimenopause, should also be avoided in endo suppression just because it has some of the same capacity for endometrial stimulation as estrogen. Taking the adrenal precursors (DHEA, pregnenolone) is a little questionable as they can ultimately be converted to estrogen; testosterone supplementation during this period will probably also be hijacked for estrogen production, so also may not be wise. Even caffeine stimulates elevations of circulating estrogen and may be implicated in the exacerbation of endo.
Check all this with your doctor, of course—but remember the bottom line: if any of these do stimulate further endo, you are the one who suffers. And you know what that's like. Since estrogen deprivation treatment only has to go on for about six months, our feeling would be to be as conservative as possible rather than risk more endo. But you have to decide this for yourself.
Living with continuous progestogen treatment
One of the things that women with endo who choose to use a progestogen on a continuous basis to suppress their endo least like about that practice is that they more or less have to put up with a progestogen-heavy hormone imbalance. Evidence suggests, however, that employing vaginal (or, in the case of women who retained their uterus, intrauterine) delivery of a progestogen enhances its concentration in local pelvic circulation while minimizing its other systemic effects as well as the cancer risks associated with progestogen use. This is becoming a more popular strategy, with a number of available hrts suitable for this use. You can read more about them in the discussion of providing for uterine protection elsewhere on this site.
Special situations: Stress
One of the most frustrating aspects of trying to balance hormones is the fact that balance is not a static thing. At the very best, it remains susceptible to the influences of other events, both within the body and without. Because we have lost the resilience of response that our ovarian feedback loops gave us, we have to tune our hormones manually, if you will, to deal with changes around and in us.
What sort of changes? Stress is the most important and frustrating one. When you undergo stress, whether it's due to illness, increased workload, or personal disasters and your emotional response, your body goes into an overdrive "fight or flight" mode. In order to call forth a number of metabolic shifts designed to shut down processes not vital to ultimate survival and reallocate resources for pure survival response, your body gears up to stress by producing a specialized stress hormone called cortisol. Cortisol is produced by the adrenal glands using progesterone or progesterone precursors as the raw materials. Since we only have a finite quantity of progesterone in our systems in surgical menopause, every molecule that is shifted to cortisol production is that much less we have available for ovarian hormone uses.
As we have seen in the sections on balancing progesterone in particular and hormones in general, any change in the circulating levels of our ovarian hormones can lead to near-universal uproar as every hormone-reliant function pushes and shoves for its share of the pot. Hot flashes are the particular hallmark of hormonal disruption, but you may also notice that your already fragile emotional state in stress is further compounded by the hormonal moodiness and emotional instability that reflect a lowered level of ovarian hormones. Your libido may disappear along with your patience. The whole realm of low-hormone signs may manifest themselves if stress goes on side-tracking your progesterone long enough.
How do we cope with this on top of whatever the original stressor is? First of all, with understanding.
Cut yourself a little slack, knowing that this is going to be an unbalanced time. Warn your family, friends, co-workers—whoever may need an alert—that you are not really the ravening witch you may suddenly turn up to be these days and that your true self will return as soon as your chemical balance is restored. Try not to panic and figure that all your work balancing is now down the tubes. If you were balanced before, you'll be balanced again when this is over and your adrenals go out of alarm mode. If your imbalance isn't too severe, just ride with it till the stressor's done with, and cut yourself some slack in the meantime. A few hot flashes aren't the end of the world, so long as you know they're not heralding the end of the world.
One thing about stress that's important to remember when we're trying to figure out where our balance went askew is that stress can happen as a result of positive as well as negative factors. Going on a much-looked-forward-to vacation, getting married, a holiday season, even a surprise birthday party: things we might enjoy can still provide stress.
There are many tactics for dealing with stress non-medically, including exercise, yoga, meditation. If you don't yet have a stress tactic, entering surgical menopause might be a good reason to develop one. Even though they won't make stressors go away, they have a proven capability to reduce the uproar of stress and its effects on our bodies.
(If you've been a long-term follower of this website, you may notice that we've removed some previous discussion from this article about manipulating progesterone doses as a coping measure. Given the current research findings to do with progestogens and cancer, it's hard for us to consider raising those risks, even in response to stress, a valid or responsible strategy. If this is something you've practiced in the past, you might want to read up on the topic to be sure you're still comfortable with it.)
If the stress is severe or especially prolonged, you may instead need to heed the signs of hormonal turmoil as a wake-up call for a small adjustment. It's the pits getting thrown back into the need to balance when you're already dealing with the stressors that did it to you, but TANSTAAFL. Life's like that. Stop, listen to your body, make those small slow tweaks and reach for a new balance.
What sort of changes? Stress is the most important and frustrating one. When you undergo stress, whether it's due to illness, increased workload, or personal disasters and your emotional response, your body goes into an overdrive "fight or flight" mode. In order to call forth a number of metabolic shifts designed to shut down processes not vital to ultimate survival and reallocate resources for pure survival response, your body gears up to stress by producing a specialized stress hormone called cortisol. Cortisol is produced by the adrenal glands using progesterone or progesterone precursors as the raw materials. Since we only have a finite quantity of progesterone in our systems in surgical menopause, every molecule that is shifted to cortisol production is that much less we have available for ovarian hormone uses.
As we have seen in the sections on balancing progesterone in particular and hormones in general, any change in the circulating levels of our ovarian hormones can lead to near-universal uproar as every hormone-reliant function pushes and shoves for its share of the pot. Hot flashes are the particular hallmark of hormonal disruption, but you may also notice that your already fragile emotional state in stress is further compounded by the hormonal moodiness and emotional instability that reflect a lowered level of ovarian hormones. Your libido may disappear along with your patience. The whole realm of low-hormone signs may manifest themselves if stress goes on side-tracking your progesterone long enough.
Coping and compensating
Cut yourself a little slack, knowing that this is going to be an unbalanced time. Warn your family, friends, co-workers—whoever may need an alert—that you are not really the ravening witch you may suddenly turn up to be these days and that your true self will return as soon as your chemical balance is restored. Try not to panic and figure that all your work balancing is now down the tubes. If you were balanced before, you'll be balanced again when this is over and your adrenals go out of alarm mode. If your imbalance isn't too severe, just ride with it till the stressor's done with, and cut yourself some slack in the meantime. A few hot flashes aren't the end of the world, so long as you know they're not heralding the end of the world.
One thing about stress that's important to remember when we're trying to figure out where our balance went askew is that stress can happen as a result of positive as well as negative factors. Going on a much-looked-forward-to vacation, getting married, a holiday season, even a surprise birthday party: things we might enjoy can still provide stress.
There are many tactics for dealing with stress non-medically, including exercise, yoga, meditation. If you don't yet have a stress tactic, entering surgical menopause might be a good reason to develop one. Even though they won't make stressors go away, they have a proven capability to reduce the uproar of stress and its effects on our bodies.
(If you've been a long-term follower of this website, you may notice that we've removed some previous discussion from this article about manipulating progesterone doses as a coping measure. Given the current research findings to do with progestogens and cancer, it's hard for us to consider raising those risks, even in response to stress, a valid or responsible strategy. If this is something you've practiced in the past, you might want to read up on the topic to be sure you're still comfortable with it.)
If the stress is severe or especially prolonged, you may instead need to heed the signs of hormonal turmoil as a wake-up call for a small adjustment. It's the pits getting thrown back into the need to balance when you're already dealing with the stressors that did it to you, but TANSTAAFL. Life's like that. Stop, listen to your body, make those small slow tweaks and reach for a new balance.
A few final words on balance
All too often, we hear from women who have spent months trying this, that and the other hormone and are at their wits' end, ready to chuck the whole idea of taking HRT because of the terrible side effects they have experienced from every brand of hormones they have taken. Often the list goes Premarin, Cenestin, Prempro, FemHrt, Estratest, Climara, and maybe even estrogen shots or birth control pills or compounded tri-est or bi-est. Every time they go to their doctor with a complaint of swollen breasts or migraines or acne, they are changed to the full dose of another brand of estrogen. Finally, they are beside themselves with misery, convinced they are going insane (and have convinced their families as well) and their doctors are telling them they are "unable to tolerate HRT" and need to see a shrink, or at least take this Prozac.
We ache with sympathy for these women. If only they had tried a really low dose, worked slowly, tried sneaking up on the correct doses, had doctors who listened to their patients and as patients had listened to their bodies, then perhaps they could have found this elusive balance they have sought so strenuously.
Please don't be afraid to educate yourself on all your options, to ask your doctor for a lower dose or to insist on a customized dose or hormone blend. If your doctor can't honor that kind of request—or at least give a convincing argument why that is not in your best interests—remember that there are other doctors who feel that HRT should suit the woman's goals, and not the other way around, just as all of the major medical consensus group documents on HRT now acknowledge. Find a new doctor if necessary and try out a more modest approach. If you need hormones, there is a way to take them. You just have to find it. Slowly, at low doses, and while listening to your body.
Often, failure to achieve hormone balance is due to the influence of other problems and factors. We've discussed the fact that smoking and drinking influence your hormone needs and steadiness of hormone levels. Other special situations and lifestyle factors can also complicate finding balance, and elsewhere on this site we've looked at some of those special circumstances as well. Many women come to surgical menopause with other longstanding health problems, and a number of other women develop health problems in their menopausal years. All of these things will impact our hormonal needs, some to greater extent and some to lesser.
We will never be static. Our year of greatest challenge will be the first postop one, in which we make our greatest adjustments as we enter this new lifestage. But every year thereafter will still see changes. Our hormone balance is never "done." But if we work at it, if we learn to really listen to our bodies, we can provide for our needs and meet those changes in our future using these same tools and continuing to provide for our greatest level of health and wellbeing.
We ache with sympathy for these women. If only they had tried a really low dose, worked slowly, tried sneaking up on the correct doses, had doctors who listened to their patients and as patients had listened to their bodies, then perhaps they could have found this elusive balance they have sought so strenuously.
Please don't be afraid to educate yourself on all your options, to ask your doctor for a lower dose or to insist on a customized dose or hormone blend. If your doctor can't honor that kind of request—or at least give a convincing argument why that is not in your best interests—remember that there are other doctors who feel that HRT should suit the woman's goals, and not the other way around, just as all of the major medical consensus group documents on HRT now acknowledge. Find a new doctor if necessary and try out a more modest approach. If you need hormones, there is a way to take them. You just have to find it. Slowly, at low doses, and while listening to your body.
Often, failure to achieve hormone balance is due to the influence of other problems and factors. We've discussed the fact that smoking and drinking influence your hormone needs and steadiness of hormone levels. Other special situations and lifestyle factors can also complicate finding balance, and elsewhere on this site we've looked at some of those special circumstances as well. Many women come to surgical menopause with other longstanding health problems, and a number of other women develop health problems in their menopausal years. All of these things will impact our hormonal needs, some to greater extent and some to lesser.
We will never be static. Our year of greatest challenge will be the first postop one, in which we make our greatest adjustments as we enter this new lifestage. But every year thereafter will still see changes. Our hormone balance is never "done." But if we work at it, if we learn to really listen to our bodies, we can provide for our needs and meet those changes in our future using these same tools and continuing to provide for our greatest level of health and wellbeing.
Hormone level testing
This seems like it should be a wonderful tool: measure the hormones you have and just adjust your doses till you show the correct lab results. Alas, but it's not that simple (you knew we were going to say that, didn't you?). Hormone tests are inaccurate in a variety of different ways, they are difficult to interpret, and norms are so broad as to be nearly meaningless. Let's look at the problem in more detail.
Normal levels tend to be very broad because in addition to cycling up and down every moment of every day of the month, women vary a great deal in what is normal for them. Any single hormone level test is only a snapshot of what your circulating level in your blood stream is in that exact second in that particular blood vessel it was drawn from. It cannot measure the total amount of hormone you have in your system including what's in fat or stored in other forms. Even if you did have your hormone levels exhaustively checked premenopausally—which for most of us means pre-hyst—you still don't have any way to know what levels of hormones will meet your needs in your post-fertile lifestage.
Skeptical? Let's pretend for a moment that you know exactly what your hormone levels were preoperatively for every moment of the day of every day of the month, when you felt good and when you felt bad. Now, think about what you were doing with those hormones—what you needed them for. Or, in other words, what needs you were fulfilling with them such that the needs and supply balanced out causing you to feel your best. Why, a lot of those hormones were dedicated to their primary function of supporting fertility: cycling eggs up to ready and your uterus with a nice thick linking to receive them.
But now jump ahead in time to post-hyst. We're no longer fertile; we no longer have that uterus to support and cycle. In fact, being in menopause sends a signal to our bodies that we don't need a whole lot of things that were part of our reproductive lifestage any more. That means that we can cross off all of those fertility needs from our list of jobs for hormones to fill. And that in turn means we don't need as many individual hormone molecules to fill these reduced job quotas if we want everything to balance out just right between supply and demand.
And how many molecules of hormones can we cross off of those perfectly-balanced pre-menopausal values for these no-longer-needed fertile functions? Why, nobody has the slightest clue. There's no chart; there's no research study; there's no rule of thumb; there's not even a good guess that goes along the lines of X% of your hormones go to support fertility. Nobody has a clue. So what good are pre-op hormone levels in predicting post-meno needs? Not much: if we were to blindly duplicate those levels without the need, we'd be suffering sure symptoms of excess. We just can't count on numbers and expect to use them to roll the clock back.
Even more discouragingly, if you have had gynecological health problems for a considerable amount of time pre-hyst, you probably haven't been hormonally reasonable for quite awhile, especially if you were taking hormones or hormone-affecting drugs to treat your condition. You may never have known hormone balance. The times in your cycle when you were supposed to be feeling your best, may well not have been. For a lot of us, then, we are looking for hormone balance for the first time in a long time—maybe for the first time in our lives—and we have no quantifiable reference point to work against.
But nevermind all that, you say: that's water over the dam. Let's get a blood test done now and see what it says and go from there.
Ah, but wait. If you're taking hrt and have a test done, that result doesn't take into account where you are in your dose cycle: if you take a pill once a day, your dose rises afterwards and gradually falls during the day to a low at night. If you change your patch on a given day, a level drawn before the change is going to be a bit different than one drawn after it. So a single measurement doesn't tell you anything about your average level during the day or over any broad time range, but that's what has the greatest effect on how you feel (although dose dynamics are also an element of that). If you take oral hormones and have a test drawn in the morning and one drawn late in the afternoon, they will return different levels. Which one is the "true" one on which you should base your expectations?
Even then, if you look at hormone test norms, you'll see a confusing array of values, depending where you are in your monthly cycle. If you are post-menopausal, where are you in the monthly cycle? For example, one lab gives these values for adult women:
This looks as though you can have more estrogen (and be "normal") when you are postmenopausal than in some times during your cycle when you were fertile. Huh? A lot of doctors use the mid-follicular phase levels, but as you can see, that's a really wide range. If it happens that you are one whose norm was up towards the 130 end of that range and you now test out at only 25: you are nominally "normal" and you might well feel like hell. Those test numbers just don't capture the relationship between feeling good and a number.
And then there are problems relating to the method. Hormone testing is done using several methods, each of which has its drawbacks.
You can test urine for total hormone quantities. Unfortunately, this test requires collecting every drop of urine output over 24 hours, and keeping it on ice the whole time. If it's not perfectly collected and perfectly stored and perfectly delivered, the accuracy of the test diminishes proportionately. Not altogether convenient for most of us.
You can test blood levels. This is pretty straightforward—the source for the levels we quoted above calls for just 2 cc of blood. You can get it drawn at just about any hospital lab, your insurance will probably cover it, and, assuming that the lab's machine is properly calibrated and the lab tech isn't having a bad day, the results are going to be fairly accurate.
The problem is that a blood test measures total serum estrogen. A woman taking conjugated estrogens, such as Premarin, or the potent synthetic ethinyl estrogen won't see those estrogens show up in her lab results because the standard test measures only estradiol and perhaps a couple other major estrogens, like estrone. Similarly, testing does not reflect that portion of total functional estrogen that may exist in the form of various metabolites, even though they may be active in supporting estrogen needs.
Another problem with estrogen measurement is bioavailability. A great portion of systemic circulating estrogen is bound to SHBG, a protein that locks it up so it can't be used. Well, what's the point of measuring estrogen that you can't use? Right. The problem is, the test can't distinguish even though your body can. Unless you also measure SHBG, you don't know what proportion of that estrogen is bound and which portion is free. Even measuring total SHBG doesn't tell the whole story, since it binds with a number of hormones and so you don't know how much of its capacity counts against the estrogen total.
Getting confused? Hang on, it gets worse yet.
You can also measure hormones levels in saliva. This is newer testing, generally done by private, for-profit labs. It is not accepted as legit by some doctors and most insurance companies. The labs are unregulated, so there is no independent measure of their performance or uniform, third-party standards to which they must adhere. You have to take the word of someone who makes a profit from selling you a service that this service is accurate. On the other hand, you can purchase your own saliva testing kits online or at health stores, which allows you access to testing when your doctor refuses your request for testing. Some compounding pharmacists who sell saliva kits won't work with hormone patients unless they buy a kit. Kits run from about $50 for a single hormone to $200 and more for a multiple-hormone "panel."
Since many of the companies that do testing also sell hormones or supplements or "programs," it is also reasonable to look closely at their recommendations and interpretations. While some of the labs can be quite helpful in interpreting results, others are fraught with delays, "bad reagents" and other problems. With all due respect to the labs, this is a real "buyer beware" situation.
There is also a problem with saliva testing for progesterone. Although the labs are unable to explain it, it is looking more and more as though saliva tests for progesterone return erroneously high results in women using creams. This is something that has become clearer over the past decade, as enough women have used both progesterone cream and the saliva tests to provide a reasonable sample. At first, these high results led some practitioners to recommend against use of progesterone creams because they "don't clear the system," or to tell women to stop using their progesterone because they were experiencing catastrophic overload, even though those women had no particular symptoms of progesterone excess. Some of these warnings are still up on the internet, still in use by practitioners, and continue to cause women to fear use of progesterone creams. While some of these high results are clearly backed up by signs of excessive progesterone in the women using it, many women feel just fine while testing out thousandsfold high. Many of these women also have blood tests within the normal range. So what is going on?
No one has come up with a convincing answer yet. It has been suggested that somehow the saliva tests are responding to metabolites that aren't active as progesterone in the body but still affect the test. Nonetheless, several enterprising manufacturers of progesterone creams advertise special formulations promising better delivery methods that don't cause this terrible build-up as measured in saliva tests. Since we also know plenty of women using conventional creams who are clearly showing beneficial effects and no signs of excess, we find we are just plain skeptical. Until we see something scientifically convincing, we can't wholeheartedly embrace saliva testing for progesterone.
The fact that the test manufacturers simply haven't convincingly addressed this problem in the ten or so years that it's been well known suggests that they don't have a good answer but do continue to have a profitable market. And if there is that flaw in that test, we are not convinced that the other saliva hormone tests might not have flaws of their own, given that they are essentially measuring different things than the blood tests do. There is no answer for this question of reliability until you can identify the source and extent of that discrepancy, and that has not happened. Saliva testing sounds good, but until it meets more rigorous scientific standards, we just don't feel that it is an acceptably valid technique.
So, now that we've bashed all these tests, why did we say pages and pages ago that testing does have its place? Just what would that place be?
Well, even though a test can't tell you when you are "right," it can be of some use in demonstrating where you are wrong.
If you are taking HRT and still experiencing signs of deficit, testing our with extremely low hormone levels bolsters the argument that you need to try a different delivery method. If you are in agony with signs of excess estrogen, demonstrating elevated levels may substantiate the need to decrease your dose, regardless of how that dose compares with the "norm." In other words, hormone testing comes into greatest usefulness in demonstrating great deviations from the normal range.
The other most useful situation for hormone level testing is if you feel bad but are unable to determine in which direction your imbalance has taken you. The symptoms aren't always clear, especially when we're beginning to learn what our body is trying to tell us. Similarly, some doctors are better than others at tuning; some simply feel that any complaint about hormone symptoms means we need to change brands or routes or raise our doses. Sometimes we're just lost. While testing won't tell us we're within sight of our goals, it may help point the direction in which that goal may lie. And that may be enough to get us moving again.
So testing has both its uses and its limits. So long as you know one from the other, you can use test results wisely—and sparingly of your cash—in guiding the balancing process.
"Normal" hormone levels?
Skeptical? Let's pretend for a moment that you know exactly what your hormone levels were preoperatively for every moment of the day of every day of the month, when you felt good and when you felt bad. Now, think about what you were doing with those hormones—what you needed them for. Or, in other words, what needs you were fulfilling with them such that the needs and supply balanced out causing you to feel your best. Why, a lot of those hormones were dedicated to their primary function of supporting fertility: cycling eggs up to ready and your uterus with a nice thick linking to receive them.
But now jump ahead in time to post-hyst. We're no longer fertile; we no longer have that uterus to support and cycle. In fact, being in menopause sends a signal to our bodies that we don't need a whole lot of things that were part of our reproductive lifestage any more. That means that we can cross off all of those fertility needs from our list of jobs for hormones to fill. And that in turn means we don't need as many individual hormone molecules to fill these reduced job quotas if we want everything to balance out just right between supply and demand.
And how many molecules of hormones can we cross off of those perfectly-balanced pre-menopausal values for these no-longer-needed fertile functions? Why, nobody has the slightest clue. There's no chart; there's no research study; there's no rule of thumb; there's not even a good guess that goes along the lines of X% of your hormones go to support fertility. Nobody has a clue. So what good are pre-op hormone levels in predicting post-meno needs? Not much: if we were to blindly duplicate those levels without the need, we'd be suffering sure symptoms of excess. We just can't count on numbers and expect to use them to roll the clock back.
Even more discouragingly, if you have had gynecological health problems for a considerable amount of time pre-hyst, you probably haven't been hormonally reasonable for quite awhile, especially if you were taking hormones or hormone-affecting drugs to treat your condition. You may never have known hormone balance. The times in your cycle when you were supposed to be feeling your best, may well not have been. For a lot of us, then, we are looking for hormone balance for the first time in a long time—maybe for the first time in our lives—and we have no quantifiable reference point to work against.
But nevermind all that, you say: that's water over the dam. Let's get a blood test done now and see what it says and go from there.
Ah, but wait. If you're taking hrt and have a test done, that result doesn't take into account where you are in your dose cycle: if you take a pill once a day, your dose rises afterwards and gradually falls during the day to a low at night. If you change your patch on a given day, a level drawn before the change is going to be a bit different than one drawn after it. So a single measurement doesn't tell you anything about your average level during the day or over any broad time range, but that's what has the greatest effect on how you feel (although dose dynamics are also an element of that). If you take oral hormones and have a test drawn in the morning and one drawn late in the afternoon, they will return different levels. Which one is the "true" one on which you should base your expectations?
Even then, if you look at hormone test norms, you'll see a confusing array of values, depending where you are in your monthly cycle. If you are post-menopausal, where are you in the monthly cycle? For example, one lab gives these values for adult women:
- early follicular phase 20-65 pg/mL
- mid follicular phase 20-130 pg/mL
- late follicular/mid cycle phase 50-320 pg/mL
- early luteal phase 20-100 pg/mL
- mid luteal phase 30-200 pg/mL
- late luteal 20-160 pg/mL
- postmenopausal ND-30 pg/mL
This looks as though you can have more estrogen (and be "normal") when you are postmenopausal than in some times during your cycle when you were fertile. Huh? A lot of doctors use the mid-follicular phase levels, but as you can see, that's a really wide range. If it happens that you are one whose norm was up towards the 130 end of that range and you now test out at only 25: you are nominally "normal" and you might well feel like hell. Those test numbers just don't capture the relationship between feeling good and a number.
Hormone testing methods
You can test urine for total hormone quantities. Unfortunately, this test requires collecting every drop of urine output over 24 hours, and keeping it on ice the whole time. If it's not perfectly collected and perfectly stored and perfectly delivered, the accuracy of the test diminishes proportionately. Not altogether convenient for most of us.
You can test blood levels. This is pretty straightforward—the source for the levels we quoted above calls for just 2 cc of blood. You can get it drawn at just about any hospital lab, your insurance will probably cover it, and, assuming that the lab's machine is properly calibrated and the lab tech isn't having a bad day, the results are going to be fairly accurate.
The problem is that a blood test measures total serum estrogen. A woman taking conjugated estrogens, such as Premarin, or the potent synthetic ethinyl estrogen won't see those estrogens show up in her lab results because the standard test measures only estradiol and perhaps a couple other major estrogens, like estrone. Similarly, testing does not reflect that portion of total functional estrogen that may exist in the form of various metabolites, even though they may be active in supporting estrogen needs.
Another problem with estrogen measurement is bioavailability. A great portion of systemic circulating estrogen is bound to SHBG, a protein that locks it up so it can't be used. Well, what's the point of measuring estrogen that you can't use? Right. The problem is, the test can't distinguish even though your body can. Unless you also measure SHBG, you don't know what proportion of that estrogen is bound and which portion is free. Even measuring total SHBG doesn't tell the whole story, since it binds with a number of hormones and so you don't know how much of its capacity counts against the estrogen total.
Getting confused? Hang on, it gets worse yet.
You can also measure hormones levels in saliva. This is newer testing, generally done by private, for-profit labs. It is not accepted as legit by some doctors and most insurance companies. The labs are unregulated, so there is no independent measure of their performance or uniform, third-party standards to which they must adhere. You have to take the word of someone who makes a profit from selling you a service that this service is accurate. On the other hand, you can purchase your own saliva testing kits online or at health stores, which allows you access to testing when your doctor refuses your request for testing. Some compounding pharmacists who sell saliva kits won't work with hormone patients unless they buy a kit. Kits run from about $50 for a single hormone to $200 and more for a multiple-hormone "panel."
Since many of the companies that do testing also sell hormones or supplements or "programs," it is also reasonable to look closely at their recommendations and interpretations. While some of the labs can be quite helpful in interpreting results, others are fraught with delays, "bad reagents" and other problems. With all due respect to the labs, this is a real "buyer beware" situation.
There is also a problem with saliva testing for progesterone. Although the labs are unable to explain it, it is looking more and more as though saliva tests for progesterone return erroneously high results in women using creams. This is something that has become clearer over the past decade, as enough women have used both progesterone cream and the saliva tests to provide a reasonable sample. At first, these high results led some practitioners to recommend against use of progesterone creams because they "don't clear the system," or to tell women to stop using their progesterone because they were experiencing catastrophic overload, even though those women had no particular symptoms of progesterone excess. Some of these warnings are still up on the internet, still in use by practitioners, and continue to cause women to fear use of progesterone creams. While some of these high results are clearly backed up by signs of excessive progesterone in the women using it, many women feel just fine while testing out thousandsfold high. Many of these women also have blood tests within the normal range. So what is going on?
No one has come up with a convincing answer yet. It has been suggested that somehow the saliva tests are responding to metabolites that aren't active as progesterone in the body but still affect the test. Nonetheless, several enterprising manufacturers of progesterone creams advertise special formulations promising better delivery methods that don't cause this terrible build-up as measured in saliva tests. Since we also know plenty of women using conventional creams who are clearly showing beneficial effects and no signs of excess, we find we are just plain skeptical. Until we see something scientifically convincing, we can't wholeheartedly embrace saliva testing for progesterone.
The fact that the test manufacturers simply haven't convincingly addressed this problem in the ten or so years that it's been well known suggests that they don't have a good answer but do continue to have a profitable market. And if there is that flaw in that test, we are not convinced that the other saliva hormone tests might not have flaws of their own, given that they are essentially measuring different things than the blood tests do. There is no answer for this question of reliability until you can identify the source and extent of that discrepancy, and that has not happened. Saliva testing sounds good, but until it meets more rigorous scientific standards, we just don't feel that it is an acceptably valid technique.
When is testing helpful, then?
Well, even though a test can't tell you when you are "right," it can be of some use in demonstrating where you are wrong.
If you are taking HRT and still experiencing signs of deficit, testing our with extremely low hormone levels bolsters the argument that you need to try a different delivery method. If you are in agony with signs of excess estrogen, demonstrating elevated levels may substantiate the need to decrease your dose, regardless of how that dose compares with the "norm." In other words, hormone testing comes into greatest usefulness in demonstrating great deviations from the normal range.
The other most useful situation for hormone level testing is if you feel bad but are unable to determine in which direction your imbalance has taken you. The symptoms aren't always clear, especially when we're beginning to learn what our body is trying to tell us. Similarly, some doctors are better than others at tuning; some simply feel that any complaint about hormone symptoms means we need to change brands or routes or raise our doses. Sometimes we're just lost. While testing won't tell us we're within sight of our goals, it may help point the direction in which that goal may lie. And that may be enough to get us moving again.
So testing has both its uses and its limits. So long as you know one from the other, you can use test results wisely—and sparingly of your cash—in guiding the balancing process.
Symptoms of testosterone imbalance
Low testosterone
Other things that may indicate you could benefit from testosterone include depression, lethargy, and general weakness. Women have said their thoughts seem clearer after adding testosterone. Testosterone boosts muscle mass and strength.
On the other hand, because of its risks, there is not a free lunch involved in using testosterone as some sort of legal pick-me-up or counter to the normal effects of aging. If you're feeling draggy on the initial estrogen HRT you try and the first thing your doctor suggests is perking you up with testosterone, you might want to think about that strategy just a bit: using one hormone to patch inadequacies in a maladjusted other is not actually a sound or desirable approach. In fact, the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) specifically states that we can't even determine whether or not we need to supplement other hormones until we have fine-tuned our estrogen to meet our needs as closely as possible.
The truth is that many of the results attributable to testosterone supplementation are more likely to be from better-tuned estrogen supplies, and we're just using our testosterone to augment our estrogen hrt (because of the interconversion that can and does happen when estrogen needs are unmet). And that's at a fairly substantial metabolic cost. So waiting until we know it's really testosterone we need is the first key to identifying unmet testosterone needs.
Excess testosterone
Aggression, snappiness, anger, frustration, impatience—all of these signs of exaggerated mood may be due to excessively high levels of testosterone.
Masculine characteristics such as deeper or coarser voice, clitoral enlargement, and breast shrinking are signs of excess testosterone. Male hair growth patterns—more or thicker hair on the face and breasts but loss from the top of the head and at the hairline—are typical of testosterone imbalance.
Changes caused by testosterone often mimic those of adolescence (try to hold the jokes down to a low roar, ladies). Greasy skin and hair and acne or pimples are often the very first signs you see of a high testosterone level.
Finally, weight gain and fluid retention are seen at high levels. This needs to be distinguished from muscle and bone mass enhancement that are seen at therapeutic levels, however, and because of the overlap with estrogen effects, may require looking closely at both hormones.
Balancing Testosterone
Testosterone is, ideally, the second or third hormone added and balanced in HRT. We've said this before but we'll repeat it because we think it's important and we don't want you to miss it by reading skipping around. The statement in the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) that we cannot determine our need for other hormones until our estrogen is as fine-tuned as possible makes simple, physiological sense of the kind it's hard to argue with once stated. This means that the current chic of adding testosterone to compensate for ill-fitting estrogen hrt is pretty much unjustifiable given the risks both testosterone and progesterone pose.
If, however, you don't get what you're looking for from estrogen, then it is time to look into supplementing this other important ovarian hormone.
At this point in previous versions of this article, we would suggest that supplementing progesterone before testosterone provides a safer overall hormonal profile of risks. Now that we know more about progestogen risks, especially their links to cancer, we feel that picture is much less clear. Still, all we can do is point out the dangers: it's up to you to weigh what you hope to accomplish and how you choose to get there. If you're thinking about using testosterone to boost libido, we'd like to point out that there are other areas to evaluate in the libido troubleshooting decision tree before you get to that; you might find it useful to have a look at the Sexuality and surgical menopause article to review those steps.
Okay, disclaimers about risk and benefit aside, let's look more closely at supplementing testosterone.
Testosterone supplementation for women is fairly new. Only a decade or two ago, researchers were trumpeting the astonishing news that women produced and had receptors for testosterone. Predictably, a few books were written that claimed everything a woman had wrong with her could be cured with a little testosterone, and if a little was good, a lot was better. Our stance is a lot less glamorous, but may be more survivable.
We feel that since our ovaries averaged an output of around 0.3 mg a day of testosterone, that's probably all we need of the stuff. Guys, obviously, have a lot more. Because a lot of testosterone supplements were designed for them and the experience of doctors and pharmacists is primarily with them, you may need to rein in the dose enthusiasm of the professionals. Doctors seem fairly willing to write prescriptions for testosterone, but you may need to convince them that you only want a smidgeon. For this reason, even though there is a tendency to write prescriptions for 2% or even 10% creams, a 1% or even 0.5% preparation makes a more reasonably-measureable strength for a prudent woman's dose range.
A lot of women come home from the pharmacy with their new tube of testosterone cream only to find the directions say "take as directed" and their doctor's office says something like "measure out an inch a day" when they call and ask them how they're directed to take it. The right way to approach this situation if the label doesn't show the cream strength is to call the pharmacy, speak to a pharmacist, and ask what is the strength of your cream in milligrams/unit volume and how many miligrams is in each prescribed volume dose.
Why do the numbers matter? All other things being equal, a good place to start is replacing what your body made normally: roughly 0.2-0.5 mg/day. Or even less if you are also using progesterone. By working around a normative amount, you can be both consistent and reasonable. If you need to add more later, fine—but at least you aren't going to start out at disaster level. And if you only need a very small volume every day, ask your pharmacist for a small, needle-less syringe so you can measure accurately. Your body will appreciate consistent dosing.
When you begin testosterone, it's not uncommon to feel a quick zing from it and then not much. Response time to testosterone is generally slower than with the other two hormones. It usually takes a full month or three (yes, we really just said three months) for it to take effect, and that can be a long time to wait (especially if you have a partner slavering over the prospect of a new, interested you). In addition, because it affects the balance and supply of both estrogen and progesterone, it is not unusual to get a few hot flashes in the first week or so you're taking it in human-identical form. This transitional effect does settle down as things shake out, but it can be distressing if you think you've gone after a little sexual boost without realizing you've altered your overall hormone balance.
It not unheard of to need to adjust the other hormone doses to accommodate the addition of testosterone. Some testosterone is converted to estradiol, so it's important to understand that may act as an estrogen supplement if you're not fully meeting your estrogen needs on your estrogen hrt. According to some manufacturers, men using testosterone see a 10% or more increase in their estrogen levels when beginning testosterone supplementation. This has important implications for both typical hrt balance as well as for those who cannot or choose not to supplement their estrogen levels, since as a priority, estrogen needs will be met with the testosterone before our bodies use any leftover testosterone as itself.
If you have been on testosterone a month and don't feel that you are terribly thrilled with the results, you might also explore whether you need every bit of the estrogen you are taking. Remember, estrogen in excess tends to suppress arousal and orgasm, so in that respect it counteracts testosterone; it also raises the level of a protein that inactivates testosterone.
If this seems like a confusing situation, it is. Or at least, it is from the standpoint of our trying to drive what our body does with the supplements we give it. In fact, our body prioritizes hormone needs and scalps from everything lower down on the priority list to meet higher-priority needs. Estrogen will always trump progesterone or testosterone. Which, coming full circle, is exactly why the Endocrinologists' guidelines specify estrogen adequacy as the starting point for other hormone supplementation.
The other caution that we'd like to urge on women beginning testosterone supplementation is to be sure of their cardiovascular heath beforehand. The male profile of CV risk is higher than a woman's, and much of that is conveyed through the actions of testosterone. Many careful doctors today check a woman's lipid levels (cholesterol, HDL, LDL) and blood pressure before she starts taking it, so that if they are elevated or become elevated after she has been on testosterone awhile, other interventions can be put into place to control them. Since our risks of CV disease are elevated by menopause anyway, we think that's such a sound measure that we'd urge women whose doctors haven't thought of this to request it themselves. We think sex is just swell, but for all that taking testosterone might improve it, having a stroke surely won't.
If, however, you don't get what you're looking for from estrogen, then it is time to look into supplementing this other important ovarian hormone.
At this point in previous versions of this article, we would suggest that supplementing progesterone before testosterone provides a safer overall hormonal profile of risks. Now that we know more about progestogen risks, especially their links to cancer, we feel that picture is much less clear. Still, all we can do is point out the dangers: it's up to you to weigh what you hope to accomplish and how you choose to get there. If you're thinking about using testosterone to boost libido, we'd like to point out that there are other areas to evaluate in the libido troubleshooting decision tree before you get to that; you might find it useful to have a look at the Sexuality and surgical menopause article to review those steps.
Okay, disclaimers about risk and benefit aside, let's look more closely at supplementing testosterone.
Testosterone supplementation for women is fairly new. Only a decade or two ago, researchers were trumpeting the astonishing news that women produced and had receptors for testosterone. Predictably, a few books were written that claimed everything a woman had wrong with her could be cured with a little testosterone, and if a little was good, a lot was better. Our stance is a lot less glamorous, but may be more survivable.
We feel that since our ovaries averaged an output of around 0.3 mg a day of testosterone, that's probably all we need of the stuff. Guys, obviously, have a lot more. Because a lot of testosterone supplements were designed for them and the experience of doctors and pharmacists is primarily with them, you may need to rein in the dose enthusiasm of the professionals. Doctors seem fairly willing to write prescriptions for testosterone, but you may need to convince them that you only want a smidgeon. For this reason, even though there is a tendency to write prescriptions for 2% or even 10% creams, a 1% or even 0.5% preparation makes a more reasonably-measureable strength for a prudent woman's dose range.
A lot of women come home from the pharmacy with their new tube of testosterone cream only to find the directions say "take as directed" and their doctor's office says something like "measure out an inch a day" when they call and ask them how they're directed to take it. The right way to approach this situation if the label doesn't show the cream strength is to call the pharmacy, speak to a pharmacist, and ask what is the strength of your cream in milligrams/unit volume and how many miligrams is in each prescribed volume dose.
Why do the numbers matter? All other things being equal, a good place to start is replacing what your body made normally: roughly 0.2-0.5 mg/day. Or even less if you are also using progesterone. By working around a normative amount, you can be both consistent and reasonable. If you need to add more later, fine—but at least you aren't going to start out at disaster level. And if you only need a very small volume every day, ask your pharmacist for a small, needle-less syringe so you can measure accurately. Your body will appreciate consistent dosing.
Beginning testosterone
It not unheard of to need to adjust the other hormone doses to accommodate the addition of testosterone. Some testosterone is converted to estradiol, so it's important to understand that may act as an estrogen supplement if you're not fully meeting your estrogen needs on your estrogen hrt. According to some manufacturers, men using testosterone see a 10% or more increase in their estrogen levels when beginning testosterone supplementation. This has important implications for both typical hrt balance as well as for those who cannot or choose not to supplement their estrogen levels, since as a priority, estrogen needs will be met with the testosterone before our bodies use any leftover testosterone as itself.
If you have been on testosterone a month and don't feel that you are terribly thrilled with the results, you might also explore whether you need every bit of the estrogen you are taking. Remember, estrogen in excess tends to suppress arousal and orgasm, so in that respect it counteracts testosterone; it also raises the level of a protein that inactivates testosterone.
If this seems like a confusing situation, it is. Or at least, it is from the standpoint of our trying to drive what our body does with the supplements we give it. In fact, our body prioritizes hormone needs and scalps from everything lower down on the priority list to meet higher-priority needs. Estrogen will always trump progesterone or testosterone. Which, coming full circle, is exactly why the Endocrinologists' guidelines specify estrogen adequacy as the starting point for other hormone supplementation.
The other caution that we'd like to urge on women beginning testosterone supplementation is to be sure of their cardiovascular heath beforehand. The male profile of CV risk is higher than a woman's, and much of that is conveyed through the actions of testosterone. Many careful doctors today check a woman's lipid levels (cholesterol, HDL, LDL) and blood pressure before she starts taking it, so that if they are elevated or become elevated after she has been on testosterone awhile, other interventions can be put into place to control them. Since our risks of CV disease are elevated by menopause anyway, we think that's such a sound measure that we'd urge women whose doctors haven't thought of this to request it themselves. We think sex is just swell, but for all that taking testosterone might improve it, having a stroke surely won't.
Using testosterone
Testosterone cream and gels prescriptions tend to be written in terms such as "take as directed" or "a pea-sized amount". In fact, as we mentioned above, there's quite a bit of flexibility in dosing and the ultimate goal should be, as with any hrt, using only as much as provides the desired effect.
One thing that's easier with testosterone balancing than either estrogen or progesterone is that it doesn't have to be used on a daily basis. We respond more slowly to both a dose and a dose wearing off, so it's fine to use testosterone on a weekly or few-days-a-week basis. We have to feel our way to the frequency and dose, both, that provide just the support we're looking for. But unless we're using testosterone as a major contributor to our estrogen balance, intermittent use should not cause symptoms of estrogen fluctuation. In fact, if it does, that's a good indication that we should revisit our primary estrogen hrt rather than relying upon testosterone to make up its shortfall.
Another thing prescriptions tend to be skimpy in the details on is where we should apply testosterone creams or gels or ointments. Basically they can be used anyplace away from breast tissue where we don't mind stimulating a little hair growth (no, this does not mean that if we're showing signs of balding we should apply it to our scalp: it doesn't work that way). Some women report good results using the inner thigh. Other women apply it to their labia or even clitoral tissues, and that seems to work as well. In any application, be sure to keep in mind that we really don't want to share our topical hrts with partners or children, so we should limit their direct contact with the skin to which it's applied and wash our hands properly after application.
In essence, then, the process is one of beginning with a very small amount and working upward until we fid steady support at the level we desire. If we get to the full daily amount without hitting that point, adding another day of use per week, all of them at a somewhat lower level, will give us a gradual stairstep up without overloading ourselves on a less frequent basis. This is truly a feel-your-way-along process.
Symptoms of progesterone imbalance
Many of the symptoms of estrogen excess can be interpreted as low progesterone, or at least indications of need for progesterone instead of as much estrogen. On the other hand, some things that are related to low estrogen levels are also responsive to progesterone.
In fact, the entire picture needs to be evaluated in terms of the proper ratio of the two rather than the two hormones, isolated, considered at their individual levels. While you can get into lots of complexities measuring the two values and calculating their ratios (Dr. Joseph Collins goes into this at length in his book, What's Your Menopause Type, if you really want to pursue doing it), the bottom line is that the balance needs to be even, with one counteracting the worst of the other and not inhibiting the best of it.
This does not mean taking the same dose of each or even supplementing with both hormones—as we said back in the discussion of dosing, numbers don't mean anything except relative to that one particular brand/form/hormone. Instead, it means looking at both hormones such that they reach a balanced effect in your particular body. Finding this is an experiential, not mathematic, process, so we don't feel it's especially useful to get too hung up trying to work out the numbers. Listen to your body carefully, and that will tell you what you want to know.
In particular, the excitatory effects of estrogen call out for progesterone's soothing counterbalance. Insomnia, jitteriness, anxiety—all of these may be well addressed by progesterone when they cannot be addressed by estrogen reduction alone. Mental fuzziness or moodiness are also things that could be helped by the addition of progesterone if estrogen alone has not cleared things up.
Libido and genitourinary health are also areas where adding progesterone can have notable effects. Remember, estrogen in excess inhibits orgasm, but progesterone can help you produce the additional testosterone needed to experience desire once your estrogen is as fully tuned as it can be. Incontinence and vaginal dryness are also signs that progesterone may be of help if estrogen alone has not resolved the problem. There are lots of progesterone receptors in this part of the body.
Fluid retention and painful breasts can be helped by increasing progesterone although if they are caused by excess estrogen, adjusting estrogen downward is is a much better way to begin dealing with them. Progesterone counterbalances estrogen's effect on appetite (and insulin metabolism), and becoming better balanced on the two may help limit the weight gain that estrogen may seem to cause.
Muscle aches and joint pains may indicate a low progesterone level relative to estrogen.
Dry skin or eyes can also reflect this sort of imbalance.
Attentiveness to progesterone adequacy can be very helpful when fibrocystic breasts are aggravated by estrogen, to an extent that some claim it "cures" fibrocystic breasts (we wouldn't go that far, but it does make a difference for many).
Progesterone has a soothing effect on the nerves and brain, and this taken to extremes is what is most often seen at excess. Drowsiness is often the first sign noted. To some extent, this may be an inevitable result of progesterone use. For this reason, many women take their progesterone at night. Oral forms of progesterone are particularly sleep-inducing in the way they are metabolized, so they should not be taken in the morning.
Other symptoms of progesterone excess that go beyond sleepiness are depression, apathy, and even suicidal ideation. These are not truly side effects, or signs of being intolerant of progesterone, as some critics of progesterone use have suggested. Rather, they are the normal effects of this hormone when it's present in significant excess related to needs.
Some women report that when they first begin taking progesterone, they experience dizziness and vertigo. This may be related to the fact that progesterone acts on some of the same parts of the brain and in a similar way to anesthesia. If this represents a symptom of excess, it seems to be a transitory one that clears as your system accommodates to a greater availability of the hormone. It can, in the short term, however, represent a significant safety hazard requiring some vigilance to avoid putting yourself, or others, at risk.
One mysterious (that means we don't know the physiologic basis for it happening) effect in the progesterone "intolerant" is bladder problems. Some women have either a great increase in urinary tract infections or a feeling like having an infection as soon as they try taking a "normal" progesterone dose. Since interstitial cystitis is believed to have a hormonal link, we're sure this is all tied in together somewhere—we just aren't quite sure of exactly how. What you need to know is that yes, if these symptoms start and stop with starting/stopping progesterone, they may be related to your personal level of needs. If it happens to you, you may want to get some serious lab work to determine whether you need progesterone at all, and if you do, work with exquisitely tiny doses to feel your way along.
As we've said throughout this guide, everyone's need for hormones is different. Some women respond to even very low doses of progesterone with symptoms of excess. But that's not so much an excessive susceptibility as an indication that for these women their endogenous production is adequate to provide for their needs. In practice, the range of progesterone tolerance (the difference between meeting needs and excess) can be quite narrow, and a tiny dose—or none at all—could be all that is needed to complete balance between the estrogen you're taking and the progesterone you're making if any supplementation is needed at all. Our hormones are supplements to what we are making, meant to bridge the gap between what we make and what we need; they are not something we must either take or have none at all of, even when we no longer have ovaries.
In fact, the entire picture needs to be evaluated in terms of the proper ratio of the two rather than the two hormones, isolated, considered at their individual levels. While you can get into lots of complexities measuring the two values and calculating their ratios (Dr. Joseph Collins goes into this at length in his book, What's Your Menopause Type, if you really want to pursue doing it), the bottom line is that the balance needs to be even, with one counteracting the worst of the other and not inhibiting the best of it.
This does not mean taking the same dose of each or even supplementing with both hormones—as we said back in the discussion of dosing, numbers don't mean anything except relative to that one particular brand/form/hormone. Instead, it means looking at both hormones such that they reach a balanced effect in your particular body. Finding this is an experiential, not mathematic, process, so we don't feel it's especially useful to get too hung up trying to work out the numbers. Listen to your body carefully, and that will tell you what you want to know.
Low progesterone
Libido and genitourinary health are also areas where adding progesterone can have notable effects. Remember, estrogen in excess inhibits orgasm, but progesterone can help you produce the additional testosterone needed to experience desire once your estrogen is as fully tuned as it can be. Incontinence and vaginal dryness are also signs that progesterone may be of help if estrogen alone has not resolved the problem. There are lots of progesterone receptors in this part of the body.
Fluid retention and painful breasts can be helped by increasing progesterone although if they are caused by excess estrogen, adjusting estrogen downward is is a much better way to begin dealing with them. Progesterone counterbalances estrogen's effect on appetite (and insulin metabolism), and becoming better balanced on the two may help limit the weight gain that estrogen may seem to cause.
Muscle aches and joint pains may indicate a low progesterone level relative to estrogen.
Dry skin or eyes can also reflect this sort of imbalance.
Attentiveness to progesterone adequacy can be very helpful when fibrocystic breasts are aggravated by estrogen, to an extent that some claim it "cures" fibrocystic breasts (we wouldn't go that far, but it does make a difference for many).
High progesterone
Other symptoms of progesterone excess that go beyond sleepiness are depression, apathy, and even suicidal ideation. These are not truly side effects, or signs of being intolerant of progesterone, as some critics of progesterone use have suggested. Rather, they are the normal effects of this hormone when it's present in significant excess related to needs.
Some women report that when they first begin taking progesterone, they experience dizziness and vertigo. This may be related to the fact that progesterone acts on some of the same parts of the brain and in a similar way to anesthesia. If this represents a symptom of excess, it seems to be a transitory one that clears as your system accommodates to a greater availability of the hormone. It can, in the short term, however, represent a significant safety hazard requiring some vigilance to avoid putting yourself, or others, at risk.
One mysterious (that means we don't know the physiologic basis for it happening) effect in the progesterone "intolerant" is bladder problems. Some women have either a great increase in urinary tract infections or a feeling like having an infection as soon as they try taking a "normal" progesterone dose. Since interstitial cystitis is believed to have a hormonal link, we're sure this is all tied in together somewhere—we just aren't quite sure of exactly how. What you need to know is that yes, if these symptoms start and stop with starting/stopping progesterone, they may be related to your personal level of needs. If it happens to you, you may want to get some serious lab work to determine whether you need progesterone at all, and if you do, work with exquisitely tiny doses to feel your way along.
As we've said throughout this guide, everyone's need for hormones is different. Some women respond to even very low doses of progesterone with symptoms of excess. But that's not so much an excessive susceptibility as an indication that for these women their endogenous production is adequate to provide for their needs. In practice, the range of progesterone tolerance (the difference between meeting needs and excess) can be quite narrow, and a tiny dose—or none at all—could be all that is needed to complete balance between the estrogen you're taking and the progesterone you're making if any supplementation is needed at all. Our hormones are supplements to what we are making, meant to bridge the gap between what we make and what we need; they are not something we must either take or have none at all of, even when we no longer have ovaries.
Balancing progesterone
Some of our readers will be balancing progesterone in conjunction with estrogen. Progesterone is rarely used by itself by women in surgical menopause, even though many assert that it does seem to have a role used that way in natural menopause. Why not? We agree: it seems that if progesterone can be converted to estrogen, just supplying that seems as though it should work. But it doesn't actually work out that way: women who try progesterone-alone in surgical meno just seem to suffer from the creeping dismals, spiraling into feeling worse and worse from unmet estrogen needs. While interconversion works to some extent, then, it doesn't seem to be efficient enough to run the whole system on.
Further, we have to remember that much of the publicity about progesterone use, especially the marketing-based press, is aimed toward women in natural perimenopause, not us in surgical menopause. If you're not clear on the difference, you may want to check out our article on natural vs surgical menopause before reading further here.
The only major instance in which progesterone is likely to be used by itself in surgical menopause is in the immediate post-op period following a hyst for endometriosis, when it is sometimes used to suppress the regrowth of the microscopic endo remnants left after surgery.
The estrogen/progesterone relationship is a very complex and ultimately uncontrollable one (which one gets to which receptors first), so it's very difficult to predict what alterations you'll see in both of them as you adjust to progesterone at a higher level of supply. In fact, adding progesterone is the single most complex and also drawn-out adaptation when we are balancing the three major ovarian hormone groups.
If you have been on (a roughly adequate dose of) estrogen alone and add progesterone, you may find you need to reduce your estrogen dose or already be a little low on estrogen when you add the progesterone. This is due to the well-documented action progesterone has as an estrogen-sparing hormone a well as itself being able to be converted into estrogen to make up a supply shortfall of that hormone. Whether you choose to do this "on spec" at the same time as you introduce the progesterone or whether you decide to wait to do this until after you have settled down somewhat on your progesterone dose, you should at least be aware of this possibility. There are no clear guidelines for how much of a dose reduction (if any) will be necessary, but our sense of it is that this is a rather small amount—certainly no more than 20% of your dose and probably somewhat less, if you were more or less at the right level of estrogen before.
If you are presently in a state of estrogen excess, it would seem gentler on your system as well as your risk profile to try to drop some of that estrogen, so you are down to the start of feeling low, before adding the progesterone. The idea that progesterone, because it can act counter to estrogen, will somehow reverse the effects of excess estrogen while you continue to take more estrogen than you need is a seductive but generally unrealized bit of wishful thinking.
Progesterone often makes us feel worse before we feel better, thanks to its pivotal role as a precursor of other hormones as well as its ability to share some receptors with estrogen. But that's only part of progesterone's work. It's also quite important in overall brain cell irritability, something that is pushed in the other direction by estrogen's neurostimulatory effects. At the same time, it specifically affects centers in the brain that control thermoregulation and balance (that is, physical balance as well as dizziness) and mood. These are some of the same brain areas affected by such drugs as Xanax and those targeted by some aspects of general anesthesia. Elsewhere it affects copper and zinc levels, which interact with thyroid hormone function, and metabolic (glucose metabolism) functions such as insulin uptake by cells. It tends to affect prostaglandin synthesis, which in turn has inflammatory implications throughout our systems on things all the way from joints and bowels to minute cardiovascular changes and even, it's being researched now, affecting the development of cancers. [booming ad voice]And much, much more![/booming ad voice]
Less critical to our understanding of the impact of progesterones effects are these specific details; what's more important is recognizing that all of these are tremendously complex and responsive systems in their own rights, and all of them rely on many enzymes and molecular activities (which are in turn, of course, reliant on a whole host of other factors and congruences) for proper conduct. What it all means is that when we alter the overall supply of progesterone, we are going to see a lot of changes throughout our bodies and they are going to take quite a few feedback iterations to all shake out as we adjust to this new supply situation.
Functionally, then, it's a long process (weeks to a couple months) and it tends to be an unpleasant and disruptive one for at least the first week or two when the worst (greatest) imbalanced swings are occurring. These responses can be hormonal-seeming, affecting our estrogenic-balance cues, as well as unrelated (dizziness, groggy, sleepy, mood, hunger, overall fluid balance). But these are, in those first weeks, all about the adjustment process and really not so much about the hormone itself. This is true generally of hormones and hrts, but nowhere more so than with the introduction of progesterone.
The key, then, to adding progesterone is to not be alarmed by initial reactions. Unless you keep getting worse after the first week, as we mentioned elsewhere, you may want to keep going to see how things feel after the second week. It often takes a full two weeks for initial symptoms of progesterone adjustment to abate. Shall we repeat that? It is normal to feel worse for a couple weeks when starting progesterone.
If you are starting up with both hormones together, the decision of choosing starting doses is doubled in complexity. Basically, though, the start low and go slow premise applies even more in this kind of situation.
You may want to pick your starting dose of estrogen at the lower end of the range, knowing that the progesterone may boost it, and you won't want to overbalance yourself with progesterone. For reasons given elsewhere, we think it especially makes very little sense to start these two hormones in one combined form. Starting with two separate preparations allows the doses can be tuned individually. If the doses are mismatched in one combined formulation to begin with, altering the dose of that formulation up or down is not likely to affect the underlying proportional imbalance between the two. If a combined product's convenience is important to you, you might consider using individual supplies until you determine your correct dose of each and then having them blended.
Once through those first throes of introduction, our sense of balancing these two hormones is that it is often clearer to lower the estrogen and then tune with the progesterone, so long as you are not seeing symptoms of progesterone excess.
Quite a number of progesterone cream users have reported that topical progesterone preparations seem to lose strength over time. We don't know whether it has to do with exposure to air, temperature or what, and neither have pharmacists we've asked. Nonetheless, it is a common experience to get to the bottom of a jar and feel as though you aren't quite getting enough of a dose, then start a new jar and go "whoa! this stuff really has a kick to it!"
There's no point to fussing over it, beyond making sure that you are not subjecting your supply to excessively hot or airy conditions. When they start to feel they're coming up short, many women just increase their dose a tad at the bottom of the container and scale back to the former dose when they open the next. So long as you know it's happening and it's predictable, it shouldn't send you into a tailspin. It's normal. Don't sweat the small stuff.
We don't so much go for the "estrogen dominance" terminology popularized by Dr. Lee and his advocates because to us, this seems too simplistic a concept to really describe what we're working with in surgical menopause. Instead, we try to remember that we're working with two separate but inter-related functions.
The first is how well each hormone meets our background needs for it. Regardless of how the two hormones may or may not be balanced with respect to each other, if the sum total still leaves unmet needs, we're going to have symptoms where gaps in our hormone coverage show up. Different women have different systems that are more sensitive to the fine edge of "enough" than others. For some, it's the first twinges of vaginal atrophy; for others, it's unwarranted moodiness. Whatever yours is, it's about your background ability to meet all of your hormone needs.
The other aspect of balance is how the two hormones interact relative to each other. We like to visualize this much the way an old-fashioned balance scale would look if we piled all of our estrogen effects on one side and all of our progesterone effects on the other. If the scale tilts down on the estrogen side, say, then one of two things may be happening: either we have too much estrogen on that side of the scale or we don't have enough progesterone on the other side. The scale doesn't tell us if either side has the correct amount; it only tells us the general direction of the imbalance between the two.
So too, if in our bodies we see signs indicative of estrogen excess, that might be due to too heavy a dose of estrogen but it might also be due to too light a dose of progesterone. And the same thing is true in reverse, of course: if we see too much weighting towards the progesterone signs of excess, it could be due to either an excessive progesterone dose or an overly light estrogen intake.
How do these come together? Don't they overlap? Uh huh. But it's important to keep in mind both parts of this, the needs and the inter-relationship. If we don't, we run the risk of seeing an imbalance to this side, taking a little more of the other to bring things up, then swooping into the other tilt so we add a touch of the opposite hormone...and before long, we've blown ourselves away with excesses of everything. So if we can remember that needs set the general order of magnitude and balance does the fine tuning between them, we've got a more nuanced concept as well as one that is much less likely to lead us hopelessly adrift.
Further, we have to remember that much of the publicity about progesterone use, especially the marketing-based press, is aimed toward women in natural perimenopause, not us in surgical menopause. If you're not clear on the difference, you may want to check out our article on natural vs surgical menopause before reading further here.
The only major instance in which progesterone is likely to be used by itself in surgical menopause is in the immediate post-op period following a hyst for endometriosis, when it is sometimes used to suppress the regrowth of the microscopic endo remnants left after surgery.
The big disclaimer about progesterone
We used to use progesterone as a "tuner" for estrogen without a lot of qualms. After all, we all make it, so how bad could just having a bit more, so long as that didn't put us into excess, be? Well, it turns out that the risks of progestogens (progesterone and synthetic hormonal agents that act like it) were not as well understood even a decade ago. Now that we know more about the links between progesterone use and cancer, we are a great deal more hesitant when we see women experiment with this hormone.
And interestingly, it seems that progesterone supplementation is not quite as vital as we thought around the turn of the century. Then, we were convinced that every estrogen hrt might well be smoothed of some of its rough spots by the addition of a bit of progesterone, and we considered that doing so helped us cope better with stresses. But since then, we've had both the reveal of those cancer risks and the examination of hormone physiology in such documents as the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) that results in their statement that we cannot even determine whether or not we need to supplement with hrts other than estrogen until our estrogen needs are fully met. Whether it's fallout from those or some other factors that are less visible, we're seeing far fewer women routinely using progesterone supplementation today. It's still being heavily pushed by the compounding pharmacists' "bioidentical" model of multiple hormone prescribing (which certainly makes us nervous in the light of the cancer risks), but otherwise, women seem to be neither using it nor asking about it in the numbers they once did.
And you know what's the most remarkable part of all of that? They're not missing it. We don't have a stream of women coming to our forums to complain of imbalances in progesterone or because their doctors won't give it to them. Once women are finding good balance on their estrogens, they're often in no need whatsoever of progesterone supplementation because, just as the endocrinologists' guidelines predict, well-balanced estrogen allows the body to get by on its own progesterone resources quite well. So if you're on the fence or you're concerned about the risks of progesterone that we're just starting to learn about, you might want to reconsider your estrogen tuning at this point rather than adding another hormone—and risks—to the mix. If you're needing progesterone for therapeutic reasons such as endo treatment, however, there's less of an optional aspect but you might be interested in how different dose forms may relate to your systemic effects and risks, which we explain more about in our discussion of hrt for women with a uterus but no ovaries.
Adding progesterone when you've been on estrogen
If you have been on (a roughly adequate dose of) estrogen alone and add progesterone, you may find you need to reduce your estrogen dose or already be a little low on estrogen when you add the progesterone. This is due to the well-documented action progesterone has as an estrogen-sparing hormone a well as itself being able to be converted into estrogen to make up a supply shortfall of that hormone. Whether you choose to do this "on spec" at the same time as you introduce the progesterone or whether you decide to wait to do this until after you have settled down somewhat on your progesterone dose, you should at least be aware of this possibility. There are no clear guidelines for how much of a dose reduction (if any) will be necessary, but our sense of it is that this is a rather small amount—certainly no more than 20% of your dose and probably somewhat less, if you were more or less at the right level of estrogen before.
If you are presently in a state of estrogen excess, it would seem gentler on your system as well as your risk profile to try to drop some of that estrogen, so you are down to the start of feeling low, before adding the progesterone. The idea that progesterone, because it can act counter to estrogen, will somehow reverse the effects of excess estrogen while you continue to take more estrogen than you need is a seductive but generally unrealized bit of wishful thinking.
Progesterone often makes us feel worse before we feel better, thanks to its pivotal role as a precursor of other hormones as well as its ability to share some receptors with estrogen. But that's only part of progesterone's work. It's also quite important in overall brain cell irritability, something that is pushed in the other direction by estrogen's neurostimulatory effects. At the same time, it specifically affects centers in the brain that control thermoregulation and balance (that is, physical balance as well as dizziness) and mood. These are some of the same brain areas affected by such drugs as Xanax and those targeted by some aspects of general anesthesia. Elsewhere it affects copper and zinc levels, which interact with thyroid hormone function, and metabolic (glucose metabolism) functions such as insulin uptake by cells. It tends to affect prostaglandin synthesis, which in turn has inflammatory implications throughout our systems on things all the way from joints and bowels to minute cardiovascular changes and even, it's being researched now, affecting the development of cancers. [booming ad voice]And much, much more![/booming ad voice]
Less critical to our understanding of the impact of progesterones effects are these specific details; what's more important is recognizing that all of these are tremendously complex and responsive systems in their own rights, and all of them rely on many enzymes and molecular activities (which are in turn, of course, reliant on a whole host of other factors and congruences) for proper conduct. What it all means is that when we alter the overall supply of progesterone, we are going to see a lot of changes throughout our bodies and they are going to take quite a few feedback iterations to all shake out as we adjust to this new supply situation.
Functionally, then, it's a long process (weeks to a couple months) and it tends to be an unpleasant and disruptive one for at least the first week or two when the worst (greatest) imbalanced swings are occurring. These responses can be hormonal-seeming, affecting our estrogenic-balance cues, as well as unrelated (dizziness, groggy, sleepy, mood, hunger, overall fluid balance). But these are, in those first weeks, all about the adjustment process and really not so much about the hormone itself. This is true generally of hormones and hrts, but nowhere more so than with the introduction of progesterone.
The key, then, to adding progesterone is to not be alarmed by initial reactions. Unless you keep getting worse after the first week, as we mentioned elsewhere, you may want to keep going to see how things feel after the second week. It often takes a full two weeks for initial symptoms of progesterone adjustment to abate. Shall we repeat that? It is normal to feel worse for a couple weeks when starting progesterone.
Tuning estrogen and progesterone at the same time
You may want to pick your starting dose of estrogen at the lower end of the range, knowing that the progesterone may boost it, and you won't want to overbalance yourself with progesterone. For reasons given elsewhere, we think it especially makes very little sense to start these two hormones in one combined form. Starting with two separate preparations allows the doses can be tuned individually. If the doses are mismatched in one combined formulation to begin with, altering the dose of that formulation up or down is not likely to affect the underlying proportional imbalance between the two. If a combined product's convenience is important to you, you might consider using individual supplies until you determine your correct dose of each and then having them blended.
Once through those first throes of introduction, our sense of balancing these two hormones is that it is often clearer to lower the estrogen and then tune with the progesterone, so long as you are not seeing symptoms of progesterone excess.
Adjusting progesterone temporarily
There's no point to fussing over it, beyond making sure that you are not subjecting your supply to excessively hot or airy conditions. When they start to feel they're coming up short, many women just increase their dose a tad at the bottom of the container and scale back to the former dose when they open the next. So long as you know it's happening and it's predictable, it shouldn't send you into a tailspin. It's normal. Don't sweat the small stuff.
Visualizing estrogen-progesterone balance
The first is how well each hormone meets our background needs for it. Regardless of how the two hormones may or may not be balanced with respect to each other, if the sum total still leaves unmet needs, we're going to have symptoms where gaps in our hormone coverage show up. Different women have different systems that are more sensitive to the fine edge of "enough" than others. For some, it's the first twinges of vaginal atrophy; for others, it's unwarranted moodiness. Whatever yours is, it's about your background ability to meet all of your hormone needs.
The other aspect of balance is how the two hormones interact relative to each other. We like to visualize this much the way an old-fashioned balance scale would look if we piled all of our estrogen effects on one side and all of our progesterone effects on the other. If the scale tilts down on the estrogen side, say, then one of two things may be happening: either we have too much estrogen on that side of the scale or we don't have enough progesterone on the other side. The scale doesn't tell us if either side has the correct amount; it only tells us the general direction of the imbalance between the two.
So too, if in our bodies we see signs indicative of estrogen excess, that might be due to too heavy a dose of estrogen but it might also be due to too light a dose of progesterone. And the same thing is true in reverse, of course: if we see too much weighting towards the progesterone signs of excess, it could be due to either an excessive progesterone dose or an overly light estrogen intake.
How do these come together? Don't they overlap? Uh huh. But it's important to keep in mind both parts of this, the needs and the inter-relationship. If we don't, we run the risk of seeing an imbalance to this side, taking a little more of the other to bring things up, then swooping into the other tilt so we add a touch of the opposite hormone...and before long, we've blown ourselves away with excesses of everything. So if we can remember that needs set the general order of magnitude and balance does the fine tuning between them, we've got a more nuanced concept as well as one that is much less likely to lead us hopelessly adrift.
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