Natural vs surgical menopause: what is the difference?

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

A woman is (broadly speaking) either fertile or has stopped cycling/ovulating. The moment in time when her ovarian output, which is in a long, slow decline from her peak fertile years in her early twenties till her 80s, dips below that required for cycling is called menopause. The portion of her life after she experiences that hormone output dip is properly called postmenopause. Menopause, then, is defined as that moment when she has not had a period for 12 months, and it is only a named milestone, a convenience of terminology, not a particular physical event.

A woman's normal decline in ovarian output is not even, and beginning about a decade before she reaches the point of menopause the rate of decline typically speeds up and becomes very erratic in terms of the amount of hormones produced by her ovaries. It's also typical for the balance of ovarian hormones to grow more erratic as the decline in output of each one fails to sync with the output of the others. This period is called perimenopause and it is fraught with the symptoms caused by this hormonal uproar that we normally describe as "menopausal symptoms."

But—and this is critical to making sense of this—these symptoms continue around the time of menopause and mark the entire transition, not just the time before menopause occurs. These symptoms gradually abate as the fluctuations that created them abate and the woman settles into some degree of hormonal stability again. The extent to which her hormone needs are met by her postmenopausal ovarian  output will determine the extent to which she may experience hormonal deficiency symptoms that persist beyond this transitional time. But it's this settling down that is the key to the end of this perimenopausal period, not that she has "gotten over" her need for non-fertile hormone functions.

This diagram, which is conceptual rather than a strict numerical representation, shows how these periods and events intersect in natural menopause.
For us in surgical menopause, however, there is a bit of a difference. Instead of following the normal decline in hormonal output, at some point we undergo surgery and cut off the ovarian contribution to our total hormone levels entirely. When we have our surgery, at the time the surgeon snips our ovaries free from our bodies is our time of menopause. Wherever we may have been on the natural menopausal timeline of ovarian decline before surgery, we depart from it dramatically and totally at the moment of surgery.

Following surgery, we are postmenopausal. We also typically undergo a period of transition during which our body adjusts to the sharp hormone decline plus whatever fluctuations we induce by our recovery from surgery and our menopausal strategies and lifestyle measures, including hrts. While not strictly fitting the definition of perimenopause because this time of transition is non-ovarian in nature, the symptoms we may experience will have much in common with those women in the natural menopausal progression undergo in perimenopause.

And, just as women in natural postmenopause will experience hormonal symptoms reflective of the way their postmenopausal strategies meet their remaining hormone needs, so we in surgical postmenopause will experience symptoms that reflect the overall adequacy of our strategies in meeting those needs. We don't "get over" our need for hormones but we may (we surely hope that we do) get over that chaotic time of transition.

So, again, a little sketch chart of how our hormone levels in surgical menopause map out against time and the named milestones:
This then ties into one of the very confusing concepts that is pretty important in balancing hrts in surgical postmenopause: the difference between transitional symptoms and background hormone level adequacy.

Any hormone fluctuation causes symptoms. Our bodies work very hard, constantly, to keep us on an even hormonal footing in a very dynamic world. We obviously throw a huge monkeywrench into this system when we dispose of one major component, our ovaries. Our bodies respond to this catastrophic change with symptoms due to the fluctuation. So too when we change our hrt dosage, even if by a relatively small increment, our bodies notice, and respond to, this fluctuation. Once our bodies have had some time to adjust to the transition, the magnitude of these symptoms diminishes. This can actually be a useful thing, by the way, when adjusting our hrts, since these symptoms signal to us that we have, in fact, done something effective to change our hormone levels. In that way, then, transitional symptoms play a positive role in confirming that change is occurring.

The other aspect of our hormonal situation at any given moment has to do with our background level of hormone adequacy. We have hormone needs. If the total quantity of hormones in our system at any given moment meets those needs, we're balanced and probably feel pretty good. If our background level of hormones fails to meet our needs or exceeds them, the extent to which it does so will produce symptoms that reflect both the magnitude and extent of that mismatch between supply and demand.

Where the interplay between these two become tricky and an understanding of them becomes most needed is when we are adjusting hrts. When, for example, we adjust our dose in the correct direction (towards better meeting our needs), we may still expect to experience symptoms of that hormonal fluctuation. Only once the transition is over and we settle down (a matter of a week to a couple months, depending upon the hormone and situation) can we properly determine the background adequacy of the new dose. While the transition may be shorter with smaller changes or less dramatic when it goes in a supportive direction, we cannot read its symptoms as answers to the question of background adequacy. We have to wait out the transition before that question is answered. Women who make hrt changes too rapidly risk becoming mired in continuous transition and may never be able to actually determine background adequacy until they slow down and allow their bodies to settle down.

Does that mean we cannot effectively adjust our hrts when we are in that pseudo-perimenopausal period after our surgeries? No, not at all: that is a time, as we've explained elsewhere on this site, when we have to accept the hormonal turmoil of this very major transition and just do the best we can on an ongoing basis while waiting for recovery to carry us through into healing and greater stability. But understanding that a component of that turmoil is only due to the transition and doesn't reflect our chances of attaining the hormonal balance we're working for is important. And understanding what's going on in our bodies, even in this simplified way, can go a long way towards helping us put up with the aggravations with such grace as we can muster and keeping us working in a productive direction towards better postmenopausal wellness. And that's what we're all here for, right?