HRT for those with ovaries but no uterus

Although this site focuses mainly on those who have had both an oophorectomy (ovaries removed) and hysterectomy (uterus removed), some individuals choose to retain their ovaries and only remove a diseased uterus.

Technically speaking, these latter individuals will experience natural menopause. Of course, it's a little more difficult for them to tell when their last real cycle is because they won't have periods to mark them, but when they begin to experience the symptoms of perimenopause, they'll be the same classic ones most of the population sees.

The only real difference that is likely to be obvious will be that anyone who has had a hysterectomy, even if they retained their ovaries, may go into menopause earlier than they might otherwise have done. When they do, especially if it comes particularly early, they may also find that their post-fertile ovaries don't really provide the same level of hormonal support as they might have done had they never been subjected to the disruptions of surgery.

We're not saying this to worry you if you're not there yet. But it's a possibility—by no means a certainty—to be aware of. While the ideal of natural menopause is that our aging ovaries continue to obligingly pump out enough hormones to meet our post-fertile needs, anyone who has had a hyst should be prepared to revisit that issue if it turns out that they arrive at menopause only to find they're not actually feeling so great about their coverage. Those of us who thought they might get away without having to deal with the whole concept of hrt may end up needing to revise that plan.

In general, the same strategies the vast majority employs to ease ourselves through the upheavals of perimenopause will pertain to this variety of natural menopause as well. Those of us with mild ovarian impairment may find that the over-the-counter nutraceuticals or soy estrogens in popular use may provide all the helpful boost they need to make up the gap between what their own ovaries make and what they need to maintain health and wellness. Others, though, may find, once perimenopause has settled down, that they still aren't meeting their needs well enough and they may want to go on to work with hrts to supplement themselves back up to a comfortable level of hormonal support.

Does not having a uterus change how I should use hrt?

Yes. For those without a uterus, a progestogen (progesterone or a synthetic version called, generically, a progestin) is not an obligatory part of their hrt as is for those who still have a uterus and who need to prevent the cancer that can occur when estrogen alone affects uterine tissues. That doesn't mean that these individuals cannot use a progestogen as part of their hrt or may not have another reason to take a progestogen, but it's not medically obligatory.

Instead, for these individuals in natural menopause without a uterus, any progestogen needs only to be supplemented to a level that meets their actual, demonstrated needs for it. We don't need it just on spec—our ovaries and adrenals take good care of providing for most of our needs and if we're meeting our estrogen needs well, we should have plenty of progesterone available to meet our post-fertile needs for it without supplementation. Additionally, more recent study data about the risks of progestogen exposure make unnecessary use of progestogens much more questionable than it was even a decade ago. But if some needs remain after we have adjusted our estrogen as well as we can, then we have the information we require to go on to work on meeting our progestogen needs more fully with supplementation.

Are there any other special situations that will guide my choices of hrt?

Sure. The big decision factor has to do with personal risk factors and lifestyle preferences, of course, but in some cases we also have to deal with specific other disease treatments.

The obvious one is endometriosis, which often requires a progestogen-heavy hormone imbalance for best suppression of endo growth. Other health needs that might guide hrt use and choices would include cancer risk or blood clotting disorders.

And there may be others. The point is, we need to remember that we don't use hrt in a vaccuum: it does have to fit with the rest of our life and health. But aside from not needing a progestogen to protect a uterus, whose of us experiencing this variety of natural menopause have all of the choices—and risks—of any other person in natural menopause.

HRT for those with a uterus but no ovaries

Although this site focuses mainly on those who have had both an oophorectomy (ovaries removed) and hysterectomy (uterus removed), some individuals choose to have diseased (or high-disease-risk) ovaries removed and yet retain their (healthy) uterus. Others who might fall into this category are those who have sustained such a severe chemical menopause due to cancer treatments that they are now without functional ovaries although they remain technically intact.

While they will experience the same issues to do with choosing hrt as those in full surgical menopause, the need to keep their uterus healthy must also be taken into account and this will change their ultimate hrt options.

The crux of the issue is that exposing a uterus to estrogen stimulates the growth of the uterine lining or endometrium. In our fertile years, this stimulation is necessary to prepare the uterus to support a fertilized egg. When no pregnancy occurs, our hormone balance naturally cycles to cause our unused uterine lining to be shed in the form of menstrual flow, resulting in a period.

But when we no longer have ovaries to manage this cycling, uterine health becomes an issue. If we fail to shed that lining, it can build and build and over time, this unshed lining may turn to uterine cancer. Yeah, that's bad. It's so bad that it's a fundamental rule of hrt use that anyone with a uterus must include provisions in their hrt to prevent this from happening.

Like what? There are two basic strategies: we can artificially create a hormone cycle with our dosage pattern, thus causing the lining to shed regularly in a period OR we can balance our hormones in such a fashion as to suppress that lining buildup in the first place, eliminating periods. Let's look at both of these a little more closely.

Hormone cycling

This is the classic approach. We take an estrogen hrt for part of the month and add some sort of progestogen (progesterone or a synthetic version that acts like it) for a shorter time, often a week to ten days, to stimulate a period. Many individuals find this sort of cycle reassuring, since it mimics what they experienced in their fertile years. Many doctors prefer it because they feel that their patients do best with what they are accustomed to or that they are less likely to become confused keeping track of their hrt on a short schedule.

This kind of cycling does carry a cost, however. If you suffered through PMS or your monthly cycle of ups and downs with mood swings and bloating, maybe going on doing that doesn't sound all that appealing. Maybe you would be just as happy to make fewer trips down the feminine products aisle at the store and wear more white underwear without fear. Maybe you'd like to balance uterine protection with a little more comfort and freedom from that cycling.

There is nothing magical about monthly cycles once our ovaries aren't controlling things. Research in recent years has found that we really only need to cycle a few times a year to preserve uterine health, either using oral contraceptives (while we are in our fertile years) or hrt (when we are post-fertile for whatever reason). A conservative schedule for this long-period cycling would be quarterly, although some individuals find that they can successfully go even longer without undue risk. So long as they are not having break-through bleeding (which indicates that their lining is building up beyond normal levels), they only take a progestogen every three or four months to produce a period. This requires keeping track of this schedule so we doesn't go too long without completing that cycle and it requires that we use separate estrogen and progestogen hrts—neither of which are necessarily difficult to achieve. There will still be the same ups and downs of cycling and anyone using this approach will still have periods, but they'll happen less often.

Is this strategy appropriate for all of us? Not necessarily. Those of us with endometriosis, for example, may find that this is still too much estrogen stimulation. Those with cancer risks or metabolic disease or risk factors for blood clots may not be best served by this sort of a dosing scheme. Maybe you don't consider having periods or hormonal cycling an important part of your identity at all. This is one situation in which each individual needs to sit down with their doctor and consider carefully all of the factors that are involved in their use of hrt.

Continuous combined HRT

The other approach to uterine protection involves suppressing the growth of that uterine lining by continuously and simultaneously taking both estrogen and a progestogen. The lining never has a chance to grow, so there is no need to have a period to shed it. Hey, that sounds pretty good, doesn't it?

But there's a cost, and that cost might not suit every one of us. In order to accomplish this, we must deliberately induce a hormone imbalance. We have to take more of that progestogen than we really have a need for otherwise to balance our hormones. Or, to put it another way, we need to have a deliberately progesterone-heavy balance.

For some, that's not a problem: they're perfectly comfortable with a standard dose of any of the retail progestogens made for this purpose.

Others, however, find this balance subjects them to an uncomfortable excess of progesterone effects. For them, then, the challenge is minimizing those effects while still providing the protection that their uterus needs.

And, finally, some are increasingly concerned about the risks of progestogen use that have been revealed in the past couple of decades of hormone research.

Luckily, there is more than one way to approach this problem. If we are going to use a progestogen in a continuous, imbalanced manner, it's worth trying different progestogens to see if one is less unpleasant in this regard than another. Amongst the progestins, each one is very different in structure and characteristics, and will act differently in the body. So if this is your choice, it may be worth auditioning a variety of them. Route may also make a difference, so even if your choice is progesterone itself, taking it via a different delivery route may also help you manipulate its effects.

But another way of dealing with this—and especially with the risks—is to maximize the impact of your progestogen on your uterus while minimizing it elsewhere. This is done by using a more local delivery, either via the vagina or the uterus itself. This way, the highest levels are experienced in the pelvic organs, where they're most needed, and less of that dose makes its way to systemic circulation, where it's not needed. In fact, one source suggests that this can represent a pretty significant difference:

Furthermore, vaginal administration of micronized progesterone has been shown to enhance progesterone delivery to the uterus by about 10-fold in comparison to im injection, despite the markedly higher (about 7-fold) circulating drug concentration achieved with im injection.

Further, this technique is specifically cited by the International Menopause Society in their 2011 position statement as having particular merit.

Sound interesting? There are actually several different hrts that provide for local delivery. Prochieve is a progesterone gel specifically designed for vaginal use, but some individuals have reported successfully inserting a Prometrium gelcap vaginally and allowing it to be absorbed that way (typically, overnight). Vaginal suppositories such as Endometrin are also available, as are versions that can be custom-made by compounding pharmacists. And Mirena is a progestin-releasing IUD that works directly in the uterus and so can get by with an especially low level of dosing.

We also have come across some interesting information that indicates that at least some progestins may be capable of transdermal delivery--something we probably could have put together before given that contraceptive and combined-hormone hrt patches aren't exactly new. That raises the question of whether certain of the progestin hrts meant for oral delivery could be used vaginally (at a suitably lower dose). We don't know the answer but it seems to be something that might be worth looking into if using a local progestin by other than IUD would be your preference. More on that in this news discussion.

Will I have to do this the rest of my life?

No. You will, however, need to tailor your hrt for uterine protection so long as you take enough estrogen to stimulate your uterus.

Our hormone needs diminish with age. For that reason, it's a good practice when taking hrt in any form of menopause to challenge ourselves every few years to be sure that we're taking no more than we truly need to achieve the effects that we define as important. By trying out a slightly lower dose every 3-5 years, we can find out if our bodies have been slowly easing down in needs without us noticing.

In theory, we'll all, if we live long enough, reach a point where our hormone needs are low enough that we no longer need to supplement with hrts. What we produce ourselves plus what we take in from foods and environmental contaminants will fully meet our then-current needs. And when that happens, we're probably not stimulating our uterus enough to need to continue to provide progestogen protection for it. That's something to review with one's doctor, of course, but that's the expectation. Until that time, however, so long as we've got a uterus and are supplementing estrogen, we need that progestogen coverage as well.

How will I know I'm taking enough progestogen?

You won't. The general guideline is to look for spotting. This is taken to mean that your lining is growing enough that the progestogen isn't providing adequate suppression, whether you're taking it cyclically or continuously.

If, however, you have a high risk situation where you aren't comfortable waiting for this symptom to tip you off, there's another method for monitoring uterine lining response: ultrasound measurement of the thickness of the uterine wall. This can be ordered by your doctor, is a bit uncomfortable but generally not painful, and if properly coded should be covered by most health insurance.

There is not, regrettably, any magical formula for relative doses, such that if we take this amount of estrogen, we know we'll need that amount of progestogen and then we'll be sure we're safe. Or if we have this measured level of circulating estrogen, we need that level of circulating progesterone to cover it. Hormones don't behave in a simple relationship like that—there are many other factors that can affect our hormone supplies and relationships. We can't force our hormones to go where we want and do our bidding. What we can do is provide the supply and then watch carefully to see what happens. If what happens is no uterine lining shedding, no spotting, then we most likely have the situation covered. And if we don't, then a simple ultrasound will tell us how our uterus is doing and whether we just have a brief unusual situation or whether we need to tweak our doses.

Let's repeat that, because it's pretty important: the test of our hormones is not in what we want them to do, but in what they actually do. Results are the most reliable place to focus our vision.

So that's it?

Yeah, pretty much. Outside of protecting a uterus, our other hrt needs are essentially the same as for those without a uterus: meeting our post-fertile needs as we define them while exposing ourselves to the least amount of risk possible. So the information on hrt-balancing that is covered elsewhere on this site is just as applicable to you as it is to the those in full surgical menopause.

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