Surgical menopause, hrts, and headaches

Headaches aren't special to menopause or even the surgical variety, but for women prone to them, hrt can involve some special concerns.

Headaches due to low estrogen

This may be one of the earliest symptoms to hit us after we have a hysterectomy (once the headache from not being able to have coffee before surgery wears off). Some women develop a lingering, grinding headache that they just can't shake until their hrt is properly adjusted to their needs. For them, headaches become a tuning symptom, something we know has a specific meaning for our own body.

If we've not immediately gone onto hrt after surgery, doctors are sometimes worried that a headache during the recovery period means we're having or are at high risk for a stroke and shouldn't have hrt. While there is validity to ruling stroke out, especially when we've just had surgery, and while there is a slightly higher risk of stroke in the first year of using an oral hrt, some women are left with their doctors' refusal to prescribe just because they are still afraid of that risk. That says something rather sad about their faith in their own diagnostic capabilities and it says something terrible about a woman being able to get the care she needs. Shopping for a new doctor can, sadly, be about the only way out of this trap.

Generally speaking, headaches due to low estrogen tend to abate pretty well once our estrogen levels are meeting our needs.

Headaches from high estrogen

Yes, this happens too.

Decreasing the dose is the right answer for risk and for this kind of headache. How can we tell which is which, high vs low? By the other symptoms that appear with the headaches, just as with any other aspect of hrt tuning.

In general, the tactic of adding a diuretic (water pill) to hrt with the goal of reducing fluid retention from excessive estrogen is not an effective strategy for dealing with this kind of headache, let alone the risks posed by excessive estrogen exposure. It's a typical medical response, however, to see each new symptom of imbalance as a separate disease that requires separate medication. We need to be alert to the state of our hrt balance and, if our doctor wants to prescribe diuretics when we think we're in hormone overload, we should be prepared to advocate for our own preferences. Suggesting a trial of dose reduction before adding a new drug is not an inappropriate proposal and a doctor willing to work with us should prove amenable to this kind of trial.

If going down in dose of an hrt doesn't cover our overall hormone needs but that previous dose being the next increment up presents excess, then we can understand that to mean that this isn't the best hrt for our bodies and that we will make more progress moving along to a new hrt. While we always advocate adjusting dose before giving up on an hrt that appears to be delivering, there's only so far we can adjust things. If we're bracketing our needs without being able to find an acceptable middle ground, we're there. Moving along is likely to be more satisfying sooner.

Headaches upon taking an HRT dose

Some women don't consider themselves prone to headaches but then when they begin taking hrt, BLAM. These are often the women who had semi-regular headaches during their former menstrual cycle, and if so, that's a great clue we can use in tuning our hrt.

In the situation of menstrual cycle headaches or right-after-taking-hrt headaches, the culprit often seems to be the rapid rise of estrogen levels; once a woman is a few hours or days into a dose, it abates. Because every dose of hrt takes us from a lower level to a higher one, especially early in our adjustment period, we're simply recreating the hormonal setting of those earlier cyclical headaches.

For these women, the key seems to be getting onto a stable level of hormonal support and a dependable delivery, so that they're not swinging up and down with each dose. While there will always be an uptake curve at one end of an hrt dose and a wash-out curve at the other end, once we stack several days' doses on top of each other, we reach a background level of hormonal supply that keeps us supported between doses. Some women, alas, take this sort of situation to mean they need to overlap their hrt doses or take them in tiny increments under the impression that a perfectly even and continuous delivery is necessary. In fact, however, this is something our bodies can sort out for themselves if those doses are adequate to permit us that background leveling between doses. While it's still the case that some hrts will be more comfortable than others for a woman sensitive to this dynamic, there's no single answer as to which those hrts will be.

Headaches with HRT

This is a bit different from the above situation in that a woman on a poorly-fitting hrt may have frequent headaches as part of a picture of poor coverage: jangly nerves, anxiety, poor sleep, mood instability, and a general sense that she's walking a knife edge of disaster, not at ease in her skin. This situation tends to persist as she adjusts her dose up and down and even as she changes hrts. Often, these women come to our forums summarizing their experience as "I can't tolerate hrt."

But frequently that's not the full story. Often these women, even when they've explored dose adjustments, have pretty much stuck to the estradiol hrts. And that's understandable because most of the hrts on the market today are estradiol hrts. We tend to divide the hrt market into human-identical estradiol and Premarin, and Premarin's reputation is a difficult one for many women to embrace. Routinely, more doctors seem to be offering estradiol than Premarin (or the other conjugated estrogens), and women are choosing estradiol hrts on their own.

But estradiol is the active form of estrogen and it seems that some women don't want that much activity dumped into their system at once. These women seem to do better when they use an hrt that is comprised of some or all estrone rather than 100% estradiol. Estrone is a much less active form of estrogen, even a storage form, and it's much gentler in its impact.

It feels, watching what the surgical menopause community is discussing, as though this problem is showing up more today than it did, say, a decade ago. But that was when we more freely used progesterone to take the edge off of a poorly-fitting estrogen hrt (a practice that's waning today due to better understanding of progestogens' risks) and that was when there were more estrone hrts on the market. These have mostly disappeared, now, and we think that this has left women who need them more adrift in what seems to be an all-estradiol world.

If a woman has tried various routes of estradiol hrt and still doesn't feel comfortable, she may want to explore the remaining non-estradiol hrts. These include:

  • compounded hrts with all estrone or a blend of just a bit of estradiol with mostly estrone;
  • Menest, which contains mostly estrone with a bit of equilin estrone (horse estrogen, similar to some of the compounds in Premarin);
  • Enjuvia or Cenestin or a generic for them, which contain various blends of synthetic estrogenic compounds that are mostly estrone-ish in action plus a few that are estradiol-ish; or
  • Premarin, which contains a blend of synthetic estrogenic, androgenic and progestogenic compounds that are mostly estrone-ish in action.

With the exception of the compounded hrts, these are all oral deliveries, which may not be many women's first choice these days. The women who experience this particular problem often find, however, that they are willing to accept that profile in the interests of a better hrt fit. It really can make an astounding difference from the impact of estradiol hrts.

Migraine headaches and HRT

Migraines are a miserable affliction and for some women who hoped that removal of their ovaries would put an end to a monthly brain implosion, they, disappointingly, can continue right on thanks to the efforts of our menopausal hrts.

The primary migraine triggers seem to be much like the general headache causes: hormonal fluctuations and the type of estrogen used (by which we mean, the activity of the form of estrogen the hrt contains). So when troubleshooting hrts around migraines, those are some of the considerations to work with.

Sadly, hrt alone isn't always enough to control migraines, and some women end up finding that a combination of hrt plus other drugs that are specific to migraines ends up working the best for them. Still, these hrt adjustments do give us a place to begin that can be more helpful than simply being told we can't take hrt if we get migraines.