While most women go through natural menopause about 50 years of age, there are some who undergo menopause in their 40s and even as early as 20s and 30s. Surgical menopause happens to more women than one might think. Approximately 600,000 women in the US have a hysterectomy which is the second most common major surgery among women. About 55% of women who have had hysterectomies also undergo bilateral oophorectomy. This means they experience surgical menopause as well.
What is surgical menopause?
The ovaries produce estrogen, progesterone and androgens which are essential to the regulation of the menstrual cycle. When a hysterectomy occurs, these hormones get suddenly interrupted and their levels fall resulting in symptoms of menopause. This is termed surgical menopause. Although removal of ovaries becomes unavoidable in most hysterectomy surgeries, every effort is made by the surgeon to leave the ovaries intact in order to avoid the sudden absence of hormones. Surgical menopause occurs in women who have not yet had natural menopause.
Most often, surgical menopause is caused quite dramatically when there is surgical interference like hysterectomy, bilateral oophorectomy, where both the ovaries are removed. Hysterectomy with removal of ovaries is referred to as TAHBSO, total abdominal hysterectomy and bilateral salpingo oophorectomy. This removal of ovaries and fallopian tubes lead to surgical menopause condition.
A subtotal hysterectomy is when the uterus is removed leaving cervix in place. In total hysterectomy the body and cervix are removed. In a Wertheim's hysterectomy, the womb, part of the vagina, Fallopian tubes, ovaries, peritoneum, lymph gland and fatty tissues in the pelvis are removed.
In the case of hysterectomy when the uterus is removed and ovaries remain, menstrual periods stop but significantly the menopausal symptoms occur at the same age as would naturally. Surgery is warranted in conditions such as endometriosis, ovarian cysts, fibroids, ovarian cancer and pelvic organ prolapse.
Planning a surgical menopause
- Surgical menopause is a difficult decision especially at a younger age. The younger the woman, the more problems she will encounter.
- A complete hormonal check up is essential for every woman who has to undergo hysterectomy. This way a baseline reading of the hormonal needs is obtained and one can always try to achieve these normal levels with the right hormones again.
- Post care has to be planned and it is important for a young woman undergoing hysterectomy to be under the care of a hormonal therapy specialist who can handle the side effects of surgical menopause.
- Research is still at an infant stage seeking to determine the long time effects of surgical menopause on heart disease, osteoporosis and general health especially on younger woman.
Symptoms of surgical menopause
It is observed that a woman undergoing surgical menopause experiences certain symptoms more profoundly than women going through menopause normally. Since there is abrupt disruption of hormones after hysterectomy, the menopausal symptoms are more severe, more frequent and last longer when compared to natural menopause. The symptoms are triggered by the body's sudden inability to make certain hormones due to the removal of ovaries.
Hot flushes and night sweats are the commonest symptoms of surgical menopause. It is estimated that about 75 - 90% of women who have had surgical menopause experience them. This is due to the disturbance of the central thermostat located in the hypothalamus which is kept stable by normal circulating estrogen.
Other symptoms of surgical menopause range from sleepless nights, vaginal dryness and itching to decrease in sexual desire and painful intercourse. An understanding and informed partner can help in such situations. Depression is another common result of low estrogen level. Thyroid dysfunction, bladder infections, incontinence, weight gain, migraine, and irritability are also symptoms of surgical menopause.
Management of surgical menopause symptoms:
According to the American Menopause Society, there are different treatment therapies available to cope with the symptoms of surgical menopause. Estrogen is immediately given after surgery to try to prevent the intense changes especially the hot flashes that can occur in woman undergoing hysterectomy. Estrogen replacement therapies like EstroGel have found to relieve many women experiencing surgical menopause. This is an FDA approved bio-identical estrogen replacement therapy which can help continue an active lifestyle after surgery. However the use of estrogen is itself controversial and it is not usually recommended for women with existing or high risk of cardiovascular disease. A lowest dose of estrogen for the shortest possible time is recommended.
Estrogen gel which is relatively a new preparation is prescribed. This is quite easy to use and it has to be applied to the upper leg or stomach daily. The gel works by releasing a consistent dosage of estrogen into the blood stream making the Hormone Replacement Therapy HRT option effective.
Vaginal ring is designed for women whose womb has been removed. Vaginal creams which can be applied directly to the vagina by an applicator give relief locally on the lining of the vagina and are beneficial for vaginal atrophy conditions. HRT implants which are small pellets inserted under the skin periodically once in six months supply hormones. These are surgically inserted into the fatty layers of the abdomen under a local anesthetic. HRT patches come in various dosages and these are small plasters which can release hormones into the blood stream transdermally. The patch needs to be changed twice weekly and possible side effects could be skin irritation and allergy.
Tablets are the most common form of HRT and they are for long term usage which needs to be carefully considered. It is imperative to consider the usage of all HRT preparations very carefully and regularly so as to ensure maximum benefit at the lowest possible dose with effective symptom relief and protections.
Exercise is another form of self help which is a positive therapy. Begin with small but regular walks and then gradually move over to weight bearing exercises which help to release endorphins from the brain that send feel good messages to the body.
Surgical menopause risks
- Women with surgical menopause are seven times more prone to cardiovascular disease risks.
- They run the risk of osteoporosis as estrogen plays a vital role in bone formation and without estrogen calcium is lost from the bones which when not replaced breaks easily.
- It is found that after surgical menopause in particular, bones lose roughly 3% of their mass per year for the first five years and then 1- 2% a year thereafter. Increased bone loss associated with oophorectomy results in fracture risk as well.
- Some studies have found that reduced levels of testosterone in women are predictive of height loss which may occur as a result of reduced bone density.
- Gum tissues are affected and regular dental check ups are advised to tide over this problem.
- Women younger than 45 years of age and who have had their ovaries removed face a mortality risk 170% higher than women who have retained their ovaries after oophorectomy. Hormone therapy is commonly advised as it is believed by many doctors to mitigate the mortality risks.
- There is a definite lowering of sexual desire in women who have undergone surgical menopause. This reduction is greater than that seen in women undergoing natural menopause.
Surgical menopause is definitely difficult and different when compared to the natural way. But it is important to stay positive. One can also join a local or Internet menopause support group, take breaks throughout the day, relax mentally and keep fit physically by exercising and eating a healthy diet.
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