Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.


Dear Dr. Pat,

I am 41 years old and am having a really difficult time. I had a hysterectomy for very early cervical cancer in my mid-30s. My gynecologist agreed to leave my ovaries in, since there was no medical reason to remove them. I don’t know if my symptoms are due to menopause or something else, but I hope you can help me.

I have a demanding job, two teenage children, a long commute every day, and a husband who is out of work and depressed. So for a while I thought my agitation, night sweats, and terrible sleep were all related to this stress. But the lack of sleep—or something—is causing me to be exhausted and is now affecting my ability to concentrate at work. I have to do something. I  called my gynecologist, and she said I was too young for menopause and offered me a prescription for Xanax for anxiety and sleep. She never suggested coming in to check my thyroid or any other tests.

How do I know if I am in menopause or if these symptoms are caused by some other medical or stress problem, since I don’t have periods anymore? I have never had any serious medical problem except the early cervical cancer, and there are no cancers or illnesses in my extended family. Believe me, if I am in menopause I would really like to try hormone therapy to see if it helps my symptoms.

—Phyllis

 

Dear Phyllis,
This is an excellent question. Women who have a hysterectomy while they are still having menstrual cycles do not know when they have entered menopause because the usual “loss of menstrual cycles for one year” does not apply to them. This is a case where the use of blood tests for FSH (follicle stimulating hormone) is absolutely the right thing to do.

When the ovaries age and produce fewer follicles that are healthy enough to respond to normal levels of follicle stimulating hormone, then FSH goes up in response to the low blood levels of estradiol that is produced by developing follicles.  The increased FSH then pushes the ovaries harder and harder to produce a follicle that will become “egg of the month and increase the estrogen level.” Eventually the follicles disappear and the FSH remains high permanently. FSH is useful in your situation because if it is elevated (over 30) two times over a six-week period in combination with your symptoms, then we can establish that you are certainly in a symptomatic late peri-menopausal state or in menopause.

 

You should, of course, have a complete physical exam and testing for thyroid hormone levels along with other causes of fatigue such as low iron and B12 levels, and a CBC—test for red and white blood cells. If these tests are normal and your FSH is elevated twice over a six-week period, then beginning a trial  course of low-dose transdermal estrogen is a very reasonable idea. Ask your doctor to prescribe the lowest dose of transdermal estrogen available (I suggest 14 mcg in a patch form) to start with.
If you find that you are feeling somewhat better but still suffering from disturbed sleep with night sweats, ask the doctor to increase the dose in six weeks to a transdermal patch with 25mcg of estradiol. Almost all women function very well on doses no higher than this. Higher doses of estrogen increase the risks associated with systemic hormone use, and the recommendations for hormone therapy are “to use the lowest effective dose for the shortest period of time.”  I remind patients that the goal of hormone therapy is to improve the quality of life, not take away every symptom.  Since you don’t have a uterus there is no recommendation for the use of progesterone.

It would be a good idea to see a counselor with your husband and children, by the way, when you become less symptomatic and are better rested. You are carrying a very heavy burden with all of the financial responsibilities of the family, worries over teenage children and a husband who cannot find work and is depressed. This is not an uncommon description of the lives of many women today who unexpectedly turn out to be the sole financial support of the family and yet still try to manage the home and children as well. Everyone needs to pitch in, and your husband can find new self-worth by taking on the responsibility of managing teenagers and the house. This is an opportunity, Phyllis, to make life better for everyone in your home.

—Dr. Pat

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