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 44 years old and I chose not to have children. I have a very good long-term intimate relationship, many friends,  a demanding job where I have been promoted many times and where I travel constantly to manage big projects. I had an emergency operation for a ruptured ovarian cyst, which was not diagnosed before I had an internal hemorrhage requiring a transfusion. Following this surgery, I slowly developed severe menstrual pain, pain with intercourse and chronic pelvic pain. After years of fruitless treatment, my gynecologist thought that I must have endometriosis and recommended that I have a total hysterectomy with removal of tubes and ovaries. Since I could not function in my professional life due to these symptoms, I wanted to get rid of everything that could be causing my pain. The gynecologist did not find endometriosis at the time of the surgery but found adhesions or scars everywhere from the big bleed I had with the ruptured ovarian cyst ten years prior and the emergency surgery required to fix things. The bowel was partially wrapped around the left ovary and tube and right ovary was stuck with the adhesions behind and slightly below the uterus. The good news is that I am now one year out from the surgery and no longer have pain. I am extremely grateful for this outcome.

My gynecologist told me to wait six weeks until I had recovered from the surgery before starting an estrogen pill to “control menopause and protect my bones.” She said because I was young, I should start out with a dose that would be “normal” for a younger woman. She prescribed three different pills over six months and I could not tolerate any of them. I tried Estrace, Estratab and Premarin. All of these hormone pills gave me breast tenderness, breast enlargement, nausea, water retention and seemed to be a factor in the depression that came on suddenly after the surgery. I next tried a patch but was allergic to the adhesive. I tried the vaginal Femring but I had constant yeast infections from the ring in my vagina all the time. After six months of this, both the gynecologist and I just threw up our hands and I decided to tough it out.

I have no interest in sex and I have vaginal pain when I do have intercourse. I have constant hot flashes, flushes and sweats, fatigue, terrible moods and no sleep. I have gained thirty pounds since menopause and I don’t have the will nor energy to exercise. I certainly feel bad about myself. I was always fit and energetic. My partner has been understanding but he wants me to just “pull out of this” after a year following the surgery, so my relationship is starting to suffer. I worry about my job performance in this competitive work environment as well. I have little interest in seeing people or doing things that used to interest me. I have tried acupuncture, herbal and over-the-counter menopause remedies and nothing is helping. It has been a year since my hysterectomy. I don’t have any other medical problems and no one in my family had cancer or heart disease. I live in a small Texas semi-rural area and don’t have access to a big medical center with a menopause expert. My gynecologist is a decent but overworked woman and she doesn’t have much interest in dealing with a woman like me who seems to have a bad reaction to everything she prescribes. I need help and I don’t know where to find it.

Peg

Dear Peg,

I am sorry to hear that you have had such traumatic events to deal with. It is understandable that you have had difficulty dealing with a surgical menopause from a hysterectomy and removal of the ovaries in your early forties, even though you are grateful to have resolution of the pain as a result of successful surgery. To add insult to injury, you have found no effective treatment for any of your symptoms and no hope of any treatment to come. Sometimes patients and doctors focus on a single problem or symptom without taking the time to evaluate the big picture of a patient’s life. When there is no cookie-cutter solution visible, doctors and patients sometimes agree that this is what the new normal for the patient is to be. Thank you for finding the energy to write to us. Let’s take a look at the total picture of your life as you have described it for the last year, identify pressing problems, and look for solutions that you may choose to incorporate with the advice of your health care provider.

The Big Picture
You are a 44-year-old working woman who had a real reason for a total hysterectomy and removal of both tubes and ovaries. The good news is that the surgery, including the removal of the scar tissue, has completely removed the chronic pelvic pain, heavy bleeding, and severe menstrual pain. The bad news is that one year later, you have depression, fatigue, loss of interest in sex and significant menopausal symptoms that are greatly affecting the quality of your life and your ability to function professionally. In addition, the only medical source you relied upon, your obstetrician-gynecologist, failed to find an effective conventional treatment for menopausal and other symptoms.

Problems to Solve
1. Put out the biggest fire first. Since you want effective menopausal syndrome management and have tried to use conventional forms of estrogen, consider a different kind of estrogen preparation and dose that works to manage the menopausal syndrome. You were unable to tolerate oral estrogen, you were allergic to the estrogen patch and could not tolerate the vaginal Femring due to recurring infections. First, return to your local gynecologist and ask that she contact one of the national compounding pharmacies and discuss a preparation and dose right for you. Do start with a low dose first. There are national compounding pharmacies that have been in existence for many years which accept prescriptions from doctors across the country. The pharmacists are available to discuss your response to both the dose and the delivery system (cream or olive oil base, for example). Your gynecologist was right: early menopause often causes more severe menopausal symptoms than is experienced during the normal years of long perimenopausal-menopausal transition. The problem that your gynecologist failed to recognize is that not all women respond equally to “standard” systemic hormone doses and prescribing a “normal” dose for your younger age was not right for you. If your gynecologist does not have the time to add menopause management to other professional demands, do some homework. I know that Texas is a big state but you do travel a lot for work. Look online for the nearest large medical center and find the names of gynecologists, gynecologic endocrinologists or women’s health specialists who have an interest in menopausal management. Ask for a virtual consultation to see if one of these specialists will agree to an initial consultation by phone or Skype. You can ask during this consultation if the specialist is willing to work with a compounding pharmacy to create a dose of transdermal estrogen that is right for you. Once you find someone who understands your problem and seems to be a good fit, take the time to travel for an in-person consultation. Ask that you be treated with a low dose of compounded estrogen cream and increase the dose until you reach that place where there is reasonable symptom management but no breast tenderness or fluid retention. You are unlikely to have nausea from this form of estrogen delivery since it bypasses the liver and the GI system. Once you find the right dose of estrogen delivered transdermally, you can ask your local gynecologist to work with the specialist and take over ordering the prescription from a compounding pharmacy. You will decide with your gynecologist if this is right for you and how long you should plan to use this form of treatment. The risks and benefits of hormone therapy must always be discussed with the prescribing health care provider.