Health

Surgical Menopause Before 40: What to Do When Standard Treatment Fails

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 had a complete hysterectomy for a terrible pelvic infection shortly after the birth of my only child, a son who is now 2 years old, when I was 38. When I had the hysterectomy my ovaries were removed as well because they were involved with the infection. My gynecologist told me to wait six weeks until I had recovered from the surgery and prescribed an estrogen pill to “control menopause and protect my bones.” He said because I was young I should start out with a dose that would be “normal” for a young woman. He 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 worsen my depression. I had never tolerated the birth control pill for the same reasons, actually. I next tried a patch but was allergic to the adhesive. I tried the Femring but I had constant yeast infections from that ring in my vagina all the time. After nine months of this both the gynecologist and I just threw up our hands and I decided to tough it out.

But I have no libido, painful sex, constant flashes, flushes and sweats, no sleep, fatigue and terrible moods. I have gained 30 pounds, don’t have the will or energy to exercise and I certainly feel bad about myself. I was always fit and energetic. My husband has been understanding but he wants me to just “pull out of this” after two years, so  my marriage is starting to suffer, my child is suffering and I barely manage to stay employed at my job of 10 years in HR because I just do the minimum. 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 two years 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 city and don’t have access to a big medical center with a menopause expert. My gynecologist is a decent but overworked man and he doesn’t have much interest in dealing with a woman like me who seems to have a bad reaction to everything he prescribes. I need help and I don’t know where to find it.

Janet

 

Dear Janet,

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 an unexpected hysterectomy and removal of the ovaries in your late 30s, shortly after the birth of your only child. To add insult to injury, you have found no effective treatment for any of your symptoms and no hope of any treatment to come, along with symptoms of depression and hopelessness described in your question. 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 past two years, 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 40-year-old married working mother of a 2-year-old with significant menopausal symptoms who has had the stress of an unexpected hysterectomy during the time normally used to adjust to motherhood, during the time needed to integrate a child into the personal life of the mother and the new family and during the time where optimally there is planning for the often difficult return to work with new responsibilities at home. 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. Find an estrogen preparation and dose that works to manage the menopausal syndrome. You were unable to tolerate oral estrogen in larger doses, you were allergic to the estrogen patch and could not tolerate the vaginal FemRing due to recurring infections. Compounded hormone preparations can be created using a very low dose of estradiol in a cream form that you can apply to the skin once or twice a day, depending on the dose and your response. Find a gynecologist or women’s health doctor who is willing to work with a compounding pharmacy and create a low dose of estrogen that you can tolerate and slowly increase the dose so that you can manage the symptoms that were caused by sudden estrogen loss from surgical menopause:  intense hot flashes, sweats and flushes, sleep disturbance, daytime fatigue and mood disturbance.

There are national compounding pharmacies that have been in existence for many years that 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: not only did you need estrogen for control of the inevitable menopausal symptoms but very early menopause is often a cause of osteoporosis if systemic hormone therapy is not used. The problem that your gynecologist failed to recognize is that not all women respond equally to “standard” systemic hormone doses and giving you a “normal” dose for your younger age was not right for you.

I find that it is best to start with the lowest possible dose for control of menopausal symptoms both for safety of use and to minimize the side effects that some patients have: breast enlargement, breast tenderness, water retention and other symptoms that women find unpleasant. You have a really good chance at finding a dose and delivery system that will work for you.

 

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