Benefits & Risks of HRT in Surgical Menopause

Important information to note when learning about Hormone Therapy (Natural V Surgical Menopause) :

Recommendations about estrogen use during a natural menopause ARE DIFFERENT from the recommendations around estrogen in surgical menopause. In particular, we know that the risks associated with estrogen use in surgical menopause are much lower than those associated with estrogen use in natural menopause. This is because: (1) the hormone levels are lower in surgical menopause than in natural menopause, and (2) individuals who undergo surgical menopause before the age at natural menopause (before 51)  have lower baseline health risks than older individuals entering the natural menopause.

Therefore, it is important to make sure that any recommendations that you are following are specific to surgical menopause-- because often the recommendations are quite different.  Since most doctors do not receive training in this area, it may also be important to educate your doctor by providing them with evidence-based guidelines for the management of surgical menopause.

Because studies have found that taking estrogen in the natural menopause can increase risk of cancer and other health problems, many individuals entering surgical menopause are understandably concerned about whether taking estrogen or progestogens will increase their health risks.

However, studies of estrogen risks that have been carried out in older women during the natural menopause transition do NOT generally apply to younger people who enter surgical menopause before the typical age at natural menopause (51 years). 

In the case of premature surgical menopause, taking hormones is simply replacing hormones that your body would otherwise be making up until the age of the natural menopause, which is a very different thing from taking extra hormones on top of natural hormones (as in the case for estrogen during natural menopause).

Estrogen-Therapy

This is estrogen based HRT treatments. If you have your uterus removed as well as your ovaries - you can be on estrogen only therapy. If you still have your uterus you will need additional progestogen to protect yourself from the excess build up of cells which can lead to hyperplasia.

What are the benefits of taking estrogen in surgical menopause?

Taking estrogen therapy in surgical menopause reduces or eliminates bothersome menopausal symptoms, including: 

  • vasomotor symptoms (for example, hot flashes or night sweats with sleep disturbance)

  • musculoskeletal symptoms (for example, joint and muscle pain)

  • effects on mood or anxiety (for example, feeling abnormally sad or worried)

  • urogenital symptoms (for example, vaginal dryness, frequency of urination)

  • sexual difficulties (for example, low sexual desire, pain during sex).

For those under the age of 40 entering surgical menopause, taking estrogen therapy also reduces or eliminates the serious long-term health risks associated with surgical menopause, including:


To summarize, surgical menopause is known to cause all of the above symptoms and health risks in large part due to the extremely low levels of estrogen that result from ovary removal. However, these problems can generally be reduced or eliminated by using estrogen therapy following surgery through to the typical age of menopause (51 years). Most individuals in surgical menopause choose to continue some level of estrogen through at least age 60 to maintain symptom relief.

What are the risks of taking estrogen in surgical menopause? 

In surgical menopause, there is no evidence that using estrogen increases risk of cancer, blood clot, or stroke. Note that this is different from the risks you might have heard about with estrogen therapy in the natural menopause (where continued production of some ovarian hormones persists through 80 years old).  Large studies of estrogen in surgical menopause completed in both America and Denmark have demonstrated that long-term estrogen ( 5+ years) may actually reduce risk for cardiovascular disease and breast cancer, and does not appear to alter risk of blood clots or stroke. 

In the case of breast cancer, studies suggest that estrogen does not increase risk of breast cancer when used in surgical menopause, even among those who are BRCA1 or BRCA2 carriers provided they do not have a personal history of cancer. In those in surgical menopause who have a Factor V Leiden mutation (which increases risks for blood clots), the long-term protective effects of hormone therapy may often outweigh the risks posed by the use of hormones. 

Nevertheless, if you are concerned about using estrogen due to a family history of estrogen-dependent cancers, blood clots, or other risks, it is wise to discuss this with your doctor to make sure that you are carefully dosed and monitored to avoid adverse effects of hormones in surgical menopause. Alternative medications can also be used in some extreme cases (e.g., in patients with current estrogen-positive cancers).

Of note, there is no evidence that hormone therapy causes weight gain. 

What is the risk of using “Unopposed Estrogen” in surgical Menopause?

Unopposed Estrogen can lead to an Endometrial Cancer Risk in those with a uterus. If you have kept your uterus (that is, you have NOT had a hysterectomy), it is generally unsafe to take estrogen without a progestogen (sometimes referred to as “unopposed estrogen”) since it can cause a cancerous overgrowth of the uterine lining. However, taking progestogen therapy (which comes in many forms, reviewed below) at the same time will prevent this overgrowth and make estrogen therapy safe for long-term use. Keep in mind that menstrual bleeding or spotting is not a good indicator of whether or not the uterine lining is becoming too thick; only an ultrasound can diagnose this overgrowth. On the other hand, many trials have demonstrated that a variety of progestogen options are effective for preventing overgrowth. Read more about progestogen options here:

Are there long-term health risks of estrogen in surgical menopause?

Short Answer: Not before the age of 51.

In surgical menopause, there is no evidence that using estrogen increases risk of cancer, blood clot, or stroke. Large studies of estrogen in surgical menopause completed in both America and Denmark have demonstrated that long-term estrogen in surgical menopause (e.g., 5+ years) may actually reduce risk for cardiovascular disease and breast cancer, and does not appear to alter risk of blood clots or stroke.

In the case of breast cancer, studies suggest that estrogen does not increase risk of breast cancer when used in surgical menopause, even among those who are BRCA1 or BRCA2 carriers (familial risk for breast cancer). Nevertheless, if you are concerned about using estrogen due to a family history of estrogen-dependent cancers or blood clots, it is wise to discuss this with your doctor to make sure that you are carefully dosed and monitored to avoid adverse effects of estrogen. Alternative medications can also be used in some cases.

Back to top

What if I can’t take HRT due to genetic risk of cancer or blood clots?

Some individuals in surgical menopause have a personal or family history of conditions that can be affected by hormones, and thus are more concerned about HRT risks. 

In surgical menopause, there is no evidence that using estrogen increases risk of cancer, blood clot, or stroke. Large studies of estrogen in surgical menopause completed in both America and Denmark have demonstrated that long-term estrogen in surgical menopause (e.g., 5+ years) may actually reduce risk for cardiovascular disease and breast cancer, and does not appear to alter risk of blood clots or stroke. 

In the case of breast cancer, studies suggest that estrogen does not increase risk of breast cancer when used in surgical menopause, even among those who are BRCA1 or BRCA2 carriers (familial risk for breast cancer). Nevertheless, if you are concerned about using estrogen due to a family history of estrogen-dependent cancers or blood clots, it is wise to discuss this with your doctor to make sure that you are carefully dosed and monitored to avoid adverse effects of estrogen. Alternative medications can also be used in some cases.

Back to top

Progestogen Therapy

This is progestogen based HRT treatments. If you have your uterus removed as well as your ovaries - you can be on estrogen only therapy. If you still have your uterus you will need additional progestogen to protect yourself from the excess build up of cells which can lead to hyperplasia.

What are the benefits of taking a progestogen in surgical menopause?

The main benefit to using a progestogen is that it allows you to gain the benefits of estrogen therapy without increasing your risk of uterine cancer.

What are the risks of taking a progestogen in surgical menopause?

The risks and side effects of progestogens depends on the specific type you are taking. At times, side effects may be significant enough that a change in progestogen is needed. For those who cannot tolerate any progestogen, other approaches can be used.

Micronized progesterone

Risks - None.

Side Effects - Oral micronized progesterone is rapidly metabolized to substances called “neurosteroids” (for example, allopregnanolone) that act on the GABA receptor in the brain to (usually) cause sedation and a sense of calm. For some individuals, this effect is exaggerated and intense sleepiness can result; in these cases, it is important to dose oral micronized progesterone at night before bed, and one should avoid operating heavy machinery after taking it.

With all progestogens, some people also experience physical symptoms that are similar to those seen across the menstrual cycle, including bloating, cramps, or breast tenderness.

Medroxyprogesterone Acetate (MPA)

Risks - Associated with an increased risk of breast cancer and coronary heart disease over the long-term in natural menopause studies. It also appears to have a negative impact on blood lipids.

Side Effects - With all progestogens, some people also experience physical symptoms that are similar to those seen across the menstrual cycle, including bloating, cramps, or breast tenderness.

Levonorgestrel-containing Intrauterine system (IUS/IUD)

Risks - One study demonstrated a possible increased risk of breast cancer when used with or without estrogen. Rarely, insertion of the IUD can cause perforation of the uterus.

Side Effects -With all progestogens, some people also experience physical symptoms that are similar to those seen across the menstrual cycle, including bloating, cramps, or breast tenderness.

Other progestins, including Norethindrone acetate, Norgestimate, levonorgestrel, and Drospirenone

Risks - Associated with increased risk for blood clots (particularly drospirenone), although overall risk is low if otherwise healthy. Not studied as well as MPA, but may be associated with small increases in risk for cardiovascular disease and breast cancer over the long term.

Side effects -With all progestogens, some people also experience physical symptoms that are similar to those seen across the menstrual cycle, including bloating, cramps, or breast tenderness.

Back to top

Testosterone

What are the benefits to using testosterone in surgical menopause?

For those in surgical menopause who develop low libido and arousal, testosterone may help with these symptoms. Improvements have been noted in the number of satisfying sexual episodes, frequency of sexual activity, libido, orgasm, arousal, pleasure or enjoyment of sex, sexual responsiveness, sexual self-image, and sexual or relationship satisfaction.

Some existing studies suggest that testosterone therapy does not have any impact on hot flashes, bone density, weight, BMI, anxiety, or depression, although better-controlled studies are needed to examine these possible outcomes. The limited research we do have does suggest further benefits to mood and headaches, and this ties in with what is often observed in clinical practice by some members of our Surgical Menopause Advisory Committee, but more data via carefully controlled studies is needed to give definitive answers. 

So far, in clinical trials testosterone has been found to improve sexual function in women more than a placebo. So if you are in surgical menopause and have a reduced libido - testosterone may be helpful to you.

Back to top

What are the Risks to using testosterone in surgical menopause?

Testosterone therapy for postmenopausal women and AFAB individuals, in doses that your body would naturally produce before surgical menopause, is associated with mild increases in acne and body/facial hair growth in some. 

There is very little long-term safety data available for testosterone use in women/AFAB individuals and more work is needed to determine the long-term safety of testosterone therapy.

Available data suggest that short-term transdermal testosterone therapy does not impact breast cancer risk. However, the data from studies are insufficient to determine the long-term breast cancer risk with testosterone use. Caution is recommended for testosterone use in women with hormone-sensitive breast cancer (Expert Opinion).

Testosterone should not be used in the following situations:

  • During pregnancy or breastfeeding 

  • Active liver disease

  • History of hormone sensitive breast cancer – off label exceptions to this may be agreed in fully informed women with intractable symptoms not responding to alternatives

  • Competitive athletes – care must be taken to maintain levels well within the female physiological range

  • Women with upper normal or high baseline testosterone levels / FAI.

    To read more about using testosterone in surgical menopause:

 
 
 
PBF_FinalLogo_Reg_FullColor.png

This project was financially assisted by The Patty Brisben Foundation for Women’s Sexual Health. The views expressed herein do not necessarily represent those of The Patty Brisben Foundation for Women's Sexual Health.