This is part of an ongoing series featuring interviews with physicians on topics related to hereditary cancer. This is a summary of a discussion with Ann L. Steiner, MD, an obstetrician-gynecologist and clinical professor at Penn Medicine.
The Symptoms of Surgical Menopause
Menopause is the absence of estrogen. When women stop making estrogen, this can result in several key symptoms. On average, natural menopause occurs around 51 years of age, when periods cease. Menopausal symptoms may begin before the final menstrual period when the loss of estrogen begins gradually. But if a 35 year old woman with regular, monthly periods has her ovaries removed, she is likely to be much more symptomatic then if she had gradually gone into menopause.
Surgical menopause can affect hot flashes and mood, and can increase the rate at which a woman loses bone and may develop osteoporosis. There’s a concern that younger women who go into menopause might be at an increased risk of heart disease later in life. It could also affect cognitive function. If women don’t have a history of a cancer that would contraindicate the use of estrogen, such as breast cancer, we discuss giving estrogen, both for symptoms and for potential prevention of these problems.
Potential Impact on Mood
Unfortunately, most of the menopause data is on older women going through menopause, rather than younger women going through surgical menopause. The menopausal transition can make mood disorders, such as depression and bipolar disorder, worse, although this is less affected by hormones when menopause is complete. When a younger woman has her ovaries removed, she isn’t gradually going through a transition, she is suddenly post-menopausal. There need to be more studies on mood issues and surgical menopause, but for some women there may be an effect.
Mood is also a complex issue. Menopause can lead to insomnia, hot flashes, and irritability, all of which can affect mood and cognitive function. While we do see some menopausal women getting more depressed, it’s hard to tease out the exact cause. Depression and mood disorders alone are not an indication for giving estrogen in post-menopausal women, but in some women going through natural menopause, it’s been shown to help.
Potential Impact on Sex Life
There can be a lot of impact on sex life with the absence of ovarian hormones. To begin with, the lack of estrogen can lead to vaginal dryness and pain with sex. Many issues can often be resolved with local vaginal estrogen treatment, which can help with dry vagina, pain with sex, and indirectly help desire. The ovaries also produce testosterone, as well as estrogen and progesterone, and testosterone gives you your joie de vivre. It gives you energy and libido. But unlike systemic estrogen therapy, not as much is known about replacing testosterone in women who have their ovaries removed. In this country, there is no FDA approved testosterone therapy for women.
Women who go through natural menopause and still have their ovaries continue to make some testosterone. So it’s a little different in women who have their ovaries removed. If they don’t have breast cancer, or other contraindications, they can be given estrogen therapy. It’s also important to look at other medications they are currently taking that would affect sexual function, like SSRIs, the antidepressant drugs for example, which can have a detrimental effect on sexual desire and sexual function.
How to Best Prepare Yourself for Surgical Menopause
Don’t smoke, and start or continue to exercise, and maintain a healthy weight. Get adequate calcium, preferably dietary versus supplements. Under the age of 50, the guidelines are a 1000 mg of dietary calcium per day. Also make sure to have adequate vitamin D; the recommendation is a total of 600 IUs (international units) per day, through diet or supplements.
See a physician ahead of time, before removal of the ovaries, to talk about estrogen replacement therapy. Dr. Domchek’s research has shown that for BRCA mutation carriers who don’t have breast cancer, taking estrogen to counteract the side effects of surgical menopause results in little to no additional increased breast cancer risk.
However, if a woman only has her ovaries and tubes removed but still has her uterus, then we have to give another hormone, progestin or progesterone, to protect the lining of the uterus from developing abnormal tissue such as pre-cancer or cancer of the uterus. This can occur from estrogen therapy alone. In other words, we cannot give estrogen alone to a woman who still has her uterus, because it increases the risk of uterine cancer or endometrial cancer. Progestin is needed to prevent this additional risk.
Treatment After Surgical Menopause
Finding a physician can be a challenge. There are some physicians afraid to give estrogen to women with BRCA mutations; they simply don’t want to take any chances. But the data shows there’s no reason not to treat women with BRCA mutations with estrogen, as long as the risk benefit is understood and openly discussed.
For example, the risk of not taking estrogen for a 35-year-old woman who has had her ovaries removed is that she will likely be miserable with hot flashes and it will possibly hurt to have sex, because of vaginal dryness. She may not sleep well, may not function well, and may be at an increased risk for bone loss and heart disease, and possibly have early cognitive change. That’s a lot to weigh against the theoretically small risk of breast cancer. BRCA mutation carriers are not assuming a lot more risk by going on estrogen, compared to the risk they already have. Remember, a 35 year old woman would still be making estrogen if her ovaries weren’t removed for her risk of ovarian cancer: hormone replacement therapy doesn’t give a women more estrogen than she was already making.
In studies, the general population (of postmenopausal women with an average age in the 60s), we do have data that women who take estrogen and progesterone together for 3 to 5 years may have an increased risk of breast cancer. It seems like the amount of time on combination hormones could be a contributing risk factor. Estrogen alone does not have this same risk. Age is also a factor: younger women on hormone therapy have lower risk than do older women. We generally put younger women going through early menopause on estrogen at higher doses than we would for older women going through natural menopause. We treat those younger women up until the time of natural menopause, around 51 or 52 years of age. That also applies to BRCA mutation carriers who have their ovaries removed. We reassess their symptoms and health risks at age 51 or 52. If they still need to be on estrogen after the age of natural menopause, for symptoms such as hot flashes, then we can lower the dose, because we’re no longer using it for prevention.