Surgical Menopause

In addition to the common symptoms that occur after natural menopause, special considerations apply to women who have had their ovaries removed, particularly when oophorectomy occurs before age 45 years. Women with premenopausal oophorectomy have more severe and prolonged menopausal symptoms. Their risks of adverse mood, heart disease, excessive bone resorption, sexual dysfunction, and cognitive disorders are increased compared with the general population. Retention of the ovaries carries a survival benefit for women at low risk of ovarian malignancy. Women facing oophorectomy should understand the balance of risks and benefits in order to make an informed decision.

their menopause naturally, but many of you will experience an earlier menopause as the result of an operation or other medical treatment.If an operation has removed your ovaries or other medical interventions have stopped them working, the onset of menopause and menopausal symptoms can be very sudden compared to a natural menopause.
Recovering from an operation or illness can often be challenging in itself and experiencing a sudden menopause in addition to this can be very difficult for many individuals without the correct treatment.Fortunately, a surgical menopause can most often be managed very effectively with the use of HRT.
This booklet has been written by Dr Louise Newson, GP, menopause specialist and director of the balance app.
She is also director of the not-for-profit company, Newson Health Research and Education, and is the founder of The Menopause Charity.
With contributions from Samantha Evans, former nurse and sexual health advocate and founder of Jo Divine, an online company for sexual advice, awareness, health and pleasure.For more information on Samantha Evans visit www.jodivine.com

Oophorectomy
This refers to removal of one or both of your ovaries.If both ovaries have been removed it is likely that you will experience menopausal symptoms afterwards, as there will be a very sudden drop in your levels of hormones.If only one ovary has been removed, then the onset of symptoms may be more gradual, but it is still likely that you will experience an earlier menopause than you would have done naturally.
Those of you who have both your ovaries removed will be menopausal from the day of this operation.

Hysterectomy
A hysterectomy is an operation to remove your womb (uterus).There are several reasons why you might need to have a hysterectomy.The most common ones are: heavy periods, pelvic pain (possibly due to endometriosis or pelvic inflammatory disease), prolapse of the womb, or cancer of the womb, ovaries or cervix.
There are different types of hysterectomy: Total hysterectomy: your womb and cervix (neck of your womb) are removed; this is the most commonly performed operation undertaken.
Subtotal hysterectomy: the main body of your womb is removed, leaving your cervix in place.

Other medical interventions that can result in menopause
Certain treatments for cancer can stop the ovaries from working properly and bring about an earlier menopause.As well as the operations already listed, other treatments include: • radiotherapy to the pelvic area • certain types of chemotherapy drugs to treat cancer • drugs that block the action of hormones working (for example, medication used for individuals with some types of breast cancer) Other medication treatments for conditions such as endometriosis or premenstrual syndrome can block or 'switch off' the ovaries and result in lowered hormone levels, which can in turn cause menopausal symptoms.These may be long lasting or only occur over the period of time that the medication is taken.
Symptoms of a surgical (or medically induced) menopause are the same as those when it is a natural menopause.Estrogen protects a number of different systems in your body including your brain, skin, bones, heart, urinary functions and the genital area; low levels of estrogen can affect all cells in your body.
The most common symptoms are hot flushes and night sweats, however, many people find the most troubling symptoms are the ones that affect their thinking skills and their mood as these tend to affect day to day aspects the most, such as performance at work and relationships.
If you want to know more about symptoms of the menopause, take a look at our 'Menopause and Me' booklet.

What is HRT?
Put simply, HRT or Hormone Replacement Therapy is a treatment to replace the hormones that you have lost, primarily estrogen but also progesterone and testosterone for those that need it.HRT is the most effective treatment available to relieve symptoms caused by the menopause.
Replacement estrogen can be given to your body in various ways; either as a skin patch (like a plaster), as a gel or a spray from a pump action bottle, or as a tablet that you swallow.The type of estrogen mostly used is 17 beta-estradiol, which has the same molecular structure as the estrogen you produce in your body (sometimes termed 'body identical' estrogen or HRT).It is derived from the yam root vegetable and it's usually taken through the skin in a patch, gel or spray.
The safest type of replacement progestogen is called 'micronised progesterone' (branded as Utrogestan in the UK and also body identical) and it comes in a capsule that you swallow (some women prefer to use this progesterone vaginally rather than orally).An alternative way to receive progestogen is to have the Mirena coil inserted into your uterus.This is also a very effective contraceptive and it needs replacing after five years.
Testosterone is available in a gel or a cream that is rubbed into the skin and while it is not currently licensed

How do you take HRT?
Estrogen is a very important hormone in your body and has important functions on many different systems including your brain, bones, heart, skin, hair and vagina.Taking HRT replaces the estrogen that your ovaries were producing before your operation or other medical intervention.
Progesterone is naturally produced in the body primarily to help regulate the menstrual cycle.It is used as part of HRT for those who still have a womb that take replacement estrogen.Estrogen thickens the lining of the womb and when it is taken as part of HRT there is a small risk that these 'overactive' cells could turn cancerous.Progesterone (or a progestogen) helps keep the lining thin and reduces the risk of uterine (womb) cancer.So, if you still have your womb and are taking replacement estrogen, you will also need to take progesterone (or a progestogen) too.
Testosterone is not just a male hormone, it is mostly produced in your ovaries so after your operation (or medical intervention) you will experience a reduction in the amount of testosterone in your body.As a result, you may find that your mood, energy, concentration and also sex drive are negatively affected.Taking testosterone can often improve these particular symptoms.The ideal scenario is that your doctor explains the likelihood of a surgical menopause to you -and how this might really impact your life -before any operation or treatment.A discussion around taking HRT and the risks and benefits for you personally should also happen beforehand, and if you are willing, HRT should be started immediately after the intervention.Unfortunately, this is not the case for some of you and you may have been given little, if any, information about the menopause and HRT.It can be very frightening when you experience symptoms you were not expecting and you don't understand what is 'wrong' with you.

HRT protects your future health
If you are due to have surgery involving removal of your ovaries (or treatment that will stop them from working), it is really important that you talk to your doctor -ideally the surgeon who will be performing your operation -to talk about your options for taking HRT.
For most women under the age of 60, the benefits of HRT outweigh the risks.The best type of HRT for you depends on your medical history, existing conditions, and whether you still have your womb.After hysterectomy, most of you will only need to take estrogen, and 'estrogen-only' HRT does not have an increased risk of breast cancer.The good news is that for those of

Starting HRT at the right time
as a treatment for women in the UK, it is widely and safely used by menopause specialist doctors and some GPs.Sometimes testosterone is given via a pellet or implant inserted under the surface of the skin.It can sometimes take a few months for the full effects to work in your body.More information can be found in our 'Testosterone' booklet.
Most individuals are under the age of 51 years when they have surgery to remove their ovaries.Their body's requirements for hormones at this age is greater compared to that of older women going through the menopause naturally.This means that younger women typically require much higher doses of these hormones, especially estrogen.
If you are still experiencing menopausal symptoms after your operation -despite taking HRTthen the most likely reason for this is that your dose or type of HRT needs changing.Many younger people actually need two, or even three, times more HRT than the average dose given to older women, and you may also benefit from taking testosterone too.
In addition to taking HRT, it is important to consider ways of improving your bone and heart health by eating a healthy, balanced diet, exercising regularly and reducing your alcohol intake.

Taking the right dose of HRT
you who only need to take estrogen, you actually have a lower risk of breast cancer than women who do not take HRT, which is very reassuring.
There has not been a study which shows that women taking combination body identical HRT (estrogen and progesterone) have a greater risk of developing breast cancer.There might be a small risk for women taking combination synthetic HRT but the risk is smallfor example, you have a greater risk of breast cancer if you are overweight or you drink a couple of units of alcohol a day.
If you have a history of blood clots, liver disease or migraine, you can still take HRT, but it is recommended you take the estrogen as a patch, gel, or spray, as this is associated with no risk of clots.You can also greatly reduce your risk of developing heart disease, stroke and many cancers by not smoking, taking regular exercise and eating a healthy diet.

Genital and urinary symptoms and vaginal estrogen
When there is a lack of estrogen in your body, you might notice changes to your vulva and vagina because these areas are lined with cells that respond to estrogen.There is often less lubrication, less blood supply to these cells, less of the 'good bacteria' that helps fight infection, and the lining of the vagina often becomes thinner and less stretchy.
These changes can lead to soreness, discomfort, itchiness and pain during sexual intercourse, when using tampons, or when having vaginal examinations (such as cervical screening).The soreness or itchiness can occur around the vulva area as well, and there may be more frequent episodes of thrush.In addition, the lining of the bladder and urethra becomes thinner and more prone to infections like cystitis; you may need to pass urine more frequently or have occasional leaks or accidents.
Fortunately, there is very effective treatment for this particular set of symptoms in the form of 'local' (or topical) estrogen.This is estrogen that you apply directly into the vagina and it is not the same as the HRT we have described so far.
Vaginal estrogen comes in the form of a pessary, cream, or gel that you insert (with the aid of an applicator if needed) on a daily basis initially, and then usually 2-3 times a week thereafter.Alternatively, there is a flexible, silicon ring called an 'Estring' that is inserted into the vagina and has a slow release of estrogen over a 90-day period; it needs replacing every three months.
Local estrogen is very effective at bringing relief from these uncomfortable (and often embarrassing) problems but if you wait until symptoms are severe, it will take longer for the estrogen to have a noticeable effect, so it is important to treat genital and urinary symptoms as soon as possible and continue taking it long term.For those that do not wish to take HRT, vaginal estrogen can be used safely and it is perfectly safe to use vaginal estrogen alongside HRT.
Vaginal moisturisers can also be particularly helpful at relieving discomfort throughout the day and non-hormonal lubricants can be useful for relieving pain during intercourse.
Pelvic floor exercises are very useful for strengthening the muscles around your vagina and your anus and can really help reduce urinary leaks or incontinence (and improve your sex life), when done properly and consistently.There are videos and a factsheet describing what to do on the balance-menopause.comwebsite.Pelvic floor exercises are easy to do, wherever you happen to be, and no one will notice that you're even doing them.Try to do the exercises two to three times a day if you can, maybe while brushing your teeth or some other daily activity, to help you remember.

Looking after your pelvic floor
The usual recommendation from healthcare professionals is to wait 4-6 weeks after hysterectomy before resuming sexual intercourse.This allows time for scar tissue to heal, and any bleeding or discharge to resolve.If you don't feel like resuming your sex life after this length of time, do not worry; it varies tremendously from person to person.A lack of sex drive is also a symptom of the menopause and this is commonly made worse by low mood, poor sleep or stress.If any of these symptoms persist and continue to negatively affect your sex life, speak to your doctor or nurse about it.
When returning to sex after having a hysterectomy people are often concerned about painful sex, decreased sensation, struggling to orgasm or their partner is worried about hurting them.Talk to your partner about your feelings and ask them how they feel.If sex feels painful or uncomfortable, take the focus off any penetration, and enjoy kissing, cuddling, oral sex, mutual masturbation with fingers, or use a sex toy with lubricant.
Use a sexual lubricant that is free from irritating ingredients including glycerin, glycols and parabens.Lubricants come in different formulations; water-based ones are compatible for any sex play, and with all sex toys and condoms.Oilbased lubricants are thicker, longer lasting, and are compatible with any sex toy but not with latex condoms.Silicone lubricant is slippery, long-lasting but not compatible with silicone sex toys.You may have to try several lubricants before finding one that works for you, and always do a skin test first.
Having a hysterectomy may shorten your vagina and it can feel tighter as scar tissue heals, making penetrative sex feel painful or uncomfortable.
Try different positions that prevent deep penetration and use a slim, skin-safe sex toy, or silicone dilator which helps to stretch the vagina and massage scar tissue.Using a vibrator promotes blood flow, which in turn speeds up the healing process, as well as increasing sexual sensation in and around the vagina and clitoris.If you have less sensation or take longer to orgasm, try a small bullet vibrator; these are great for solo play or with a partner.Above all, take your time to resume your sex life at your own pace and have fun.

Looking after your sex life after hysterectomy
Dr Louise Newson is a GP and menopause specialist in Stratford-upon-Avon, UK and the founder and writer of the balance app and website.
The website and app contain evidence-based, non-biased information about the perimenopause and the menopause.She created both platforms to empower women with information about their perimenopause and menopause and to inform them about the treatments available.
Her aim is for people to acquire more knowledge and confidence to approach their own GP to ask for help and advice about their hormones.She is passionate about improving awareness of safe prescribing of HRT in all stages of the perimenopause and menopause.
Louise is also the director of the not-for-profit company Newson Health Research and Education and Chair of the Newson Health Menopause Society.

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