Volume 6, Number 2: Summer Solstice, 2004

Question and Answer - with Dr. Jerilynn Prior - BC Diabetes Foundation

Question: My sister is 50 yrs. old and had a total hysterectomy, including oophorectomy, about 2 years ago. She was put on estrogen therapy (not sure of name, but was on 9 mg. per day). Her dose has recently been decreased to 3 mg. per day because she was forgetting to take her med half the time and was okay. My question is, does she need to be on anything at all, and if so, I suspect she only needs some progesterone cream?

Answer from Dr. Prior: The answer to the question you asked about whether or not she needed hormone therapy depends on whether she was still menstruating when she had the surgery, whether it was performed for a non-malignant reason, and whether she now has disturbing hot flushes or osteoporosis.

I’ve tried to summarize the good reasons for menopausal hormone therapy on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca . Briefly they are: menopause too early (doesn’t apply to your sister); severe hot flushes not helped by other therapies and osteoporosis with hot flushes. There is also an article called “Stopping Estrogen Therapy.”

Since the Women’s Health Initiative study (the estrogen arm was recently stopped because of increased strokes and no benefit for heart) we know that otherwise healthy menopausal women do not need hormone treatment. In fact those studies are quite clear about risks, especially that of blood clots with pill forms of estrogen. I never, any more, prescribe estrogen except as a patch, gel or cream.

Women who have their ovaries removed almost always lose bone rapidly following the surgery. That would be ok if their initial bone health was good. If your sister has no risk factors I would still urge her to look at the ABCs of Bone Health for Menopausal Women on the website. If she has risk factors she needs a bone density and if it is low the ABCs of Osteoporosis Treatment would be more appropriate.

One of the treatments that has been shown to treat hot flushes is progesterone cream in a dose of 20 mg twice a day. That would be useful if she has mild hot flushes/night sweats.

Otherwise, she may need to take no treatment at all! After all, menopause is not a disease!

Question: I am 46 years of age and I knew there would come a day when the “hot flushes” would start and I find it is now that I am in perimenopause (premenopause?). I just refuse to believe that I must suffer through my body’s inability to control its heating system.

I have been doing as much research as a layman possibly can regarding premenopause and menopause and interestingly, the name of Dr. Prior came up in my doctor’s office today. With much excitement I asked for a referral to Dr. Prior but did not know if she accepts patients. This is why I am emailing now. I am keenly interested in Progesterone treatment or any cutting edge information and tools for relief of these symptoms I am experiencing. I just don’t believe I have to wait it out. Can you please help?

Answer from Dr. Prior: Although I’m still following women I’ve ever seen, I am not taking new patients. However I would be happy to speak with your doctor about your situation.

In the meantime, I’d suggest you look at the material we have on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca. There are articles, in particular “Perimenopause–the Ovary’s Frustrating Grand Finale” and the Daily Perimenopause Diary and instructions so that you can track what you are experiencing.

We know a lot about treatment of hot flushes in menopause. Currently no randomized trial has tested perimenopausal women and identified an effective treatment of hot flushes. However, our clinical experience suggests that cyclic natural progesterone (Prometrium) is both effective and a safe therapy in women with hot flushes and periods. There is a handout about Cyclic Progesterone Therapy also on the website.

Question: I would like advice on assembling a team for diagnosing and treating my perimenopausal symptoms and other conditions, as well as providing me with support and access to services.

At the moment I am feeling pretty well. Since I have not had a period for many months I may be approaching menopause, which may partly explain the reduction of my symptoms. Certainly I have used (extreme) lifestyle modifications to assist myself in coping. I have suffered symptoms which have been debilitating to me, which have caused me to live in a condition of disordered thought for several years and significant pain for the better part of one year. This has disrupted my life and nearly bankrupted me.

I have not been diagnosed as perimenopausal. I have been variously diagnosed as having Post Traumatic Stress Disorder (which is probably also true), having anxiety starting several years ago, and as having had anemia and gastrointestinal bleeding within the last year. I also believe I had symptoms of Mild Traumatic Brain Injury (from a motor vehicle accident several years ago ), and may have had health effects from removing around 12 mercury amalgams from my mouth about five years ago.

I would like to provide some information, but hope my letter doesn’t sound bleak. I am feeling better and therefore am writing this letter. I would like to be tested, to know what is going on with my body and mind as a basis for treatment. Some questions which I have follow: What pertinent tests (including endocrinological) are available in BC, in Canada, or elsewhere, to examine me? What practitioners or clinics could help me? What insurance plans could help or could have helped me to afford alternative medical treatments, counseling, and to provide money to support me during an extended (though temporary) illness?

Answer from Dr. Prior: First of all it sounds like you are very close to ‘graduation!’ That’s what I consider menopause–you will reach that when you have been a year without flow. Menopause is a normal part of every woman’s life and doesn’t need any treatment. However, if it came before the age of 40, or if you know you have osteoporosis (especially if you also have hot flushes) or if you have persistent, disturbing hot flushes then and only then does menopause need treatment. We have learned from the Women’s Health Initiative Estrogen plus Progestin trial results that hormone therapy is not healthy for menopausal women who don’t have one of those three situations mentioned above. We now know the same about estrogen therapy.

This is the time of perimenopause when you are more likely to experience hot flushes and night sweats. But often if they only start now they are mild and go away quickly. You may also notice some vaginal dryness. That usually only needs some water soluble (over the counter) lubricant.

I trust you have looked at the BCERF website (www.bcendocrineresearch.com) which has the article ‘Perimenopause The Ovary’s Frustrating Grand Finale’. That will help you understand perimenopause which it sounds like you have almost completed. There is also information on our Centre for Menstrual Cycle and Ovulation Research website (www.cemcor.ubc.ca).

Now’s a good time to think positive and look ahead to many healthy years. You don’t need a specialist. You can deal with your family doctor for any problems. If you live in BC and have a perimenopause problem you and your family doctor can’t solve, you can ask your family doctor to phone me.

Perimenopause can be quite rough, and it sounds like you’ve had a difficult time of it. You can rejoice when it is over!

Question: I need your help. I had a total hysterectomy five weeks ago. Since then, I am literally falling apart, and cannot get the doctors here to either listen to me, or else I cannot get an appointment at all. I guess they don’t consider endocrinology an emergency. I am basically treating myself because the doctors aren’t listening to me.

I switched from Premarin to Menest because I thought the Premarin made me feel mentally foggy. I discovered that Premarin does contain androgens (they don’t tell you that) because it was making my skin break out. I am now taking a .625 Menest and a .3 Menest every day because on the .625 alone I was still having night sweats. It seems, however, that I am still not getting as much estrogen as on the Premarin because my skin is still dry, and I don’t know if Menest has as much or any androgens in it as Premarin.

Now for the worst part, the part I need immediate help with. Since the hysterectomy, I have arthritis symptoms almost overnight. I can’t get an appointment with an endocrinologist here. I’ve been trying to get an appointment with an endocrinologist who can write prescriptions for compounds because I think my DHEA, which used to be high, and other hormones are all messed up.

The doctors, my OB/GYN group, pooh-poohs me when I try to talk to them about it. They won’t order blood work yet, but I am extremely chemically sensitive, and drugs affect me immediately.

I don’t know what to do. I am at my wit’s end about all of this. I need to get the right treatment so I can go on with my life.

Thank you very much.

Answer from Dr. Prior: It sounds like life is pretty rough right now. I will do my best to provide you with some ideas and support. However, I can’t really know what is going on without having seen you and taken a history as well as done a physical exam.

It is not uncommon to feel badly after having a sudden removal of your ovaries. The natural menopause or perimenopause transition is a more gradual process with spikes and dips over about 10 years.

The first and most important thing is that you get a prescription for oral micronized progesterone (Prometrium) 100 mg and take 3 capsules at bedtime (as long as you aren’t allergic to peanuts–the medicine is in peanut oil). This will help your sleep (improves deep sleep by 15%), help the estrogen to control night sweats and may also help your joint symptoms.

I strongly suggest that you use a kind of estrogen that is a patch or a gel rather than a pill. We now know that important risks for blood clots (increased by 211% over placebo) occur in menopausal women on estrogen pills. Estrogen delivered through the skin is less likely to cause clots.

Other things that will help with the hot flushes/night sweats are some regular exercise and some relaxation (such as yoga). I’d also recommend 400 IU of vitamin E, 1200 mg of calcium/day (with 500 mg at bedtime) and at least one multiple vitamin to provide 400 IU of vitamin D. Calcium has been shown to decrease PMS-like symptoms in a randomized double blind trial.

I don’t know anything about you and what you do and what supports you have. But I would urge you to be with people you trust, to talk with close friends or family and to start thinking about what you are good at and that you want to do with the rest of your life. It is really easy, when life/hormones/health are disrupted as yours have been, to focus on illness and lose perspective.

Please also go to the Centre for Menstrual Cycle and Ovulation Research website at: www.cemcor.ubc.ca. You will also find the Daily Menopause Diary that you can use to track changes you are experiencing. Knowing changes helps you to better understand and deal with them.

I know that you will soon start to feel better.

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

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