The Dr Louise Newson Podcast - 026 - Surgical Menopause - Dr Rebecca Lewis & Dr Louise Newson

Episode Date: December 3, 2019

In this week's episode, Dr Louise Newson chats to her good friend, Dr Rebecca Lewis, who is also a clinical director at Newson Health Menopause and Wellbeing Centre. Together they discuss surgical menopause. Surgical menopause can often be very different to a natural menopause because it happens very suddenly. Women who have their ovaries removed during an operation are plunged into the menopause straight away. In addition, women who have a hysterectomy without their ovaries being removed still have a higher risk of an early menopause. Dr Newson and Dr Lewis discuss the most effective ways of treating surgical menopause. Dr Lewis' Three Take Home Tips: Think about menopause before your surgery - be aware of the symptoms you may experience. Discuss HRT with your surgeon before surgery. Have a solution and treatment plan in place before the operation.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So I'm delighted today. I've got Rebecca Lewis with me again. We've already recorded one podcast together, but today we're going to talk slightly differently about women who have had a surgical menopause. So women who have had really an enforced menopause.

So welcome, Rebecca. Hello, Louise. To some of you who might have listened to Rebecca's and me talking before might know or might know from the website, Rebecca is a very dear friend and colleague and she is also one of the medical directors here in my clinic in Stratford-Pron-Avon. So thank you for coming this morning. It's a pleasure. Nice to be here. Obviously, we see lots of menopoles or women, don't we, from all ages.

And as a lot of you know, listening, the average age of the menopause, in the UK is 51. So that's a year after your last period, you can be officially menopausal. And usually it's because there's a natural decline in our ovaries, the hormones drop. But for some women, they have a so-called surgical menopause, don't they? So explain what that means. So, I mean, some women obviously have to have a hysterectomy for various reasons and removal of the ovaries as well. That's called a total hysterectomy and bilateral salpingo ufrectomy. And the then these women are plunged into the menopause and I use the word plunge because it literally is that they can go from a normal level of hormones to suddenly having no hormones at all

and these are the important hormones to help with our functioning estrogen and testosterone and the ovary that's the main producer of these hormones of the ovary so when we lose these hormones we're plunged into into the menopause and so the symptoms can come on very quickly and dramatically and can really flaw some women and it's a shock because often they're so consumed with their actual operation and for the reason they're having their operation the sort of menopause effect is forgotten. Yeah, so it's not always spoken about. I mean, we as you know, work out of the nice guidance, the National Institute of Health

and Care Excellence, Menopals guidelines that are very clear, aren't they, that women who are having surgery should be discussing their hormones before the surgery. So not afterwards when they're in crisis, but beforehand they should be prepared. As soon as the word hysterectomy is mentioned, it should go alongside, well, what about the menopause? Because even if women retain their ovaries, having a hysterectomy itself, a removal of just the womb, it does increase our risk of having an earlier menopause. So why is that? Because if you, the ovaries are what produced our hormones. That's right. The womb is literally just an organ, isn't it? It's just an organ that's sort of added on to the ovaries.

But research has shown that it's something probably to do with the blood supply. If we remove the womb, the blood supply is affected to the womb. And that affects decreasing blood supply to the ovaries, increasing their risk of failure earlier. And that's quite hard, isn't it? Because we know that for most of us, certainly over the age of 45, we don't need a blood test to diagnose the perimenopals or menopause. But if our period stop or change, and we have symptoms, then it's likely with perimenopausal or menopausal. But once you've had a hysterectomy, but you've got your ovaries in.

Yes. You don't necessarily know, do you? It could be more difficult to know where you are, exactly, because the ovaries will probably continue to function for a little while afterwards, but you're not having periods, so you can't track it from those sort of symptoms. So that's why it's really vital for women to be informed of what are the symptoms of the menopause so that they can think, aha, this is what's happening, I understand what's happening.

So it's less frightening. And, you know, they feel more able to cope with these symptoms if they know beforehand. So, of course, estrogen gets everywhere, doesn't it? And often women are completely fooled by the psychological symptoms of the menopause, which they hadn't anticipated. So people who are running around feeling very well before their hysterectomy, symptoms of the menopause could be that they're suddenly starting losing sleep.

They're not sleeping properly at night. They become more anxious. Their mood is lower and flat. And they have muscle pains all over as well. And they just feel more irritable. Can't cope with things so well. More weepy. All these sort of things I think are really important to highlight and discuss.

So people are aware because often you can imagine people may feel like this and think, gosh, I must be depressed. Perhaps go to their GP and say, look, since the hysterectomy, I've got over that. I know it's a big thing. but I felt really low and flat and depressed and I think I need some help perhaps with antidepressants or something

which is the wrong diagnosis. Absolutely. So I certainly, we use, don't we, here in the clinic, the green climacteric questionnaire which if you put in questionnaire and the search function on the menopause doctor website, you can easily get it. And if you're having some of these symptoms, it doesn't mean that you are menopausal or perimenopausal

but if they've changed since an operation then you should really be thinking. Yes, I find the green climacteric school really helpful because it just sets out all the different symptoms. There's a myriad of symptoms. And it sets out all the different symptoms that women can experience and doesn't include irregular bleeding. So it helps women know where they are. Just to guide us, isn't it? And I think it's harder. I mean, I saw a lady a couple days ago in my clinic who'd had cancer of the cervix. Yes. And, you know, very traumatic. It'd been picked up, thankfully, quite early, but she'd had chemotherapy. She'd had had radiotherapy.

and she had, she didn't realise at the time, being flawed into the menopause because of that. So again, it's an unnatural menopause, but she still had her womb. She still had her ovaries, but they were affected by the radiotherapy. But when she went back to the doctor, they said, well, you are going to be low, tearful, sad, because you've had cancer. That's right. And so she was focusing on that, understandably. But now looking back, she realised it was due to her hormones. We see this a lot, don't we?

Of course you've been through a big operation and maybe because of a cancer diagnosis. And, you know, I've had chemotherapy. Well, of course that makes you tired and not feel well. And everyone always says, well, it must be the surgery, must be the chemotherapy. Of course you're going to be anxious because you've got a diagnosis perhaps of cancer. And all that is true. But actually, a lot of their problems could be due to the low estrogen state they're in. And that increases anxiety and lowers mood.

and is a big contributor to their symptoms. And once these ladies have then got optimised with their reaching levels, they are much, much better. Their anxiety is much improved. They're sleeping well. They're happier. And the mood is back to normal. And we need to think about future house, don't we?

But so a lot of women, not all, but a lot of women who have a surgical menopause are often quite young, aren't they? Yeah. So if they're certainly under the age of 51, the average age of the menopause, certainly in their 30s, They have to have hormones, don't they?

It's vital. And this is a really important point if you can get this across. Women, for whatever reason, really, if they've had early menopause, be it surgical or natural, they really must have hormones until they're age 51. And that's because of the health benefits. Because of the health benefits. If they don't have hormones until the age of 51, they have an increased risk of death, increased cardiovascular disease, increased risk of osteoporosis, plus increased risk of dementia and type 2 diabetes.

So it's hugely important. There's lots of conditions out there. We both were at a very interesting lecture recently at the British Menopause Society Conference and even things like kidney disease, psychosis, depression, one of them was even drug abuse increased in women that had their ovaries removed early. Yes. It's because these hormones get everywhere. That's right.

They get everywhere. And they're so vital for females to function properly and are beneficial to our health. And the good thing about having hormone replacement therapy under the age of 45 is that you get all the benefits because it's restoring estrogen that's lost. So you get all the benefits on the arteries keeping them healthy for the heart and the brain and decreasing osteoporosis and dementia and etc. But you don't have the increased risk because the good thing is there's no increased risk at all. There's no increased risk, for example, of breast cancer. Yes, which is really important because...

Really important to know that if you take HR team, there may be a small risk after the age of 51, but that's very, very small. But women in an early menopause do not have that increased risk. But if a woman's had a hysterectomy, the general consensus from some good studies is that if they don't have any progesterone or a synthetic progestogen, even over the age of 51, they don't have an increased risk.

That's right. Yes, if they have had a hysterectomy as well. Yeah. So it's good news if you've had a hysterectomy as well. Good news if you've had a hysterectomy. Yes, once you've gone through that, you don't have got to the gesturone, which is possibly linked with the increased risk of breast cancer. Obeit small, albeit small, very small. But certainly I know, I'm sure you're the same.

If someone's had a hysterectory in the past, and being told often incorrectly that they can't have HRT because people worry about the risks, we can reassure them because the studies have shown that women who have estrogen-only. Absolutely. Absolutely. do not have an increased risk, do they?

That's right. That's the good news. Forever. You know, that carries on. So if someone say in their 30s or 40s, it's going to have their ovaries removed, what should they do? Do you think? What should we be advising?

So really it's preparation, I think, isn't it? Before the operation that they need to be told that if they're having the ovaries removed, they will go into menopause. And actually what this is. Can't avoid that, can you? No, if the overmover is, sorry, that that will happen. And it's losing these vital. hormones estrogen and testosterone need to be aware of the symptoms that they will cause,

which we've discussed with a green climacteorate scale, those sort of symptoms of the psychological symptoms and muscular symptoms as well as hot flushes. And actually how hormone replacement can prevent that. And the implications of being a young woman plunge into the menopause of the long-term health risks. The increased risk of cardiovascular disease, osteoporosis, dementia, type 2 diabetes and how HRT will prevent those. And it's very important, is it? Because I see some women or some women contact me through social media and say,

well, I'm going to get through it naturally. I've had an early man because I'm going to do it naturally. So, I mean, I'm sure you would say the same. It's unnatural to not have hormones when you're young. We are designed to have hormones, certainly until 50. Physiologically, we're designed to do that. And nature would say that because of the increased risk of heart disease and all the long-term health implications.

if we deny women hormones, certainly before their age 51. So having your ovaries removed is very important to have this discussion. Yes. Either with the surgeon, potentially your GP, a nurse, a doctor, anyone who's interested in the menopause. Before the operation. So we're prepared. We discuss HRT, how we're going to give HRT, etc. After the operation.

After the surgery, yeah. So then the most important hormone is estrogen, isn't it? Yeah. And then there are different ways. aren't there of having estrogen? Yes. It can be given orally or given through the skin. We always prefer through the skin

because it's got less side effects or less complications. The problem is with oral estrogen. It's metabolised, it goes through the stomach and it's metabolised by the liver. And as a result of this metabolism in the liver increases the clotting factors, which can increase our risk of stroke and blood clots. Having it orally also,

it's metabolised to different types of estrogen, which are not body identical. it's not exactly the same physiological situation as we are before the operation with oral estrogen. That's why we prefer transdermal estrogen, which literally means estrogen through the skin, and that can be given by a gel or a patch. That goes straight into the bloodstream and is not metabolised or changed. And it stays as that what we call body identical estrogen, which means exactly the same estrogen as our body's produced. So the body likes it because it's self, it's not foreign, it's not alien. So we have a body.

less side effects with that. There's no increased risk of blood clot or... So that could be started quite soon after the operation. Indeed, yeah, exactly. Straight away. Some people are told, wait for the first six weeks. They're worried, I think this is historical from the oral estrogen, as I just said, it could increase

your risk of blood clot. You wouldn't start tablets. So we would never start tablet straight away because you're a risk of blood plot after an operation because you're immobile and in bed and you have those lovely stockings on your legs to stop clot. But you can start transdermal estrogen because that doesn't increase your risk of blood parts.

So, yeah, so estrogen is really important and there are different doses, aren't there? So depending, sometimes on the age, but sometimes how women metabolise estrogen and certainly younger women tend to need higher doses, even higher than what's licensed, don't they? They do, higher than what it says in the BNF, definitely, just to control their symptoms properly. And that's quite safe to have higher doses. It is, it is. And certainly here in the clinic we sometimes do blood tests to check the estrogen levels to make sure women are absorbing it. That's right.

And having enough. That's fine if sometimes people need two patches or they need six, eight, ten pumps of gel sometimes. They do, especially if they're young. We see that. But we do often monitor their blood levels and they're just satisfactory. They need to be above a certain amount to offer maximal protection to the heart and the bones anyway. So it's important to check that that's occurring and that they are absorbing it. properly because everyone's different how much they absorb from a patch.

And I always think it's a bit like if a person with diabetes has insulin or someone with an underactive thyroid has thyroxin, the dose is often very different, aren't they? Very different, yeah, because we're individuals. And that's the individualised approach is so important. Yeah. So then have estrogen, which often really helps with many symptoms, doesn't it? But then some women still find that their libido is reduced, their mood, their concentration, their energy is reduced.

yet their estrogen level is quite good. So then what would you recommend for them? Well then this situation would probably mean that they would benefit from testosterone replacement. Because you think testosterone is only in men, don't you? But actually it's a really important female hormone. Because we produce more testosterone than estrogen, don't we? Absolutely. The ovary produces more testosterone than estrogen, which is amazing fact.

And we never get taught that. No, no, it's a fact I only learned recently, really. I mean, at medical school we don't, but at school we don't, nothing prepares us to the fact that we have testosterone in our bodies. Women need testosterone as well as estrogen quite often. And people also worry if you give testosterone and they're going to grow a beard and become

manly. And no, what I like about this body identical HRT is it's literally physiological. So that's, as a doctor, that is perfect for me. It's replacing exactly like we'd like and replacing what is lost. Not to high, high

doses, just replacing it. So the woman can feel back to her normal and functioning normally. And testosterone is an important, especially for women who've had a new phrectomy, we've taken all the ovaries out because it's the main producer of testosterone. We get a little bit from our fat glands and adrenal glands.

The majority is from the ovary. So young women who've had their ovaries removed often really miss testosterone, don't they do? They do. And there used to be a patch, didn't there? They used to be a testosterone patch. And the licensing guidelines were that women, who were young, who'd had surgical menopause,

we're allowed to have it. Yes. And then it just sort of petered out. Yeah. It wasn't because of any risks. No, it wasn't. We've used it for decades, testosterone replacement. It was a great effect.

And now we don't have a license preparation, do we? No, it's a shame. I think it's just because it fell out of favour, fashion or something some years ago. But it was very, very effective for women. But we do use a product here in the clinic called Androfoam, which is made especially for women in Western Australia. And it's a product made for women. And it's a cream.

so it's given through the skin. And that really helps. Testosterone replacement really helps. Not only libido, a million things affect libido, but testosterone is important and helps libido. But it also helps things that you may not have thought about, but concentration, brain fog, memory, and mood a little bit. And that's because we've got testosterone receptors in our brains, haven't we?

It is. It is. Again, like estrogen testosterone gets everywhere. So things like our motivation can't be. bothered that sort of feeling. It helps get, I'll get up and go, Ajwa de Vive, if you like. She's really important, isn't it? And I think recently there's been a big global consensus statement published, hasn't there? Lots of the menopause societies and also some of the endocrine societies have all got together and they've agreed

how safe testosterone is. And there's good evidence regarding it helping and improve libido as well. And even at the end it does say, we need to have a licensed preparation for women, doesn't it? That's right. It's so important. You know, it is shocking. And also, I think, very sad that we've got testosterone license for men. We can buy Viagra. You can buy Viagra for the counter. Yeah.

I think there's two things, isn't there? So some people think that sex isn't as important for women as it potentially as for men. And clearly this is outrageous. It's outrageous, isn't it? We see a lot of women, and I speak to a lot of women in my clinic and elsewhere, who tell me in confidence that they haven't had a sexual relationship for often, one, two years sometimes longer. Yes, frequently they say. And, you know, we know that it has a big effect psychologically, physically, emotionally, everything else as well. Yet it's almost

embarrassing to talk about. And it's a great to do, is that, yes. And we know, I'm not naive, we know that lack of libido or reduced libido is not just a hormone, certainly in women. It's more complicated than that. Yes. Yes. But like you say, the other aspects, that can improve with testosterone, such as mood, energy, motivation, stamina. People then feel better in themselves. Yes, so they're happier. So if your self-esteem is back to normal, you're feeling yourself, literally, just feeling yourself. You're going to probably have a higher chance of having a healthier, sexial relationship.

Yeah, because your relationship with your partner is going to be better, isn't it? You're not irritated by them. You're not weepy. You're feeling good about yourself. You know, it's so important, and it's shocking how women have been neglected in their sexuality has been neglected. Absolutely. And that's just, it's obvious to see how easy it is for a man, and I'm pleased that that has happened, that they can obtain Viagra, etc, quite easily. But yet, women have been neglected.

And they still are being neglected, don't they? Yeah, yeah. It's a real shame. And we have a product here that is known and proven to improve libido. Yeah, it's not licensed. Yes. And that's the tragedy. So in the NHS, doctors, if they're confident in prescribing testosterone,

can give the male testosterone, which we've often done in the past, haven't we? Yeah. In the NHS, you can give the male testosterone in lower doses. And the safest one is probably test a gel, which comes as a sachet, make the sashay last seven to ten days. It's a bit of a faf, but it's doable. So that's if a woman is listening and really wants to get it through the NHS, first you have to find the right doctor, and that can be quite hard.

Yes, because not many doctors know about it. No, no, because the training is really not always there for healthcare professionals. So you can ask if there's a local menopause clinic or if there's a doctor with a special interest in the menopause. Some people have told me they find out who the doctor is to see through Facebook. So if there's a local Facebook group, you could sort of find out from that ask around. Some people have even changed surgeries. And all these things are doable, but it can still be difficult. Yes.

GPs are allowed to prescribe the angiophem that you've mentioned, privately if they're confident because we're not allowed to prescribe it on the NHS because at the moment it's not licensed. We hope it will be licensed. It's more expensive because it's a private prescription but it works out about 80p a day doesn't it? Yeah, that's right. It's not ridiculously expensive but obviously there is a cost. And both the hormones, the estrogen and testosterone derived from the yam, aren't they? Yes, it's from root vegetables. There's no pregnant mares urine or anything like that. And it's a natural body. the identical product at the end.

And so physiologically, women do much better on this type of HRT than maybe older types of HRT they've had, which is an important point, I think so. And I think also when women talk about wanting to do things naturally, actually it's very natural replacing your hormones. And I'm sure you've seen, I've certainly seen lots of women who have taken supplements because they want to do what they call naturally. Yes. And when you look at the ingredients of some of these...

It's quite horrifying. It is, isn't it? They're not regulated. There's no evidence base behind them and many of them. Yet here we have HRT, which is exactly the same structure as our own estrogen and progesterine and testosterone that we use. With years and years of evidence of good safety evidence behind it, it's so safe. And I think one of the problems that's probably worth mentioning is that when you open the packet of your estrogen or hormones, it will talk about risk of, clot risk of, heart attack, risk of this, because it groups it as a hormone.

and it groups it like it is a tablet estrogen. Or like the pill, for example. Absolutely. Controceptive pills. It's exactly the same warnings with contraceptive pills, which are quite different hormones, aren't they? Completely different. They're synthetic, their tablet.

And a lot higher dose. But they haven't changed. So anyone who's listening to this and gets hold of some HRT, opens a packet, thinks, well. Could be quite alarmed, couldn't they? Very alarmed. And also think what we're talking about is absolutely rubbish. Yes.

And so. They're outdated, in fact. They are outdated. They're more relevant for the combined oral contraceptive pill. And they've extrapolated that incorrectly related for HRT. So there are a few women, aren't there, who have had a hysterectomy and their ovaries removed. So it's a surgical menopause. But still need progesterone, aren't they?

Because there's always a question. People say, well, that's the third hormone, don't I need it? Yes. There's a few women who quite like progesterone, because it can help with a bit of sedation. People feel a bit calmer, don't they? Yes, they feel calmer and helps her sleep. So this is the body identical, micronized progesterone. Yes, it's very good to help women sleep at night.

And they just feel a bit calmer on it as well. So that's quite a thing. So I've got a few, not many ladies who have been on estrogen and testosterone, and they feel that something's a bit missing somehow. And usually they're a bit younger. And I often give them progesterone for a few months. And I have got some who say, yes, I feel better. We don't need it physiologically, do we?

No, the only reason we give progesterone, really, is for women who have got a womb, eastern on its own, potentially can thicken the lining of the womb, which if left, could go on to a hyperplasia, which is not always healthy. And to prevent that, you take a progesterone, which keeps the lining thinned. So if a woman has had their ovaries removed,

but still has their womb, then they need to have progesterone. They do, because they've got the womb. lining, which is... That's really important to know. So there are some women who have a surgical menopause, but keep their womb. So it's important that those women have a hysterectomy. And we see increasingly, I think, because there's this Angelina Jolie effect of women who have been diagnosed with a brachene. They've got just family history of breast cancer.

Yes. They have their ovaries removed early. So they have an early menopause. Yet they're being told they have a risk of breast cancer, you can't have HRT. That's shocking. That's shocking because they've had the ovaries removed when they're young, they need their hormones, like we said earlier, until their age 51. If they have got a womb, they will need a progesterone as well.

But it's vital that they have these hormones. And I think there's a confusion because the reason these women are having their ovaries removed is because they've got a risk of ovarian cancer because of the brachene. That's right. Whereas there are some women who have had breast cancer who have their ovaries removed because the cancer specialist doesn't want any hormones around. Yes. It's a very different indication.

Yes. For prevention, the ovaries are removed to stop ovarian cancer. Yes. So it is safe then for these people to have HRT. In fact, their risk is very low because they've often had a bilateral mastectomy and ophrectomy. So actually, you know, they should have HRT in my opinion. Yeah. And actually sometimes people, when they have their ovaries removed for this reason,

sometimes elect to have their womb removed as well so you don't have to have a progesterone but this is a very individual choice but it's discussions that should be had before so in the pre-op assessment or in your clinic appointment before you go to the operation so you're very clear why you're having the surgery yeah what exactly has been done and your future with the hormones certainly when we were at medical school usually people would take they were doing a hysterectomy they'd say let's take the ovaries out as well because that's will take it out. But there's a change. There's a complete change. Yes, exactly.

Euphrectomy used to be thought, well, while we're here, we'll take them out. Well, we know how disastrous that is, losing your recent early. But even when you're sort of 45 or above, they often keep the ovaries in. Because ovarium... They can squeeze a bit more. And ovarium function is important in sometimes ways we don't quite understand about the aging, preventing the aging process. We know that people have had an early ophrectomy have much.

higher risk of all sorts of disease, I think you said earlier, even like asthma. Yes, that's right. And drug addiction and things. So there's lots of effects of ovaries. So I think if a woman has, for example, fibroids or something, a polyp, something in the lining of their womb, and the surgeon's suggesting to take everything out, I think we should be questioning as women, do we want our ovaries in or not? And certainly what some consultants are doing now is just removing the,

womb, often with the cervix. And then they're saying, come back when you're 55, we'll do a keyhole procedure, day case, take your ovaries out then. Because after 55, it's unlikely they'll produce much good hormones. And I think that's quite a sensible move actually. Yes. Increasingly, if you're in your 30s, 40s, you have to question why you're having your ovaries taken out. Exactly. It's important organ for women producing essential hormones. Yeah. So I think that's really useful. I'm hoping people will find that interesting and just give them some food for thought when they're contemplating having a surgery and hopefully help their discussion. So before we finish Rebecca, in usual style, could I have three take home tips? So these are be tips for women who haven't had surgery yet, who what could they do? So first of all, when they're contemplating surgery, they need to think about menopause, okay? Because if the ovaries are going to be taken out, they're going to be plunged into the menopause. So they need to be a of what these risks of an early menopause potentially can be and the solutions to it. And to discuss with the surgeon about HRT following the surgery and what type of HRT to use

and how soon to start it because transdermal these shouldn't can be started straight away. So it's getting being pre-warned anticipating symptoms and having a solution before the operation. So it's all organised and sorted. before they have the operation. That's really useful. And there's lots of information. Obviously on my website and the British Menopause Society have some information. Nice guidelines have information.

But just make sure you do your homework is really key, isn't it? Totally. And if you've had surgical menopause and you're listening to this and thinking, I'm still suffering, what would you say? Oh, please don't. It's so vital that you have your hormones, especially if you're under 45. And how safe HRT is for the vast, vast majority. Get the right health.

help get the right house to get to the GP. Absolutely. So thank you ever so much. That's a pleasure. Thank you. For more information about the menopause, please visit our website www. www.combector.com.uker.