Variations on HRT.
Post Hysterectomy and Oophorectomy
Women who have had a hysterectomy should have continuous oestrogens without progestogens and thus treatment should be straightforward without bleeding and without PMS type symptoms produced by gestogens which often limit the acceptability of HRT. However, these women may need a higher dose than is usual for the vasomotor symptoms and as the surgery usually occurs in premenopausal women they may well, like those with a premature menopause need oestrogens for a longer duration for relief of symptoms.
If the ovaries have been removed these women would have lost their ovarian androgens and be at risk of developing the Female Androgen Deficiency Syndrome (FADS) characterised by loss of energy, loss of libido, depression, loss of self-confidence and headaches. (32) These are frequent complaints in women who have had a hysterectomy with loss of ovaries and have been receiving a low dose of oestrogens over the years. These symptoms can usually be eradicated by the addition of testosterone, either in the form of implants (licensed for women in many countries) or Testogel, which although effective will have to be used off-licence in women using about one quarter of the dose recommended for men. However, the fact that it is not licensed in a particular country is not a good reason to deny women this important item of treatment. It should not be forgotten that testosterone is not only a normal female hormone but it is present in higher concentrations in young women than oestradiol.
Estradiol and testosterone implants are the most effective and convenient
route of administration for these women with the pellets inserted into
the wound on closure and repeated approximately every 6 months as a simple
office procedure (15). The fact that it is an old drug lacking in patent
or profit or the benefit of costly licensing studies does not reduce
its value in hysterectomised women or those with problems of loss of
energy and libido or depression.
Peri Menopausal Depression
There are many patients in their forties with severe recurrent depression, sometimes cyclical, who will respond well to transdermal oestrogens. These patients with reproductive depression often reveal the changes of mood with changes in hormone levels because of a past history of post natal depression, premenopausal depression as well as the severe depression in the peri-menopausal years of the transition. Often they state that they were last well during the last pregnancy many years ago. They then developed post natal depression which became cyclical as premenstrual dysphonic disorder (PMDD) when the periods returned having only about 10 good days per month free of PMS periods and menstrual headaches. The depression then becomes less cyclical and more constant. (33)
These peri-menopausal women respond well to moderately high doses of transdermal oestrogens (either moderately high doses 100µg-200µg) which not only suppress any residual cycle but have a mood elevating effect. As these women with hormone responsive depression are often progestogen intolerant, the continuous oestradiol treatment should be supplemented with progestogen tablets for 7 days of each calendar month rather than the orthodox 14 days. A Mirena IUS is also useful preventing the recurrent depression that often occurs with progestogen
Oestrogens do not convincingly help the depression of post menopausal women apart from the domino effect of removing night sweats/insomnia or vaginal atrophy and sexual dysfunction. It seems to have little significant effect in the absence of these classical menopausal symptoms.