Antidepressants Blog

There is considerable confusion about hormone replacement therapy for a variety of reasons. In the past, very little good research was carried out on this topic, partly because no one has ever died from the menopause; and because most medical research is concerned with wider, life-saving issues. The situation is altering now because there is a more enlightened attitude to the effect of well-being on the woman, her family, and the community generally.

Confusion has also been created to some extent by the media. How can a reporter be expected to sort our medical detail? The media has often confused the issue just as the whole situation was becoming clear. The current confusion has made doctors afraid to give therapy, and women afraid to accept it. Some people are now being unnecessarily deprived of relief because of fear of the side-effects.

Some women need no help at this stage, others need it for a few months or a few years, or recurrently as the symptoms recur, and a few women need it for life. Some women who come into the clinic do not come back because they are urged to get off hormones either by their family or by their own consciences after reading press articles. Some people dismiss the whole business of menopause as a state of mind, and tell these women to pull up their socks and get on with it. In one survey carried out in our clinic, a high proportion of women who had complained of treatable symptoms had been told that they were menopausal, given a prescription for a tranquilliser and dismissed. On the other hand, there was a vogue in the 1960s in the United States for putting all women on oestrogens after the menopause, as it was regarded as a deficiency disease, much the same as diabetes. This vogue did not reach Australia to any extent.

We know it is not wise to give oestrogen to all women. For some, in whom oestrogens are contraindicated, it could even be dangerous. In addition they have side effects. Also, oestrogens do not reverse the ageing process, as some hope. They only alleviate symptoms which are oestrogen dependent.

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This depends on the severity of your problem.

Simple measures Some women manage well with a lubricant cream such as KY jelly.

Local oestrogen creams and pessaries For those who do not want oestrogen tablets for general symptoms, and indeed a dry vagina may be their only symptom, local oestrogen creams or pessaries are the answer. Some patients feel these creams are unaesthetic and messy. If these are used, however, the absorption may be the same as if a similar dose is given by mouth and progestogens therefore should be given at regular intervals to shed the built-up lining of the uterus.

Oestrogen replacement therapy This cures vaginal dryness dramatically in 100 per cent of cases if this is due to oestrogen lack, and the result is obtained within weeks. The dose for this symptom alone is small and would certainly be your choice if other methods have failed. Vaginal dryness is a common symptom, and those doctors who deny that it is, I feel, do not enquire about it. It is important for doctors to be aware of people’s reticence in discussing such matters. This symptom has such a profound effect on marriage, and is so easily relieved.

The case history could be included here of a woman I saw twenty years after her ovaries had been surgically removed for endometriosis. With the removal of her ovaries her oestrogen production had stopped and she was suffering from lack of oestrogen. She was downcast and depressed, and she had not had intercourse for 14 years. On examination, her vagina was so constricted that I could introduce only a cotton bud to take a smear at routine examination. She complained that she was so dry and irritable in her vaginal area that she could hardly sit still. After a fortnight of oestrogen taken orally and applied locally I could readily introduce a bi-valve speculum. Her vaginal tissues had reverted to normal and she was happily having intercourse. The effects of the treatment are as rapid as that.

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Hysterectomy

Hysterectomy means removal of your uterus only. This means you no longer have periods because your uterus and its lining have gone. It does not mean that your hormones have been removed as well. If your ovaries are left they still produce hormones which are still being released into the bloodstream.Therefore, after recovering from your operation, your sex life should not be affected at all.

Oophorectomy

Removal of your ovaries is oophorectomy, and menopausal symptoms result as the ovarian hormones are no longer being released into the bloodstream. Both hysterectomy and oophorectomy mean you can no longer have children.

Oophorectomy is an important decision and should be discussed with your doctor. Once your ovaries are removed the natural supply of oestrogen is stopped, except for small amounts produced outside the ovaries. You must weigh up the very small risk of developing diseased ovaries (and this is the risk taken by every other woman in the community), against the loss of one’s own hormones, the supply of which may continue, if only in a reduced way, until the upper age level if your ovaries remain. You and your doctor must sort this out before operation.

Only one ovary may be removed. This is sometimes done when one ovary is less diseased than the other, particularly in a younger woman. The remaining ovary will still produce eggs and hormones, and, if the woman’s uterus is present, she may still conceive.

You must know the facts It is important to know why you should have a hysterectomy and what it involves, so that you know precisely what will be done and feel satisfied that it is necessary. You and your doctor must sort this out before the operation. I am surprised at the number of women I see who do not know what they have had removed or why it was done. A large number of women, by the time they are sixty, have had hysterectomies. It is important to weigh up the need for any major surgery as there is a risk attached to such a major operation. For this reason, I feel having discussed it fully with your gynaecologist, if you have any doubts in your mind at all, you should have a second opinion from a quite unrelated gynaecologist.

Irradiation of ovaries

Irradiation of ovaries may occur when adjacent areas are irradiated; or it may be used as an alternative to surgery. Hormone production ceases when ovaries are irradiated, and menopausal symptoms may occur quite suddenly as the hormones are cut off, and in these instances the symptoms may be more severe.

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Thrombosis No cases of thrombosis have occurred in our clinics. Thrombosis connected with oestrogens has been reported with the oral contraceptive pill, which contains synthetic ethinyloestradiol in doses higher than those generally used for menopausal symptoms. In our menopause clinics we use the so-called naturally occurring oestrogens Premarin, Progynova, Ogen and Oestriol. These hormones are reported to produce no increase in the incidence of thrombosis in the doses used.12 Also, I must underline, the dose used to control symptoms after the menopause is usually lower than the lowest dose of oestrogen in any contraceptive pill on the market.

Blood pressure Blood pressure does not usually go up with the doses used; in fact, as the patients settles, it generally goes down (about 10 mm of mercury). If the blood pressure does go up, as it does in a small percentage of cases, this is not an absolute contraindication to oestrogen therapy. The dose may be adjusted, the preparation may be altered or the blood pressure may be treated separately.

Sore breasts Some women get sore breasts, but these settle as the dose is adjusted.

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Just as with any feature that is declining in function at this time, the skin needs greater attention. A good diet, plenty of fluids, and a decrease in cigarette and alcohol consumption all play a part. Moisturisers and night creams are also very useful.

Facial exercises My seventy-six-year-old aunt, who has hardly a wrinkle on her face, swears by facial exercises, and although I have no personal experience of them, exercise is so beneficial in general that I have no reason to doubt that they work.

Plastic surgery This is becoming more and more common and has a definite place for some. If removal of your wrinkles can improve your outlook, if your skin is past repair by simple methods, then this may help you dramatically. Enquire carefully, get good advice as to who achieves the best results, and ask all the necessary questions at your interview – for example you should know the expected results, time off work and in hospital, and costs involved. You may decided on a full facelift or a smaller treatment, for example on the eyelids or removal of puffiness from under the eyes.

Increase in pigmentation

Although increase in pigmentation with oestrogen occurs with the oral contraceptive pill, I have never observed this in dose levels used for oestrogen replacement therapy.

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