120. Navigating Hormone Health After Hysterectomy

What if surgery to remove your uterus solves one problem—but leaves you with a dozen new questions? In this episode, Dr. Monica Minjeur breaks down what happens to your hormones after a hysterectomy, whether your ovaries were kept or removed. Learn how to recognize symptoms of hormone imbalance, what lab testing still matters, and how restorative medicine offers a clear plan for sleep, libido, mood, and long-term health.

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Transcript

Speaker 2: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if surgery to remove your uterus solves one problem, but leaves you with a dozen new questions? Do I still have hormones? Can I still ovulate? Should I take estrogen or progesterone? Today, we're going to make some sense out of hormone health after hysterectomy, whether your ovaries were conserved or removed, and outline a clear restorative plan for feeling like yourself again. So let's start as always with a story about a patient of mine who we'll call Penny. Now Penny came to see me at about 41 years of age. She was a busy mom and a teacher after years of dealing with heavy cycles and lots of bleeding, her gynecologist recommended a hysterectomy in order to treat what they thought was suspected adenomyosis and fibroids. Now, initially after surgery, penny had some relief. She had both her uterus. And her cervix removed, but they left her ovaries intact. However, after a couple of months, she started to notice night sweats, brain fog, decreased libido, and new vaginal dryness, and wondered what happened to my hormones. Her post-op visit with her gynecologist focused on the incision, the restrictions, the drainage, but didn't really dig into her hormones at all. A few months after that post-op visit, she noticed that she was feeling worse. She was wired and hyper at night, but depleted during the day. She didn't have a menstrual cycle to understand what was going on, and now intimacy was becoming more painful. Penny came to see us at our clinic and we helped to map out her symptoms and did some labs. We showed that her ovulation levels were consistent with ovarian function, meaning they were still firing how they were supposed to, but she had significant fluctuations in her estrogen levels and her luteal phase. Progesterone was low even when timed with our presumed signs of ovulation. She had symptoms that were suggested of genital urinary syndrome of menopause, otherwise known as GSM. Despite having labs that did not show that she was yet into menopause, so we built out a plan for penny, including oral progesterone, local vaginal estrogen, as well as systemic estrogen, and worked to restore her pelvic floor with referring her onto physical therapy. Okay, within a few cycles, penny noted that her sleep had improved. Her vaginal dryness had improved. Libido had increased, and her mood was much more stable. More importantly, we gave Penny the education she needed to understand what was going to happen next and what she needed to pay attention to, to know when something more dramatic had changed. So let's start off with a couple important pieces here in that if you are somebody who still has your uterus, why it's not the best idea, just to rush to hysterectomy. So many women feel like after they're done having babies, they just want the cycles to stop, to turn off, to quit being burdensome. And I'm here to tell you there are lots. Of things that we can do and look at first and other options that don't include just removing your uterus in order to help with whatever symptoms it is that you may be experiencing. Part of the reason why we don't wanna just rush to hysterectomy is that there are some potential long-term consequences and side effects that many women suffer from, for example. Women that have a hysterectomy, especially at a younger age, less than 35, are at an increased risk for high cholesterol, high blood pressure, obesity, coronary artery disease, heart arrhythmias, and even stroke. Despite keeping your ovaries intact, many women after hysterectomy will go through early ovarian failure, which can mean an earlier onset of other menopausal symptoms like hot flashes, irritability, moodiness, and vaginal dryness. Many women with a hysterectomy also suffer from pelvic floor disorders, whether that's prolapse of the vagina or of the rectum, urinary incontinence. And regardless of whether the cervix is kept intact or not, many women still have dysfunction of their pelvic floor. We also know that long-term studies show increased risks of cognitive impairment and dementia, especially if your ovaries are removed. Increased risks of osteoporosis and issues with sexual function, especially if you've had your ovaries removed. Now, this is not to say you're for sure going to get all of these symptoms, but I also want people to understand that it's not just as simple as just removing the uterus. These things come with potential long-term side effects that you can't just reverse. In addition to the fact that a hysterectomy is considered a higher risk surgery, it is not without risk. Most of the times a hysterectomy is very, very safe, but there are potential things to consider here. Now, maybe you've already had a hysterectomy, and that's the primary focus that I want to talk about today because there are some situations where a hysterectomy is warranted or required, or maybe this has already been done before you had the discussion knowing what else could be done. So let's start with a few terms in general so that we can all be on the same page about what we're talking about. The other piece here is that I want you to make sure that you understand if you've had a hysterectomy. Which of your parts are still present? So for example, a partial hysterectomy oftentimes will mean that your uterus is removed, but you still have your cervix, which is kind of the end part of the uterus itself. So this can also be called a Supra cervical hyster. A total hysterectomy generally means that your uterus and your cervix were removed. And then if you also have had done a bilateral cell pringo ectomy, that means your ovaries and your tubes removed. Cell pringo is just the tubes. So if you've had. Sal Ectomy, that means that the tubes were removed. If you've just had an ectomy, that means that just your ovaries were removed. Now, it typically would happen that if you had your uterus removed and your ovaries removed, they would not leave your fallopian tubes present. The only time that we typically will see tubes that are left is if your ovaries are also left in place, but most often when your uterus is removed, the tubes are removed with them. So. All that to say. If you aren't sure which pieces and parts you have left, go back and check your operative notes. Ask your surgeon so that you can understand which pieces and parts you still have present. So a key principle here and why this makes a difference is that your uterus does not produce hormones. Your ovaries. So if your ovary stayed intact, you will still make estrogen, progesterone, and testosterone levels to varying degrees, and you may still actually ovulate on a regular basis. You just don't have the monthly bleed in order to realize that that's what's happening. If you had your ovaries removed, you typically will enter surgical menopause immediately with a drop off on estrogen, progesterone, and androgen levels. And this is typically more impactful of symptoms like sleep, mood, libido, brain, heart, bone, and urogenital health. Now, even if you have your ovaries present, you can still have symptoms. They may just be much less severe. So what we typically find is, is that stress, sleep loss contemporarily blunt or impair ovulation from happening, which can then impair that luteal phase, which would normally be from the time you ovulate until your next bleed starts. Loss of that menstrual bleed obviously makes it more difficult for you to understand where exactly you are in your cycle. But there are still ways that we can track what's going on, whether that's a urinary LH surge, whether that's a temperature spike, and in some women, they still will identify signs and symptoms based on pain or discomfort if that was something that they previously had noticed. And most commonly we want to pay attention to localized estrogen deficiency. So even if your labs show that you have normal blood levels of estrogen or that you're not in menopausal range, the shift of estrogen in the vaginal tissues can occur, which can lead to problems as far as sexual dysfunction. Pain, discomfort, and also the pelvic floor can have issues because we've had surgery, which can lead to scar tissue, muscle guarding, adhesions, and all of these things are really important to understand that they can be longer term symptoms. So what do we do and how can this look differently if you are suffering from any of these symptoms of post hysterectomy syndrome? Now I'm gonna start with talking about if you still have your ovaries. So if you did not have an ectomy. So we can still map ovulation. Again, as I mentioned, looking at LH surges, looking at lab testing, we can oftentimes confirm ovulation with a progesterone level done to assess the strength of that luteal phase, as well as the strength of ovulation that occurred. We also will start with our basic lab panel to check all of the hormone levels, and then we will decide what makes the most sense for you from a treatment standpoint, depending upon your symptoms and your labs. So for example, we oftentimes will utilize cyclical bioidentical progesterone after ovulation. If we find that your ovulation function was weak or progesterone levels are low, treating with progesterone can often help to improve your sleep. Your mood and your libido. If your primary symptoms are that genital urinary syndrome of menopause, dryness, burning, increased tendency for urinary tract infections, even with a normal estrogen level localized vaginal estrogen can be. On the flip side, we will utilize systemic estrogen, meaning estrogen that goes to your whole body, especially if you have low estrogen levels or if you're having symptoms of hot flashes, mood swings, or if there's any concern for bone density. Now, typically, if that's the case, we are always recommending, again, topical estrogen, whether that's a patch, whether that's a topical cream, because there are generally less side effects from the topical estrogen. If you are struggling with any problems as far as pain with intercourse, pelvic pain, urinary incontinence, we're always going to refer you to a pelvic floor physical therapist to talk through all of those structural issues and help to regain the tone that your muscles in the pelvic floor need. And then finally, if you are struggling with any sort of nutrient deficiency, we will always talk about getting enough protein for healing, making sure your iron stores are repleted because many women have low iron. If they've been suffering from long, prolonged times of bleeding. If you have a history of endometriosis, we wanna pay special attention to not giving too much estrogen because we can still have a flare up of endometriosis symptoms if there is excess estrogen. And this is another important point is, is that if you have. Endometriosis and you have your uterus removed, you can still have all the same symptoms of endometriosis unless those endometriosis lesions were also removed. So please make sure that if there is any endometriosis present that that is also getting treated or taken care of, ideally before you go down the path of hysterectomy, but certainly at the time of hysterectomy, if that is what's deemed necessary. Now if your ovaries were removed at the time of hysterectomy or after or before and you've gone through surgical menopause, it's important that we discuss hormone therapy early, nearly across the board. Most women will require some sort of estrogen therapy and progesterone therapy is not required if you don't have a uterus. It can be beneficial again in cases of sleep disturbance, anxiety, or breast discomfort. Sometimes when we provide you with the estrogen support you need, that can actually increase breast tenderness, and so we will offset that with progesterone instead. If your androgens are also low, we consider treatment typically with DHEA, which will help to increase those testosterone levels. It gives you enough of the building blocks to go on and build more of the hormone levels, and in some cases, we will recommend utilization of low dose testosterone directly, but usually we aren't in need of that because oftentimes the DHEA will do enough. Again, similar to if you had your ovaries still present, we often will provide that localized vaginal estrogen cream to help with tissue health and prevention of urinary tract infections. This is across the board, very well studied, and we find that we can actually save lives when we are treating with vaginal estrogen to prevent urinary tract infections as it is one of the most common causes of debil. As well as leading to infections, sepsis and death, especially in older women. So anything we can do to help prevent that earlier on is going to be helpful for you in the long run. If you had your ovaries removed. We also want to make sure that we are doing a baseline bone density test to evaluate if you have additional risk factors, making sure to optimize calcium vitamin D protein, as well as that resistance and strength training in order to help an offset any problems as far as bone density loss. Now as always, we need to make sure that we're personalizing hormone therapy along with your medical history, family history, and considering non-hormonal supports if hormone therapy is not appropriate. So for example, if you are somebody who has had a personal or close family member with. Estrogen or progesterone responsive cancer, something like breast cancer, uterine ovarian cancer, or if you have personally suffered from blood clots, heart disease, or stroke or thyroid dysfunction, it is always incredibly important to make sure you are working with somebody who is knowledgeable in these nuances because it is not a blanket statement that everybody should be on hormone therapy across the board. Let's talk about a couple of common challenges that we see. The most common thing that we run into with people that have had a hysterectomy is they're not sure when they ovulate or if they're even ovulating. My best recommendation is to utilize the urinary LH strips. Now, these aren't perfect, but they are one of the things that can help to reliably pick up ovulation. If it's happening, you may need to try them over the course of two to three months. And if you're still having troubles, working with a medical professional can help to test your levels of progesterone to determine if and when you are ovulating. Another common issue we find is, is night sweats or troubles with sleeping happen, even if you still have your ovaries there. And so one of the common things we'll pay attention to with this is a trial of cyclic progesterone. This oftentimes will help with. Sleep and we reassess after two to three cycles to make sure that it's the right fit for you. There are multiple different dosages of progesterone that we utilize, as well as different timing that we can use depending upon your symptoms. Another common challenge that we find is decreased libido, and oftentimes this can be directly from pain with intercourse. If this is the case, we are always talking about utilizing local vaginal, estrogen targeted lubrication. Gradual exposure and working in grace to say this doesn't need to all happen all at once. We oftentimes also find that decreased testosterone levels and or DHEA levels can also add to that decreased libido. So making sure we're looking at all the pieces that play a role and really con understanding what your needs are. If you're struggling with mood troubles or brain fog, it's really important to prioritize sleep. Getting adequate protein. And again, considering that nighttime progesterone, if you are having troubles with sleep in general, if you're struggling with weight or metabolic shifts, we wanna really dial in on resistance training. So this is going to be core exercises, weight training, and again, this doesn't have to be ridiculous amounts of weight that you're lifting, but really just focusing on where can I help with getting that regular exercise and activity in. Okay. We also want to address insulin levels if they're elevated, to focus on balancing appropriate amounts of protein and carbohydrates. And most importantly, if you go through this whole process and you're still having symptoms, it's important to recheck lab levels. Make sure that we're ruling out any other shifts or changes because sometimes we correct one hormone imbalance and another one will show up. Or sometimes something has not been completely checked in the first place, and we want to make sure that we're addressing all of the components. If you're still struggling with systemic symptoms of pain or intercourse problems or urinary incontinence, always focusing in on this pelvic floor therapy. And again, this can be something that you need to do for longer term. It generally is not going to correct after just a couple of sessions. So what are some things that you can do now if you've had a hysterectomy? Number one, if you are unsure of your surgical status and what pieces and parts you still have present. Figure that out. That can be really impactful to guiding what your next steps should be. If you are not sure if you're still ovulating and you still have your ovaries present, you can start with charting your cycles LH strips. Using a symptom diary to estimate your ovulation, even if you don't have a bleed, can help when it's time to order targeted labs and timing of your medications. If you are struggling with tissue dryness or pain. Talk to your doctor right away about local vaginal estrogen and pelvic floor physical therapy. Please do not feel like you have to suffer from this. Just because others say that it's common doesn't mean that it has to be normal. And then finally make sure that you are discussing hormone treatment therapy, especially if you've had your ovaries removed almost universally. It is now recommended to start on estrogen plus or minus progesterone therapy in addition to local vaginal therapy in order to help prevent those long-term risks that we talked about. Imagine if your post hysterectomy plan didn't end at your postoperative visit with just looking at your incision, but rather a continued clear roadmap for hormones, sleep, libido, and pelvic comfort. Over the course of a few months, you could know whether or not you're ovulating, if your ovaries are still intact. If you have the right support for your tissues and bones, and a better understanding of navigating the next steps for your overall hormone and long-term health,

Speaker: 20:38

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