Author: DR. N

Dr N,

I read with interest your comments on the importance of testosterone in HRT therapy if one is experiencing low libido. I am 54 yrs old and had a complete hysterectomy at 48 due to a very large fibroid attached to my uterus. I started estrogen treatment right away and have felt fine physically but have experienced a big loss of desire and pleasure in the libido department. My ob-gyn suggested Estratest, a combo of testosterone & estrogen but I did not find any significant improvement. You suggested a different delivery system for the testosterone. Could that make a difference in the effect for me? I currently am on .625 Premarin daily…I previously enjoyed a healthy sexual relationship with my husband so this is a real bummer for both of us…..Please advise…Thank you.

Hi,

Although Estratest is effective for some women who have a decreased libido following a hysterectomy I don’t prescribe it. There are more effective and safer options. The most effective would be hormone pellet implants of estradiol and testosterone. Other alternatives  would be injections of depo testosterone every 2 to 4 weeks depending on the dose used. Another option would be a compounded estradiol/testosterone gel. Ultimately, when all else fails, subcutaneous hormone pellet implants rarely fail to restore libido and sexual response.

Dr N

Dr N:

I had a “total” hysterectomy in January. My ovaries and all were removed. My OBGYN put me on the Climara patch. (I tried Premarin but had hot flashes and mood swings) After a “dip” in my sex drive that I couldn’t stand, I got him to give me a shot of testosterone. Boy did it ever help, and I am sure pleased with it’s results! The only problem I am having now is that the patch will not stay put for more than 3-4 days. It starts wrinkling and crawling, and gets real annoying. I know my “no-where-near perfect” body, with its folds and all, doesn’t make an ideal sticking place, especially on the weeks I wear it in front. Yet, I have just as much trouble keeping it in place when it is on my upper hip. Any suggestions?

Reply:

Hi,

Actually, you have a number of options. If you like the way things are going with the Climera and the testosterone shot, you can probably stay on this program, but remember that the injections only last about a month and usually need to be repeated approximately every 4 weeks. One way is to insist that you be given extra patches to replace the ones that fall off. If you can afford it or your insurance company is willing to pay for it, there is no reason that you can’t put on a new patch every day.

Another option is to use estrogen gel which can be made for you by a compounding pharmacy. This is basically the patch without the stickum and you just rub it on once a day. Alternatively, you can use hormone implants of estrogen and testosterone, which usually work great and then you wouldn’t have to do anything for the 4-6 months that they usually last.

If you read the Methods of HRT section of the web site, it will provide additional insight.

Dr N

Dr N:

I am a 50 year old diabetic (insulin dependent) woman who had a hysterectomy 9 years ago. I stopped taking Estrogen 6 months ago because of the controversy regarding breast cancer and also because I was experiencing breast pain. I am now experiencing night sweats, vaginal dryness and fatigue. I am also concerned about heart disease. I saw the product ESTROVEN advertised on television. Is it a good replacement?

Reply:

Hi,

I’m sorry that you’re having a problem.

I don’t think Estroven is effective in the treatment of menopausal symptoms or has any effect in preventing the long term health problems of menopause associated hormone deficiency

I do not think estrogen causes breast cancer. I do feel however, based on the available research, that women who have undergone a hysterectomy and are without the benefit of appropriate non oral bio-identical hormone replacement have a lower life expectancy associated with an increased risk of cardiovascular disease, strokes and osteoporosis.

Let me know what and how you do.

Dr N

Dr N,

I recently saw an article on the TV that chronicled one woman’s attempt to document the need for monitoring hormone levels in individual women so that their HRT dosages could be adjusted specifically for each woman. Do you know where I could get more info on this subject?

Thanks

Reply:

Hi:

This is an important issue, but the answer is different than some might expect.

Every woman’s metabolism and absorptive ability is unique, and it is prudent to see if the hormones that are being taken are actually in the bloodstream and are at therapeutic levels.

For instance, some women are unable to absorb and/or metabolize oral HRT products well. Testing them will reveal low or absent levels. On the other hand, some women on oral HRT products in whom the tested levels appear to be adequate, continue to experience symptoms of hormone deprivation.

The likely explanation is that oral HRT products, irrespective of their individual chemical structure, or whether of natural or synthetic origin, are metabolized and altered by the liver following their gastrointestinal absorption, Most women are able to accomplish this in a manner that retains enough of the bioactivity of the ingested HRT product so that it still performs it’s intended function…

The problem in interpretation arises, when the metabolized substance is close enough to the bioactive compound to fool the testing procedure, but not precise enough to perform it’s bioactive role. So, if this is not understood, confusion arises, as to why the patient is having symptoms in the face of seemingly adequate hormone levels.

The advantage of the non-oral route is that since it bypasses this “bolus” liver effect, if the administered HRT substance is bioactive in it’s initial form, it remains so. And, any measurement results in a more accurate assessment of it’s potential activity.

All this being said, you don’t treat blood tests, you treat individuals. Everyone, has their own specific response to treatment. Hormone replacement that results in blood levels in the low end of the accepted therapeutic range may relieve symptoms and provide it’s preventative health function in some menopausal women. But, the same levels may be completely inadequate in women who require a higher blood level for optimum effect.

Some menopausal women and physicians get caught up in using blood tests in an attempt to “mimic nature.” One of the advantages of menopause is that you can avoid mimicking nature. By bypassing some of the monthly hormonal fluctuations that are necessary to trigger ovulation and insure reproductive ability, the menopausal woman can avoid the negative symptoms such as PMS that are associated with those wide fluctuations.

Another concept that one sometimes hears about, is the need for pretreatment assessment of hormone levels. There are a number of pitfalls that should be avoided.

Women who appear to be menopausal by cessation of their menses, and women who are nearing menopause but still menstruating, may have “normal” blood levels, but still be experiencing severe menopausal symptoms. It is not appropriate to use blood levels as the sole indication to treat or not to treat a patient The reason for their symptoms in the face of “normal” blood levels is that their systems are struggling to maintain their hormone levels. If their hormones are replaced, their systems are relieved of this responsibility and the symptoms usually abate.

If a woman has had her ovaries removed, there is no reason to measure hormone levels prior to treating heras there is no longer a source for their production. Regardless, if it is her wish, the testing should be done.

So, the measurement of blood levels is a useful tool in insuring that HRT substances are actually getting in the bloodstream. However, it should never be used as the sole determinant of dosage. One should never loose sight that a level that is appropriate and optimal for one woman, is not appropriate for all women.

Dr N

Dr N:

Two weeks ago I had a hysterectomy with ovaries removed. It was an emergency surgery for abnormal bleeding. I am 48 years old. Due to some blood clots in my legs I can not take HRT for at least 6 months. I am looking for some reliable books to read about my situation. Which books would you recommend and what do you think about alternative HRT? In mean time I am searching for the best solution for me concerning estrogen replacement.

I would like to get your opinion on it, for there a lot of herbal and dietary supplements for estrogen. I also would like to get your opinion on weather should I go to doctor’s prescribed estrogen after 6 months, or should I stay on “natural” ones, that are obtained in health food stores or through internet adds.

I have no other health problems.
Dr. N thank you so much.

Reply:

Hi,

This is a problem, that puts you in a difficult situation.

As, you have had your ovaries removed, there has been a dramatic fall in your sex hormone levels. The long-term negative affects in terms of quality of life and longevity are well recognized.

One of the risk factors for blood clot formation is having an abdominal or pelvic surgery, so this may explain the reason for your clot formation as opposed to something in your system making you more susceptible to this problem. On the other hand, having previously developed a clot in the veins of your legs might make them more susceptible to further similar episodes. In addition, there are some inherited disorders of blood coagulation that may cause irregular vaginal bleeding and still increase the incidence of clot formation.

What to do?

It might be reasonable to consult with a hematologist to see if you have any type of coagulation disorder. However, although this is possible, you probably do not. However, I would still consider looking in to it.

As far as HRT for you, look at it this way. The degree of hormone deficiency that you are now exposed to will almost certainly have a negative impact on your quality of life and your health. In view of this HRT seems reasonable for you, as you may not have any further problems with clot formation. I would choose one of the non oral forms of replacement, such as a patch, as this method is likely to have less potential for altering the clotting mechanism. You need to discuss this thoroughly with your physician.

The over-the-counter herbal products and dietary estrogen preparations do not offer any significant reduction in menopausal symptoms or provide protection from the long-term negative affects of hormone deprivation.

Let me know what and how you do.

Dr N

Dr N:

Hi, discount I am a 36yr old female. I am going to a total hysterectomy with removal of my ovaries in less than two weeks. I have to admit I am really scared about this surgery. I have had endometriosis for several years. It is now at the point where I am in pain more than not. I am ready for the surgery, here but scared at the same time. I hear some women say it is the best thing that they have done. What has me scared is the HRT. My doctor wants to start me on estrogen after the surgery, site but he has not said anything about testosterone. Is this not something that is automatically part of your HRT? I have a very patient and understanding husband who is also concerned about the effects of surgery and HRT. Do you start on HRT right after surgery? How soon after starting HRT do you see effects? I have read so much and am now confused. I have read some the emails from your “Hysterectomy and Happy” site. I hope I will be in this category.

Thank you for your time.

Reply:

Hi,

It is a frightening prospect. Any surgery would be, but when you superimpose the hormonal considerations, it is even more disturbing.

I can’t say what other Dr’s would do, but I would start the HRT as soon as possible following the surgery. Some Dr’s delay HRT for a while, following surgery for endometriosis. Their rationale is that it lowers the possibility of a reoccurrence, although my own feeling is that does not make a difference. Either there is endometriosis left behind, or there is not.

Some Dr’s give an injection at the time of surgery or even put a patch on the patient when their done. I know some physicians in England that drop hormone pellets in the subcutaneous tissue before they close the incision. My own preference is to offer testosterone to any woman who does not have ovaries.

Discuss these issues with your Dr and see what he says.

Let me know what happens.

Dr N

Dr N:
Although I am grateful that I am basically a healthy individual, I am very distressed (and so is my partner) at the fact that my libido has dramatically declined. I had a complete hysterectomy about 12 years ago due to fibroids. I have been given since that time .625 milligram estrogen. Although I feel otherwise healthy and look much younger than my age – I am very concerned. One of the problem is that my clitoris has lost just about any sensitivity. Is there any hope to revert this condition. I used to be hot to trot but it’s all gone.
Hopeless

Reply:
Hi,
It is not unexpected that you are feeling the way that you are. In fact I have had a number of women tell me very similar things over the years and not surprisingly, most of them have had their ovaries removed. In short, you likely require a more appropriate HRT program, including some testosterone. I have addressed this in the area of the web site, Sex and Menopause, and Sex and Libido with HRT.
If you have not read these sections of the web site, it is important to do so as they may provide some insight.
If the an appropriate HRT program is instituted, your chances of regaining your sexuality, including your clitoral sensitivity, are close to 100%. A program of this nature would include testosterone and at least for hypothetical reasons, avoid the oral route. When estrogen is given orally, the level of SHGB, (Sex Hormone Binding Globulin), in the blood becomes elevated. SHGB binds to testosterone, leaving less available to exert its positive affect on sexually involved tissues and libido.
If your physician is unable to do this for you, find another one. Your quality of life is too important to do otherwise.
Let me know what and how you do.
Dr N

Doctor N,
Your site is great! It answers a lot of questions and is filled with great information.I have some additional questions.
Do you only need HRT if you have had a hysterectomy or are going through menopause?
Can reduced libido be a VERY early symptom of menopause?
I am a 35 year-old female. I am married now for 9 years and have been with my husband for 15 years. We have always enjoyed a very active sex life. About a year ago, I started having reduced libido. I didn’t notice it at first. My husband only recently brought it up and I am now devastated. What I thought was just busy lives is really just my reduced interest. I would very much like to have this interest back. Reading your site, I see that there may be some hormonal things going on. I brought it up to my doctor, and she wants to do a psych evaluation on me. I don’t think that is the answer. I have a great job, a great marriage and a wonderful new home. My life is happy and relatively stress free except for the stress of no interest in sex.
Some additional info about me; I have no children and have been on Lo Ovral for 18 years. My mother started menopause at about age 45. Are there more questions you have for me that would allow you to help me more? I’ll be glad to answer them.
Will there be a way you can me direct to someone who can help? Is there any over the counter (i.e. herbal) remedy that will work?
Thank you in advance for any information you can give me.

Reply:
I am glad that you like the site and I appreciate your comments.

Do you only need HRT if you have had a hysterectomy or are going through menopause?
• This a personal decision. All post menopausal women are by definition hormonally deficient and will continue to be so.
Can reduced libido be a VERY early symptom of menopause?• It can be, but in your case it is more likely related to your oral contraceptive. This is a common side effect and is due the “first liver” pass of oral contraceptives inducing the liver to produce elevated levels of a substance (SHGB) which binds to testosterone and leaves less available to support your libido and the effect of the oral contraceptive reducing the production or ovarian testosterone.
I would read the section of the web site, Sex & Libido With HRT, as this addresses this issue.
Although I cannot be certain, I would think that based on the information you have shared with me that this is a more likely explanation than a psychiatric problem. Your doctor may not be aware of this side effect of oral contraceptives.
I think that you have 2 reasonable options to consider. (1) You could just stop the oral contraceptives for a few months and you would likely have a return of your libido if this is the cause of the problem. You would have to use an alternate method of contraception during this time and if you did not resume the oral contraceptives. (2) You could add some testosterone to your regimen and see if this is of help. I would use a non-oral approach if you do this preferably a transdermal testosterone gel.
You should discuss these issue with your doctor and I would be interested to hear what she says.
There is no herbal remedy that I know of that would be of help.
I hope that this information is of help to you as you are obviously distressed about this.
Dr N

Dear Doctor, salve
Two weeks ago I had a hysterectomy, which the Doctor left my ovaries. Six days after surgery I began to have night sweats, which occurred every hour on the hour. I had been put on premarin, due to the fact that my ovaries may not be functioning. Last Wednesday I went back to the doctor to say that this was not helping me. He then put me on estratest. As of last night I still have continued to have night sweats. I am to the point that I do not know what to do. In four weeks I have to go back to work, and I cannot imagine being up all night and trying to put in a full day. I was wondering if there were any suggestion?
I read in your literature provided that a blood test should be performed to determine if it is even my ovaries functioning or could it be my thyroid? I would appreciate any information you could provide me with because to no avail, nothing else has worked. One more thing, I forgot to mention that I am 43 and this was an emergency surgery.

Reply:
Hi,
It sounds as if you are very uncomfortable. It is not at all uncommon for ovaries to fail following hysterectomy and there is a section of the web site that addresses this issue specifically. It is called Ovarian Failure Following Hysterectomy and you should read it carefully.
As far as a blood test is concerned, even if the results are normal, it does not matter. The point is that you are having significant symptoms and this is an indication that your ovaries are failing. As you mention, there is the possibility that this may be a thyroid problem, but although this should be tested for, it is an unlikely cause, given your recent surgery.
If the Estratest does not relieve your symptoms soon, I would consider changing to a non oral form of HRT, such as a transdermal patch or gel. If you use the gel, you will have to obtain it from a compounding pharmacy, such as College Pharmacy and they can be contacted through the link on my “links” page. If all else fails, subcutaneous hormone implants rarely fail to relieve symptoms.
Dr N