Abstract
Surgical menopause (bilateral oophorectomy) is commonly undertaken during a hysterectomy to treat various medical conditions. Menopausal symptoms can be particularly severe due to the sudden loss of ovarian function. This clinical toolkit is intended to guide healthcare professionals caring for women undergoing surgical menopause. Women commonly experience vasomotor symptoms, sexual dysfunction and an increased risk of cardiovascular and osteoporotic disease. Compared with a natural menopause, loss of libido can be more pronounced following a surgical menopause. Hormone Replacement Therapy (HRT) plays a significant role in managing surgical menopause, especially in women aged under 45 years old. All women undergoing surgical menopause should have adequate counselling regarding the hormonal consequences of surgery and the role of HRT with a view to provide individualised, patient-centred care.
Key Points
Surgical menopause (bilateral oophorectomy) is commonly undertaken during a hysterectomy to treat various medical conditions Menopausal symptoms can be particularly severe due to the sudden loss of ovarian function in both pre/post-menopausal women, although current evidence characterising this is limited Vasomotor symptoms, sexual dysfunction, increased risk of cardiovascular and osteoporotic disease and loss of fertility are some common consequences Libido loss can be more prominent than in a natural menopause HRT (Hormone Replacement Therapy) plays a significant role in managing surgical menopause, especially in women <45 years old (provided there are no contraindications such as personal history of hormone dependant cancer) All women undergoing surgical menopause should have counselling and be provided with information about the hormonal consequences of surgery and the role of HRT, both before surgery and before leaving hospital, with clear communication to the primary care team
What is surgical menopause?
Surgical menopause is the removal of both ovaries (bilateral oophorectomy) before a woman goes through biological menopause. 1
Menopause is a physiological state in a woman’s life that occurs at the end of her natural fertility, resulting in a loss of menstrual cycles. Around the ages of 45–55 years, the ovaries stop producing mature oocytes, which in turn affects the normal menstrual cycle, leading to reduced levels of oestrogen and progesterone. Natural menopause is usually defined by at least 12 months of amenorrhoea, along with various characteristics including vasomotor, psychological, and sexual symptoms. 2 The duration and intensity of symptoms can vary significantly between patients; hence, a tailored, individualised approach is recommended. Menopause usually occurs naturally; however, it can be induced either chemically (using pharmacological treatments) or surgically for various reasons.
Indications for surgical menopause
Bilateral oophorectomy is usually performed due to either benign or malignant underlying pathology, often at the time of hysterectomy. 1 In particular, women who are carriers of the BRCA 1 or 2 mutations are at significantly higher lifetime risk of developing breast or ovarian cancer and may undergo bilateral salpingo-oophorectomy as risk-reducing surgery.
Common consequences of surgical menopause
Management of surgical menopause
Use a holistic approach when counselling women, including lifestyle measures. Current guidelines state all women <45 years old undergoing surgical menopause should be offered HRT until age 51, unless there are contraindications to treatment such as a personal history of hormone-dependant cancer. Oestrogen-only HRT can be used in women without a uterus (hysterectomy). Women retaining their uterus MUST receive combined oestrogen and progesterone combinations to reduce the risk of endometrial carcinoma. Further treatment or treatment in post-menopausal women should be reviewed based on symptoms.
Women should be offered treatment by menopause specialists if required, especially younger women who require long-term (>5 years) symptom management.
8
Lifestyle interventions
Diet, reducing caffeine and alcohol Exercise Smoking cessation Blood pressure management Optimal glucose and lipid control Psychological support including cognitive behavioural therapy
Pharmacological interventions
HRT (either oestrogen-only or combined oestrogen/progesterone preparations): In BRCA carriers swap to non-hormonal at age 50/51 yrs Including Tibolone (licensed for endometriosis) Topical vaginal oestrogen pessary/cream, vaginal DHEA Testosterone gel or implant Selective serotonin reuptake inhibitors (SSRIs), clonidine or gabapentin Alternative therapies e.g. red clover, black cohosh
Hormone Replacement Therapy (HRT)
Benefits associated with HRT are as follows: Vasomotor symptom relief: HRT reduces vasomotor symptoms in most women, although symptoms may persist in younger women and require higher doses of oestrogen. Discontinuation of HRT can result in a recurrence of vasomotor symptoms. Libido: Tibolone can be helpful for women with low libido due to some androgenic activity. It may also be used in women with endometriosis who have had a hysterectomy and bilateral oophorectomy but may have some endometriosis deposits remaining.8 Topical vaginal oestrogen, dehydroepiandrosterone (DHEA) and supplemental testosterone can be used to treat vaginal dryness/atrophy and reduced libido respectively if necessary.
9
Bone: HRT reduces the risk of osteoporotic fragility fractures and might improve muscle mass and strength.
10
,
11
Cardiovascular disease: Hormone replacement is likely to lower the long-term risk of cardiovascular disease associated with surgical menopause.
12
Dementia: HRT is likely to improve cognitive function and lower the risk of dementia in younger women who have had a surgical menopausal
13
Risks associated with HRT include
2
,
14
: Venous thromboembolism: risk is increased with oral HRT but not increased from baseline with transdermal preparations. Women with an increased baseline risk (including BMI >30 kg/m2 should be offered transdermal HRT) A perceived risk of HRT is breast cancer. However, data suggest that women <50 years on HRT do not have an increased risk of breast cancer.
15
A recent meta-analysis published in The Lancet suggested that women <50 years who were post-menopausal and on HRT had an increased risk of breast cancer. The control group, of age-matched post-menopausal women, however, was inappropriate as an early menopause reduces breast cancer risk. The population for comparison should have consisted of age-matched normally cycling women.
16
The consensus statement issued from the BMS states that women aged <50 years using HRT do not have an increased risk of breast cancer.
For women undergoing surgical menopause due to endometriosis
8
: - Continued combined oestrogen/progesterone HRT is advised following hysterectomy in women who have widespread endometriosis to reduce the risk of stimulation and malignant transformation of endometrial deposits. - Changing to oestrogen only at a later date due to a better safety profile can be considered but must be balanced with the risk of reactivating endometriosis and potential malignant transformation of endometrial deposits. - HRT should be reviewed and suspended if symptoms recur.
In summary, surgical menopause can have significant consequences both short term and long term. Clear information and advice should be provided both before and after surgery to both the patient and her primary care team.
Footnotes
Author Contributorship
Both authors contributed to the development of the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Guarantor
Both authors act as guarantors for the work.
