While these women will experience the same issues to do with choosing hrt as women in full surgical menopause, the need to keep their uterus healthy must also be taken into account and this will change their ultimate hrt options.
The crux of the issue is that exposing a uterus to estrogen stimulates the growth of the uterine lining or endometrium. In our fertile years, this stimulation is necessary to prepare the uterus to support a fertilized egg. When no pregnancy occurs, our hormone balance naturally cycles to cause our unused uterine lining to be shed in the form of menstrual flow, resulting in a period.
But when we no longer have ovaries to manage this cycling, uterine health becomes an issue. If we fail to shed that lining, it can build and build and over time, this unshed lining may turn to uterine cancer. Yeah, that's bad. It's so bad that it's a fundamental rule of hrt use that women with a uterus must include provisions in that hrt to prevent this from happening.
Like what? There are two basic strategies: we can artificially create a hormone cycle with our dosage pattern, thus causing the lining to shed in a period OR we can balance our hormones in such a fashion as to suppress that lining buildup in the first place. Let's look at both of these a little more closely.
Hormone cycling
This is the classic approach. We take an estrogen hrt for part of the month and add some sort of progestogen (progesterone or a synthetic version that acts like it) for a shorter time, often a week to ten days, to stimulate a period. Many women find this sort of cycle reassuring, since it mimics what they experienced in their fertile years. Many doctors prefer it because they feel that their patients do best with what they are accustomed to or that they are less likely to become confused keeping track of their hrt on a short schedule.
This kind of cycling does carry a cost, however. If you suffered through PMS or your monthly cycle of ups and downs with mood swings and bloating, maybe going on doing that doesn't sound all that appealing. Maybe you would be just as happy to make fewer trips down the feminine products aisle at the store and wear more white underwear without fear. Maybe you'd like to balance uterine protection with a little more comfort and freedom from that cycling.
There is nothing magical about monthly cycles once our ovaries aren't controlling things. Many women today have found that they only need to cycle a few times a year to preserve uterine health, either using oral contraceptives (while they are in their fertile years) or hrt (when they are post-fertile for whatever reason). A conservative schedule for this long-period cycling would be quarterly, although some women find that they can successfully go even longer without undue risk. So long as they are not having break-through bleeding (which indicates that their lining is building up beyond normal levels), they only take a progestogen every three or four months to produce a period. This requires that a woman keep track of her schedule so she doesn't go too long without that cycle and it requires that she use separate estrogen and progestogen hrts—neither of which are necessarily difficult to achieve. There will still be the same ups and downs of cycling and she'll still have periods, but they'll happen less often.
Is this strategy appropriate for all women? Not necessarily. Women with endometriosis, for example, may find that this is still too much estrogen stimulation. Women with cancer risks or metabolic disease or risk factors for blood clots may not be best served by this sort of a dosing scheme. This is one situation in which a woman needs to sit down with her doctor and consider carefully all of the factors that are involved in her use of hrt, not something to just wing on her own based on how she feels.
Continuous combined HRT
The other approach to uterine protection involves suppressing the growth of that uterine lining by continuously taking both estrogen and a progestogen. The lining never has a chance to grow, so there is no need to have a period to shed it. Hey, that sounds pretty good, doesn't it?
But there's a cost, and that cost might not suit every woman. In order to accomplish this, we must deliberately induce a hormone imbalance. We have to take more of that progestogen than we really have a need for otherwise to balance our hormones. Or, to put it another way, we need to have a deliberately progesterone-heavy balance.
For some women, that's not a problem: they're perfectly comfortable with a standard dose of any of the retail progestogens made for this purpose.
Other women, however, find this balance subjects them to an uncomfortable excess of progesterone effects. For them, then, the challenge is minimizing those effects while still getting the protection that their uterus needs.
And, finally, women are increasingly concerned about the risks of progestogen use that have been revealed in the past couple of decades of hormone research.
There is more than one way to approach this problem. If we are going to use a progestogen in a continuous, imbalanced manner, it's worth trying different progestogens to see if one is less unpleasant in this regard than another. Amongst the progestins, each one is very different in structure and characteristics and will act differently in the body, so if this is your choice, it may be worth auditioning a variety of them. Route may also make a difference, so even if your choice is progesterone itself, taking it via a different delivery route may also help you manipulate its effects.
But another way of dealing with this—and especially with the risks—is to maximize the impact of your progestogen on your uterus while minimizing it elsewhere. This is done by using a more local delivery, either via the vagina or the uterus itself. This way, the highest levels are experienced in the pelvic organs, where they're most needed, and less of that dose makes its way to systemic circulation. In fact, one source suggests that this can represent a pretty significant difference:
Furthermore, vaginal administration of micronized progesterone has been shown to enhance progesterone delivery to the uterus by about 10-fold in comparison to im injection, despite the markedly higher (about 7-fold) circulating drug concentration achieved with im injection.
Further, this technique is specifically cited by the International Menopause Society in their 2011 position statement as having particular merit.
Sound interesting? There are actually several different hrts that provide for local delivery. Prochieve is a progesterone gel specifically designed for vaginal use, but some women have reported successfully inserting a Prometrium gelcap vaginally and allowing it to be absorbed that way. Vaginal suppositories such as Endometrin are also available, as are versions that can be custom-made by compounding pharmacists. And Mirena is a progestin-releasing IUD that works directly in the uterus and so can get by with an especially low level of dosing.
We also have come across some interesting information that indicates that at least some progestins may be capable of transdermal delivery--something we probably could have put together before given that contraceptive and combined-hormone hrt patches aren't exactly new. That raises the question of whether certain of the progestin hrts meant for oral delivery could be used vaginally (at a suitably lower dose). We don't know the answer but it seems to be something that might be worth looking into if using a local progestin by other than IUD would be a woman's preference. More on that in this news discussion.
Will I have to do this the rest of my life?
No. You will, however, need to tailor your hrt for uterine protection so long as you take enough estrogen to stimulate your uterus.
Our hormone needs diminish with age. For that reason, it's a good practice when taking hrt in any form of menopause to challenge ourselves every few years to be sure that we're taking no more than we truly need to achieve the effects that we define as important. By trying out a slightly lower dose every 3-5 years, we can find out if our bodies have been slowly easing down in needs without us noticing.
In theory, we'll all, if we live long enough, reach a point where our hormone needs are low enough that we no longer need to supplement with hrts. What we produce ourselves plus what we take in from foods and environmental contaminants will fully meet our present needs. And when that happens, a woman is probably not stimulating her uterus enough to need to continue to provide progestogen protection for it. That's something to review with one's doctor, of course, but that's the expectation. Until that time, however, so long as we've got a uterus and are supplementing estrogen, we need that progestogen coverage as well.
How will I know I'm taking enough progestogen?
You won't. The general guideline is looking for spotting. This is taken to mean that your lining is growing enough that the progestogen isn't providing adequate suppression, whether you're taking it cyclically or continuously.
If, however, you have a high risk situation where you aren't comfortable waiting for this symptom to tip you off, there's another method for monitoring uterine lining response: ultrasound measurement of the thickness of the uterine wall.
There is not, regrettably, any magical formula for relative doses, such that if we take this amount of estrogen, we know we'll need that amount of progestogen and then we'll be sure we're safe. Or if we have this measured level of circulating estrogen, we need that level of circulating progesterone to cover it. Hormones don't behave in a simple relationship like that—there are many other factors that can affect our hormone supplies and relationships. We can't force our hormones to go where we want and do our bidding. What we can do is provide the supply and then watch carefully to see what happens. If what happens is no uterine lining shedding, no spotting, then we most likely have the situation covered. And if we don't, then a simple ultrasound will tell us how our uterus is doing and whether we just have a brief unusual situation or whether we need to tweak our doses.
Let's repeat that, because it's pretty important: the test of our hormones is not in what we want them to do, but in what they actually do. Results are the most reliable place to focus our vision.
So that's it?
Yeah, pretty much. Outside of protecting a uterus, a woman's other hrt needs are essentially the same as for a woman without a uterus: meeting her post-fertile needs as she defines them while exposing her to the least amount of risk possible. So the information on hrt-balancing that is covered elsewhere on this site is just as applicable to you as it is to the women in full surgical menopause.
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