Here is a lecture given in March at Sibley Hospital by Drs. Marilyn Jerome and Tara Abraham.
The video looks at the data regarding the risks and benefits of hormone replacement therapy. It discussed the options, and alternatives. Click on the link to view the lecture.
Should I have a hysterectomy, or are there other options?
Perhaps is was suggested that you consider a hysterectomy for heavy bleeding or fibroids. These problems are very common in women in their late 30’s and 40’s. You should know that there are non-surgical options that can control symptoms and avoid a major surgical procedure.
First of all, anyone with abnormal bleeding or a pelvic mass should be evaluated. Although uterine cancer is rare in women before the age of 50, a pelvic sonogram and/or an endometrial biopsy can evaluate the uterus and ovaries and decrease that concern.
Heavy menstrual cycles can be controlled often by using oral contraceptives. Birth control pills are very safe for women in their 40’s if they are not smokers or hypertensive. Birth control pills will manage the irregularity of the intervals between cycles that occurs in peri-menopause, and
markedly decrease the amount of flow. Additional benefits of oral contraceptives are that the pills can eliminate some of the hormonal irregularity of the peri-menopause which can cause hot flashes, mood changes, and insomnia.
If heavy bleeding is the issue, an IUD containing progesterone will often make the menstrual bleeding very light or absent, while also providing contraception. The progesterone IUD lasts for 5 years, and is inserted easily in the office.
Minor surgical procedures can also control heavy bleeding. A uterine ablation is a procedure that cauterizes the endometrial lining, so that bleeding is markedly reduced. Most often the procedure is performed in the hospital, but some doctors perform this in the office. A hysteroscopy and D&C (dilation and curettage) may be performed at the same time to evaluate the endometrial cavity. The results are permanent and should be performed after childbearing is completed.
If you have fibroids that are in the uterine cavity, a procedure can be done that resects these fibroids. There are several devices that shave off the portion of the fibroid which is in the cavity, and if most of the fibroid can be removed, bleeding can be markedly reduced. This procedure is most often done in the hospital as a same-day surgical procedure, and the recovery is minimal. Most patients would be able to go back to work in a day or two.
If you have large fibroids and they are causing symptoms of heavy bleeding or pressure on other organs, a minimally invasive procedure, a uterine artery embolization, can be done by a radiologist. The uterine artery is catheterized through a vessel in the groin, and the uterine artery is blocked by small pellets that block the vessels that supply blood to the fibroids. The result is that the blood supply to the fibroids is cut off, and the tissue undergoes necrosis or cell death. Most patients need pain killers for several days, but the size of the fibroids decrease over the next several months, and menstrual bleeding is often much decreased.
Although each case is individual and a physician who performs gynecologic procedures can help you decide which procedures are applicable to your situation, it is important to know your options so that you can make an informed decision.
Marilyn C. Jerome, MD
Foxhall OB-Gyn Associates
Genitourinary syndrome of menopause (GSM) is defined as symptoms of vaginal dryness, painful intercourse, vulvar discomfort, urinary frequency and urgency, incontinence, and increased frequency of bladder infections. These symptoms are caused by the thinning of the estrogen sensitive tissues of the vagina after menopause, due to the lack of estrogen in these tissues. The most effective treatments for these symptoms are topically applied vaginal estrogen products. Women who are at risk for breast cancer or who have had breast cancer are often very reluctant to use any products that contain estrogen, even if the dose is small.
The North American Menopause Society along with the International Society for the Study of Women’s Sexual Health have collaborated to review the literature in this area and have developed a consensus statement to guide physicians regarding the safety of prescribing vaginal estrogen for women who are at high risk for developing breast cancer, or who have already had breast cancer.
There are over 3 million breast cancer survivors in the US. Many survivors experience GSM symptoms, and often at a younger age because of treatments which decrease estrogen. It is important to discuss these symptoms with your health care provider and know your options. Some clinicians are reluctant to treat patients because of the lack of data that assures safety in particular populations.
In approaching the discussion with your physician, begin by noting your symptoms: vulvovaginal burning and dryness, painful intercourse, inability to have penetration, urinary frequency and urgency, incontinence, and increased frequency of urinary tract infections. Your physician should examine you to determine if there are any conditions such as a vaginal infection or inflammation that could lead to these symptoms.
Next, consider breast cancer risk which can be determined by several models that can be easily calculated. For women who are breast cancer survivors, consideration for risk of recurrence should take into consideration factors including the time since diagnosis, stage and grade of disease,
hormone receptor status, use of aromatase inhibitors, severity of GSM symptoms and their effect on quality of life. Consultation with your breast cancer oncologist should be included in decision making.
Here are the options for treatment:
1. Vaginal moisturizes are used for symptoms of dryness and must be used frequently and independently of intercourse.
2. Lubricants are used during intercourse to reduce pain from penetration and friction. The ideal lubricant has the same pH and osmolality of the vaginal tissue and should not include parabens, flavors or scents, glycerin and spermicides that can be irritating.
3. Vaginal dilators in graduated sizes can be used to maintain the caliber of the vagina and stretching of the tissues.
4. Vaginal vibrators can be used independently or with other sexual activity.
5. Pelvic floor physical therapy can relieve pain from pelvic floor muscle spasm and vaginismus (involuntary muscle spasm of the vagina which makes penetration difficult).
6. Vaginal estrogen can be inserted as a cream, pill or vaginal ring. Because of the difference in products, methods of administration, amount of cream administered and site of administration (lower vagina vs. upper vagina), and the quality of the vaginal tissue (thinner vaginal epithelium is more absorptive than thicker tissue), the amount of systemic absorption varies. Observational studies including data from the Women’s Health Initiative have not shown any evidence of an increased risk of breast cancer in women who used vaginal estrogens. One study did not find an increased risk of recurrent breast cancer in women who used vaginal estrogen products after the diagnosis of breast cancer. The message here is that the available evidence is reassuring, but in making a decision, risk should be considered.
7. Vaginal DHEA, prasterone, has shown evidence of improvement in sexual function. The suppositories are used daily, at least in the first month of use. The DHEA is converted to estrogen and testosterone in the body, although the levels are small and in the postmenopausal range, the difference is significant. It has not been tested in breast cancer survivors.
8. SERMs: Ospemifene if a selected estrogen receptor modulator which acts like estrogen on the vaginal tissue. It is an oral table taken daily. It is not approved in the US for use by women with breast cancer, and its effect on breast tissue has not been studies.
9. Topical lidocaine 4% applied to the vaginal opening prior to penetration can reduce pain, but it can also reduce sensation.
10. Vaginal testosterone can be compounded for use as a vaginal gel, but is not FDA approved. Testosterone is converted to estrogen in the body, and there is evidence that use of vaginal testosterone increases serum estrogen levels.
11. Estriol is considered a weaker estrogen produced in women during pregnancy. It can be compounded but is not FDA approved and there is not data to determine its safety in patients with breast cancer.
12. Vaginal lasers are now being used to improve the integrity of the vaginal epithelium.The effect of the vaginal laser is to increase vascularization of the vaginal epithelium which increases lubrication with sexual excitation. It also increases the thickness of the vaginal epithelium as well as increased collagen and elastic fibers in the submucosa.Studies in breast cancer survivors demonstrated significant improvement in GSM symptoms and improved sexual function.
As with other medical conditions, an evaluation with a gynecologist is the best way to evaluate risks and determine which treatment is appropriate for your individual situation.
Consensus Recommendations: Management of genitourinary syndrome of menopause in women with
or at high risk for breast cancer: consensus recommendations from the North American Menopause
Society and the International Society for the Study of Women's Sexual Health,
Menopause. The Journal of the American Menopause Society, Volume 25, No. 4, 2018