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Treatments

Introduction

In premature ovarian failure, the ovaries are no longer producing adequate levels of oestrogen, an important hormone.  Oestrogen is important for bone and cardiovascular health as well as general well-being.   

The body makes many hormones and, in general, when a hormone is lacking it needs to be replaced. For example, an under-active thyroid gland is treated with thyroid hormone and diabetes is treated with insulin.  In the same way, oestrogen can be used for premature ovarian failure.  Many of the symptoms of premature ovarian failure, such as hot flushes and night sweats, can be effectively treated with oestrogen.

The ovary makes oestrogen, progesterone and some of the ‘male’ hormone, testosterone and the amount of all three produced after menopause declines dramatically. Oestrogen and progesterone are prescribed in a variety of combinations tailored to suit the needs of the woman to alleviate her particular symptoms and to protect bone density.

It may be necessary to work through several different types of hormone replacement therapy (HRT), before you find the one that is right for you, so be prepared to make changes with time. HRT was originally designed for older women and women with premature ovarian failure may need higher than average doses of oestrogen. For example, double the standard doses are sometimes required.  This is not harmful - it is just that a young woman's body may need more oestrogen than an older woman. It is also possible to prescribe each component of HRT separately and thus to tailor the mix of oestrogen, progesterone and testosterone to the individual’s requirements.

Why Oestrogen And Progesterone?

Oestrogens are used in HRT to alleviate menopausal symptoms such as hot flushes, night sweats and vaginal dryness. As regards osteoporosis, oestrogen can improve bone density and prevent bone loss, although how far the bone is strengthened varies greatly.

Progesterone has a very clearly defined role and must be given to all women receiving oestrogen who have a uterus or womb. The reason for this is that oestrogen used on its own can cause cancer of the endometrium and this danger disappears when progesterone is given.

Progesterone is given either in monthly or 3-monthly cycles (to produce monthly or 3-monthly bleeds), or continuously, in which case there will be no periods.  All women who have not had a hysterectomy (womb removed) need to take progesterone with any form of oestrogen except low-dose vaginal preparations, in order to prevent build-up of the lining of the womb which can occur if oestrogen is taken alone.

Continuous progesterone (continuous combined HRT) is only suitable for women who have not had a period for at least a year, as otherwise break-through bleeding will occur.  The HRTs which cause periods are called cyclical HRTs.  Progesterone is generally provided as part of an HRT - in a tablet or patch.  It can also be prescribed separarely.  Another way of giving it is via the Mirena intra-uterine system, which sits inside the womb and last for 5 years.  Women using the Mirena generally get either light periods or none at all, but irregular spotting can be a problem, especially in the first 3-6 months.

Do I Need Testosterone?

The ovary makes about half of the supply of testosterone – the other half comes from the adrenal gland. Some women find that lower testosterone levels reduce their sex drive and their energy levels. Up to half of the women with premature menopause may benefit from testosterone therapy. Testosterone replacement is available in the form of implants, tablets, gel, injections or patches. Testosterone treatment only causes excess hair growth and acne if used in too high a dose; for this reason its use needs to be monitored so that it is merely replacing what would have normally been produced by the ovaries. It is something to discuss with your specialist if you are suffering from a low libido or persistently low energy levels in spite of adequate oestrogen replacement.

Different Types Of hormone replacement therapy (HRT)

Combined HRT

Tablets and patches are forms of combined (oestrogen and progesterone together) HRT. Using combined HRT usually involves taking a form of oestrogen continuously and progestogen for 10-14 days of every month, these may be in a calendar pack similar to the pill. When the progestogen is finished a period or withdrawal bleed will occur, however these are often lighter than previously experienced.

Continuous Combined HRT

Continuous combined HRT involves taking both hormones everyday without breaks. In theory, therefore, no monthly bleeds should occur. However, it may be 2-3 months before they disappear and, in younger women, spotting or bleeding may be a persistent problem and regular withdrawal bleeds may be preferable.  Continuous combined HRT is not suitable for women who have recently experienced premature ovarian failure or who are still having irregular periods as break-through bleeding will occur.

Natural And Synthetic

A lot of literature about HRT talks about the difference between natural and synthetic forms of oestrogens. The term ‘natural’ is somewhat misleading as you are not putting fresh human oestrogen into your body whichever formula you take.

A simplistic analogy is orange juice on sale in supermarkets – whatever we buy whether it is fresh, from concentrates etc - is it actually the same as squeezing the oranges yourself? No!

Natural

The following are a few examples of ingredients that may be listed in the contents of your HRT:

  • Oestradiol valerate
  • Micronisedoestradiol
  • Piperazine oestrone sulphate

Tablets containing oestradiol, oestriol, and oestrone are often called ‘natural’ oestrogens as they contain or give rise to chemicals that are the same as the oestrogens found naturally in women; as before they enter the blood stream they pass through the gut and the liver and have been converted to oestrone. See Hormones .

Conjugated equine oestrogens are contained in the two preparations listed below:

  • Premarin
  • Prempak-C

These are also described as ‘natural’ as the oestrogen in the urine of pregnant mares is very similar to that in women. Is the way that this is farmed natural? This is something that you need to make up your own mind about.

Synthetic

The following substances are so-called synthetic hormones:

  • Dienoestrol
  • Ethinyloestradiol
  • Mestranol

These are known to be more potent than natural oestrogens. They are largely used in the contraceptive pill as they are strong enough to stop pregnancy which HRT is not.

Progestogen

Progestogens are usually made from plant sources and resemble progesterone, which is produced by the ovary in the second half of the menstrual cycle. The two main types of progestogen used in HRT are those which more closely resemble progesterone C21 e.g. dydrogesterone and medroxyprogesterone acetate and those derived from testosterone C19 e.g. norethisterone, norgestrel and levnorgestrel.

C19 progestogens can give rise to more side effects such as mood swings, depression, headaches and breast tenderness.

C21 progestogens convert into progesterone.

Oral Preparations

Tablets

Tablets are the most commonly prescribed form of HRT. Tablets come either as oestrogen alone, if you have had a hysterectomy, or oestrogen and progestogen combined. There are many different preparations available and many different doses. The dose listed on the packet is likely to be in milligrams. Tablets contain higher doses than patches as they have to pass through the gut and the liver which reduce the active amount the body receives. For many of us, tablets are familiar, convenient and discreet. They must be taken daily but are easily kept in your handbag if you travel a lot. For others though, tablets can be a daily reminder of a medical condition they would rather forget about.

Be aware that you may experience breast tenderness and nausea. If you forget to take a pill, there could be breakthrough bleeding.

The Contraceptive Pill

All oral contraceptive pills contain ethinyloestradiol, a strong synthetic oestrogen designed to prevent ovulation, and so they have often been used as HRT in young women. Oral contraceptive pills are, however, stronger than natural oestrogens and probably carry a higher risk of blood clotting (thrombosis) than occurs with oestradiol valerate or conjugated oestrogens. For many women with an oestrogen-deficiency, oral contraceptives may be unnecessarily strong for use as HRT. More importantly, oral contraceptives provide oestrogen for only three weeks in every four – the fourth week being ‘pill-free’. For women who are oestrogen-deficient, the lack of oestrogen during this pill-free week can cause symptoms and it seems more appropriate to provide oestrogen continuously as with most forms of HRT.

The Pill can be obtained free of prescription charges. Psychologically for teenage girls the pill may be a more acceptable form of replacing oestrogen as it doesn’t have the stigma of old age that HRT may have. For women in their teens and early twenties, taking the Pill may make them feel more in touch with their peer group. On the flip side, taking the Pill for women in their 30’s could be a stark reminder of their loss of fertility.

Non-oral Preparations

Non-oral preparations (also known as Parenteral Systems) do not have to be broken down by the liver, a process known as first pass metabolism. These preparations are, therefore, often favoured for women with diabetes, epilepsy, gallstones or kidney disease.

Patches

Patches are clear plastic squares that are applied from below the waist to the top of the thigh. Generally speaking, the higher the dose the larger the patch. They are changed once or twice a week on regular days.

Patches allow oestrogen to be slowly absorbed through the skin providing a more gradual and, therefore, natural release than a tablet.

Patches are particularly useful for women with liver disease or raised triglyceride levels which are associated with diabetes. They also have fewer side effects than the tablets, so if you have problems with tablets you may want to give patches a try.

Be aware using patches may lead to an allergic reaction to the adhesive or to skin irritation.

Gel

Not commonly prescribed for women who have experienced a premature menopause. Oestrogel works in the same way as patches, through the skin. The gel is rubbed onto the underside of the upper arms or legs or lower body. It must be allowed to dry and the area must not be washed or have other lotions applied to it for at least an hour. Skin contact must also be avoided during that time so applying at night while lying next to your partner is not advisable.

Implants

Implants involve a minor procedure, whereby the implant is inserted beneath the skin of the abdomen or buttock approximately once every six months. However, if you decide to stop taking HRT or the dose is incorrect, implants can be difficult to remove. On the positive side, once implanted you can pretty much forget you are on HRT. If you decide to have implants, you should ensure that blood tests are taken before a new one is inserted. This is due to the fact that the take up of the oestrogen in the blood stream varies from woman to woman and over prescription may lead to tachyphylaxis, a form of oestrogen dependence or addiction. Progestogen tablets will also be needed.

Creams And Pessaries

These are not usually used alone for premature menopause, they are used primarily to relieve vaginal dryness and itchiness. They do not, however, protect against osteoporosis nor do they help alleviate hot flushes and night sweats. A plastic applicator, a bit like a syringe, delivers a measured dose of oestrogen cream into the vagina.

These preparations raise the levels of hormones locally and do not affect the whole body. They are useful for women who can not take systemic HRT.

It is not uncommon to still experience vaginal dryness in spite of being on adequate oestrogen replacement.  This can cause discomfort and pain on intercourse.  If you are in this situation it is worth trying a vaginal cream or tablet.

Vaginal Ring

This is a synthetic ring impregnated with oestrogen which is inserted into the upper third of the vagina and worn for 3 months at a time. This can cause discomfort.

Alternative Therapies And Herbal Remedies

Alternative Therapies

HRT is not the only method of helping to:

  • control premature menopausal symptoms
  • limit the risk of osteoporosis
  • reduce the risk of heart disease

There are a number of vitamins, herbs and other nutrients that can help you manage your early menopause.

Warning: Always consult your doctor before taking any alternative therapies or supplements. There are many preparations available and you should investigate the pros and cons of taking them as you would with HRT.
Always remember that although some preparations may help with hot flushes, they will not protect your bones from osteoporosis or protect against cardiovascular disease.
Some herbal remedies have strong oestrogenic properties and, as such, may not be suitable for you if you are unable to take oestrogen for other medical reasons.
Note: For more information on this subject an Alternative Therapies Fact Sheet is available.

Phytoestrogens

Phytoestrogens are plants and foods that have either plant-based oestrogen or precursors to oestrogen in them, such as soy, red clover, flaxseed and alfalfa. They act as a balancing agent where oestrogen is concerned, boosting levels and thus relieving menopausal symptoms such as hot flushes and vaginal dryness. Food sources are:

  • soy
  • lentils
  • chick peas
  • kidney beans
  • garlic
  • celery
  • seeds (such as linseed, sesame, pumpkin etc)
  • grains
  • fruit
  • vegetables
  • sprouts (such as alfalfa)
  • some herbs and spices (cinnamon, sage, red clover and hops).

Soy

Eating soy products seems to be a healthy choice. Japanese women suffer fewer menopausal symptoms than their Western counterparts and this is thought to be due to the large amount of soy in their diet. Soy is widely available in many different forms as an alternative to dairy and meat products. As well as helping to eliminate menopausal symptoms, soy can also help reduce the risk of heart disease and cancer (particularly breast cancer). When choosing soy products, you may wish to go for organic produce where possible, as otherwise it could be genetically modified, and it may be best to eat it as traditionally eaten rather than as textured vegetable protein or such like.

Flaxseed (also Linseed)

Flaxseed contains another source of phytoestrogens called lignans. Although lignans are found in other foods such as beans, rye, fruit and vegetables, linseed has an exceptionally high concentration. A tablespoon a day is all you need. However, if you buy linseeds, you will need to grind them before sprinkling on food to obtain the nutrients. Like soy they also contain essential fatty acids. Flaxseed is good for lowering cholesterol, reducing the risk of heart disease and breast cancer, as well as alleviating menopausal symptoms.

Red Clover

Rich in phytoestrogens, red clover is taken as a supplement to help alleviate menopausal symptoms. This should not be taken at the same time as HRT.

Herbal Remedies

Black Cohosh

Relieves hot flushes, night sweats and vaginal dryness.

Evening Primrose Oil

Contains essential fatty acids. May benefit women who suffer from breast tenderness as a result of taking HRT.

Sage

Can relieve hot flushes and night sweats. Can be taken in the form of a tea.

St John’s Wort

Do not take this without consulting your doctor. Effective treatment for depression, sleep problems and anxiety.

Dong Quai

Often used for hot flushes.

Siberian Gingseng

Believed to increase oestrogen levels, boost energy and vitality, and reduce anxiety and tension.

Chaste Tree

Also known as Agnus Castus this is a strong but slow acting herb, to be used with care. May be useful for hot flushes and mood swings.

Wild Yam

Often confused with natural progesterone, wild yam roots can be used as a hormone balancer.

Vitamins and Minerals

Vitamin D

Essential for healthy bones as it helps the body absorb calcium. An estimated 15 minutes of sunshine (without sun tan lotion!) is all that is required. Other sources are eggs, milk, mackerel and fortified margarines.

Vitamin E

May help to reduce vaginal dryness and hot flushes. Sources include wholegrain cereal and rice, nuts and egg yolks.

Calcium

Calcium is a must in the prevention of osteoporosis. What you eat can make a huge difference to your bone health since calcium, whether in the form of low-fat dairy products, dark-green leafy vegetables or nuts, is vitally important for bones. Current UK government recommendations are that perimenopausal and postmenopausal women should not allow their calcium intake to fall below 1500mg per day (1 pint of semi-skimmed milk contains 750mg). Again you may wish to choose organic produce when choosing dairy products. See fact sheet on Osteoporosis.  More information is also available on the National Osteoporosis Society website www.nos.org.uk

Note: For more information on this subject an Osteoporosis Fact Sheet is available.

Zinc

Important for the immune system. The body is not able to store Zinc and its absorption is lowered by taking hormones. Helps Vitamin D to absorb calcium. Sources are seafood, eggs, green vegetables and pumpkin seeds.

Magnesium

Important for bone health and good for sleep problems. It is just as important as Calcium in the prevention of osteoporosis. Sources are apples, seeds, nuts and dark-green leafy vegetables.

Other resources

The following websites & Publications offer useful information:

Marilyn Glenville's website contains useful sections on menopause and osteoporosis written by Marilyn, a leading nutritionist who is also a patron of The Daisy Network.

The National Institiute of Health - dietary supplements website this is an American website which will enable you to search for supplements so that you can make informed choices.