Question 65

47 year old woman with problems adjusting to HRT following a hysterectomy

Dear Doctor N:

I am 8 weeks post op (hysterectomy and bilateral oopherectomies for enlarging complex ovarian masses that were benign, 47 years old, history of myomectomy and adenomyosis and chronic anemia, family history of ovarian cancer). My surgeon put me on a Climara patch .05mg post op and saw me at two weeks post op. I was doing reasonably well then, and he discharged me back to my family doctor. Week 3 & 4 I began to have night sweats but my most disturbing symptom was onset of depression (which I had never experienced) with overwhelming feelings that I wished that I had had cancer so I could just die. I did not feel myself at all, and I also felt my thinking was very fuzzy. I was still taking motrin prn for pain (I had stopped narcotics after 7 days post op). My family doctor saw me at 4 weeks post op and immediately increased my estrogen by adding estratest full strength once daily at bedtime, and estrogen vaginal cream daily for 2 weeks. Within 24 hours I felt much better. What a relief. However, about a week after I stopped the cream I started to feel depressed again, and realized that the depression came when my patch was due to be changed. Changing the patch helped somewhat but I still didn't feel as well so I added a second patch. Since then I feel "back to normal" and my thinking is also clear again. I am so relieved because I was afraid I would never feel like myself again.

I have a few questions:

1. Am I on too much estrogen? 2 Climara patches .05 mg plus estratest daily
2. Should I switch to all oral estrogen since the patch seems to lose potency before 1 week is up? Or should I cover the patch when I shower and avoid baths? Right now I am planning to change the patches at different times so one will always be less that 4 days old.
3. My libido is still diminished so should I try two estratest tabs daily and quit the patch? (My doctor said the estratest patch does not stick well - that is why she put me on the oral dose.)
4. Do you have any other suggestions? I don't have any negative side effects from the estrogen that I'm aware of (no breast tenderness or nausea).

Thank you for listening

Reply:

I am sorry that you are having this problem.  A few thoughts from my own point of view:

• It is very unlikely that you are receiving too much estrogen, however, if this is a concern, ask your doctor to take a blood test to measure the levels.
• Whenever possible always choose non oral therapies such as a patch over oral therapy such as the tablet. The rationale for this is detailed in the 5 part section, How to find a HRT program that works for you and doesn't cause side effects. The first part has been posted and you can access it from its link on the Main Menu of the home page. http://www.DrN4U.com
• As you have suggested, change the patch twice a week instead of once as you may be very sensitive to falling levels of estrogen. You can also use the 0.1 mg strength as this is the same dose as 2 of the 0.5 mg.
• I believe you would be better off if you just add some non oral testosterone replacement, such as a testosterone gel, or subcutaneous hormone implants to what you are taking, or consider one of the other non oral options. Look at the section, Methods of Hormone Replacement Therapy and Ask Dr N question 52 for more about this. There will also be specifics about this in the new 5 part section.
• The more of the information you read in the web site that addresses Hysterectomy and HRT issues , the more enabled you will be to make appropriate decisions about your HRT program. Discuss these issues with your physician.

I hope that this of help and please let me know how you do.

Dr N