Question 9 - Hysterectomy, Exams Following

Dear Dr. N.,

Just happen to find your web-site and found it very helpful! But! I never seem to hear of anyone who has a similar case to me. So here goes-February 1983 (age 33) I had a total hysterectomy a specialist here in California saved my life & seemed stunned to find "myxomatous leiomrosarcoma". I am 49 yrs and I have been taking premarin 1.25 since. Current Dr. insists I need a pap smear before refilling my premarin prescription- well I don't understand-Why since it's all gone!

Also I am interested in finding alternative to Premarin and especially finding out if there is a way a Dr. can determine the hormone levels in me. Current Dr. is a GP and I've only been to him 1x. He seems to be good. He diagnosed my husbands diabetes before it was confirmed with tests! Perhaps you could shed some light on my situation. When off Premarin (like right now) I suffer from emotional upsets, hot flashes & lack of sleep. Any info is greatly appreciated.

Thanks (Instant Menopause at 33) in California

Reply:

Hi ,Sorry you are having problems.

First, I’ll try and give you an answer as to why your physician may think it’s necessary for you to have an examination.

Yes, your uterus and ovaries may be gone, but continued pelvic examinations are necessary for good medical care. It is my practice to schedule patients for yearly pap smears and pelvic examinations even if they had previously had undergone a hysterectomy.

The pelvic exam is a helpful part of assessing the effectiveness of your HRT program and monitoring you for any reoccurrence of your malignancy or complications of the surgery. Even in situations where the hysterectomy is done for non-malignant problems, routine scheduled exams are valuable. An inspection is made at the time of the exam for any abnormalities of the labia and vagina, including malignant and non-malignant tumors and any skin or mucous membrane problems. The presence of any bulging of the bladder (cystocele) or rectal structures (rectocele) visible in the vagina is noted and addressed if indicated.

A pap smear is very important as vaginal cancer, although uncommon when compared to cervical cancer, is possible. Unfortunately, as you are well aware, uncommon malignancies may not be common ...but they do occur.

The "manual" part of the pelvic exam even in the absence of the the uterus and ovaries, remains valuable for detecting abnormalities of the remaining structures in the pelvis. This would include the bladder, pelvic walls and a portion of the bowel. The digital rectal exam which is a good idea to perform at this time is important for detecting abnormalities of the anal or rectal tract within the reach of the examining finger, including hemorrhoids, fissures and malignancies. A specimen of stool if present at the time of the examination can be collected and tested immediately for the presence of blood. If the stool tests positive, this may indicate a problem of the gastrointestinal tract and a further investigation is in order.

A breast exam should be done during this appointment and mammogram scheduled if indicated.

A blood pressure measurement should be taken at this time and any changes noted and followed up if necessary. Weight should be determined and any unusual gain or loss addressed.

It is true that many of these things can be done by other physicians that the patient is seeing. But, for some, this is the only physician contact that they have and the only opportunity to be survailed for conditions that are health and life threatening. Some physicians may suggest that certain exams need not be done routinely or should be done less frequently. Often, this recommendation is made on the basis that the exam is not "cost effective". Simply put, a determination has been made that the expense-benefit-ratio in their view does not justify doing the test routinely. If you are the one who ends up with the medical problem, this concept may not seem so reasonable to you.

Addressing your hormone questions

There maybe no benefit to have your hormone levels determined right now while you're off HRT. You said you had a "total hysterectomy", by which I believe you mean your ovaries were removed as well as the uterus. This being the case, your levels of biologically active estrogen and testosterone are so low that they probably are not detectable. The ovaries, the source of estrogen production are gone and although some testosterone-like hormone is produced by the adrenal gland, I have found the levels of both hormones usually undetectable.

Ovarian removal at a pre menopausal age is an endocrinological catastrophe. The fall in the levels of estrogen and testosterone is abrupt and for all practical purposes complete. The effect on those women who are without the benefit of HRT is often devastating in terms of life-altering symptoms and long-term consequences of sex hormone deficiency on health, quality of life and longevity. This potentially is very real and I encouraged my own patients who fell in this catagory to try to never be without HRT. After ovarian removal many women will not respond to the more routine HRT programs and may need a more individualized regimen of HRT. Be sure and read the Menopausal Symptoms, Hormone Deficiency, and Methods of HRT pages of the website as they will provide some additional information that may be useful to you with regard to additional HRT options.

Please let me know how you're doing.

Dr N