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Practice patterns with hormone therapy after surgical menopause

      Abstract

      Objectives

      To describe practice patterns with hormone therapy (HT) in women after a surgical menopause and to describe their experience of hot flashes and other menopausal symptoms.

      Methods

      This was a cross-sectional chart-review with telephone follow up interview of women between the ages of 20 and 50 years who had a hysterectomy and bilateral salpingo-oophorectomy (BSO) before menopause at an academic teaching facility in Edmonton, Canada between December 1, 2006 and November 30, 2007.

      Results

      Seventy women were interviewed. Mean respondents age at surgery was 44.3 (±5.2) years and mean time since surgery was 10.2 (±3.8) months. Twenty-eight women (40%) were started on HT after surgical menopause; 23 (33%) were still taking HT at the time of the interview. Estrogen therapy (ET) was the only HT prescribed in all instances, with over half the women on transdermal estrogen at time of the interview and 70% on ET doses equivalent to 0.625 mg conjugated estrogens. Women not taking HT were more likely to experience daily hot flashes (74% vs 30%, p = 0.006) and to classify them as moderate or severe intensity (57% vs 47%, p = 0.033). Night sweats and difficulty sleeping were reported equally in both groups.

      Conclusions

      Over 2/3rd of women were not on HT after a surgical menopause and many of these women were still having daily hot flashes. Targeted patient education prior to surgery or at discharge may help improve the management of menopausal symptoms and long term health consequences in women after a surgical menopause.

      Keywords

      1. Introduction

      Hysterectomy with bilateral salpingo-oophorectomy (BSO), also known as a surgical menopause, is associated with a rapid drop in sex hormone levels, leading to menopausal symptoms such as hot flashes, decreased libido, depression, and vaginal dryness [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • Wild R.
      Introduction to special issue on surgical menopause.
      ,
      • Gallicchio L.
      • Whiteman M.K.
      • Tomic D.
      • et al.
      Type of menopause, patterns of hormone therapy use, and hot flashes.
      ]. These symptoms, particularly vasomotor symptoms, tend to be more frequent and severe as compared to women with natural menopause. [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • Wild R.
      Introduction to special issue on surgical menopause.
      ,
      • Gallicchio L.
      • Whiteman M.K.
      • Tomic D.
      • et al.
      Type of menopause, patterns of hormone therapy use, and hot flashes.
      ].
      Several studies have shown that early menopause, from either BSO or natural causes, has been associated with low bone mineral density and an increased risk of fractures [
      • Gallagher J.C.
      Effect of early menopause on bone mineral density and fractures.
      ,
      • Melton L.J.
      • Khosla S.
      • Malkasian G.D.
      • et al.
      Fracture risk after bilateral oophorectomy in elderly women.
      ]. Observational studies have also shown that early menopause may be associated with an increased risk of coronary heart disease, and there may be a greater risk in women with BSO as compared to natural menopause [
      • Melton L.J.
      • Khosla S.
      • Malkasian G.D.
      • et al.
      Fracture risk after bilateral oophorectomy in elderly women.
      ,
      • Rossouw J.E.
      • Prentice R.L.
      • Manson J.E.
      • et al.
      Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause.
      ,
      • Rivera C.M.
      • Grossardt B.R.
      • Rhodes D.J.
      • et al.
      Increased cardiovascular mortality after early bilateral oophorectomy.
      ,
      • Lokkegaard E.
      • Jovanovic Z.
      • Heitmann B.L.
      • et al.
      The association between early menopause and risk of ischaemic heart disease: influence of hormone therapy.
      ,
      • Allison M.A.
      • et al.
      Oophorectomy, hormone therapy, and subclinical coronary artery disease in women with hysterectomy: the Women's Health Initiative coronary artery calcium study.
      ]. Furthermore, surgical menopause, especially at an early age, can lead to increased dementia or cognitive impairment [
      • Wild R.
      Introduction to special issue on surgical menopause.
      ,
      • Rocca W.A.
      • Bower J.H.
      • Maraganore D.M.
      • et al.
      Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause.
      ].
      Due to the onset of menopausal symptoms and the increased risk for osteoporosis and cardiovascular complications in early menopause, many premenopausal women undergoing BSO will require hormone therapy (HT) unless there are contraindications. HT is often continued until the average age of menopause (51 years) [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • North American Menopause Society
      Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
      ,
      • Haney A.F.
      • Wild R.A.
      Options for hormone therapy in women who have had a hysterectomy.
      ,

      British Menopause Society Counsel Consensus Statements. Premature menopause; 2007.

      ]. Unfortunately, there are no clear guidelines describing the use of HT in women after surgical menopause [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • Haney A.F.
      • Wild R.A.
      Options for hormone therapy in women who have had a hysterectomy.
      ]. Higher doses of HT are often required for symptom relief; however current studies describing doses required in surgical menopause are lacking [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • North American Menopause Society
      Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
      ,
      • Haney A.F.
      • Wild R.A.
      Options for hormone therapy in women who have had a hysterectomy.
      ].
      The publication of the results of the Women's Health Initiative (WHI) hormone therapy trials caused much confusion on the overall risk of HT [
      • Writing Group for the Women's Health Initiative Investigators
      Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principle results from the Women's Health Initiative randomized controlled trial.
      ,
      • The Women's Health Initiative Steering Committee
      Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial.
      ]. Even though it was a primary prevention trial targeting older, post-menopausal women who were not symptomatic, the confidence of women and health care professionals with using HT for menopause symptoms was reduced, after the WHI. It is recommended that the results not be extrapolated to younger, symptomatic women or those with early menopause [
      • North American Menopause Society
      Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
      ]. However, studies have shown changing attitudes and practice patterns with HT since the WHI, in menopausal women, including those with surgical menopause [

      US Department of Health and Human Services Food and Drug Administration. Non-contraceptive estrogen drug products for the treatment of vasomotor symptoms and vulvar vaginal atrophy symptoms recommended prescribing information for health care providers and patient labelling; 2005.

      ,
      • Langenberg P.
      • Kjerulff K.H.
      • Stolley P.D.
      Hormone replacement and menopausal symptoms following hysterectomy.
      ,
      • Parente L.
      • Uyehara C.
      • Larsen W.
      • et al.
      Long-term impact of the women's health initiative on HRT.
      ,
      • Hersh A.L.
      • Stefanick M.L.
      • Stafford R.S.
      National use of postmenopausal hormone therapy: annual trends and response to recent evidence.
      ,
      • Buist B.S.
      • Newton K.M.
      • Miglioretti D.L.
      • et al.
      Hormone therapy prescribing patterns in the United States.
      ,
      • Silverman B.G.
      • Kokia E.S.
      Use of hormone therapy, 1998–2007: sustained impact of the Women's Health Initiative Findings.
      ].
      This study was undertaken to identify current practice patterns with HT in women who have undergone surgical menopause. Our objectives were to determine the proportion of women started on HT after surgical menopause and to describe their experience of hot flashes and other menopausal symptoms.

      2. Methods

      2.1 Participants

      This study targeted women, between the ages of 20 and 50 years who had undergone a surgical menopause at an academic teaching facility in Edmonton, Canada. Women were included if they had a hysterectomy and bilateral salpingo-oophorectomy (BSO) between December 1, 2006 and November 30, 2007. The timeframe was chosen to ensure each woman was interviewed at least three months after her surgery to allow sufficient time for women to have started on therapy for symptom relief. Women were excluded if they had a previous diagnosis of early or premature menopause by non-surgical (e.g. natural) means prior to surgery, or were unwilling or unable to participate in the phone interview or did not speak English. Natural menopause was defined as spontaneous cessation of menses for 12 months prior to surgery. The study was approved by the University of Alberta Health Research Ethics Board.

      2.2 Design

      This was a cross-sectional chart review with telephone follow-up. Women who had a hysterectomy and BSO at the study facility were identified using ICD-10 intervention codes for hysterectomy and BSO (1RM89* or 1RM91*) and (1RB89* or 1RD89*). Data collected in the chart review included demographics, medical history, date of surgery, physician, indication for surgery, smoking and alcohol use, medical conditions, contraindications to HT, prior HT use and HT prescribed on discharge. Body mass index (BMI) was calculated as weight/height2 (kg/m2). Indication for surgery was defined as the diagnosis documented in the discharge summaries.
      Women meeting inclusion criteria were sent an information letter outlining the study, and request for permission to contact them to complete a brief telephone interview. Patients were contacted by telephone two weeks later to carry out the interview and verbal informed consent was obtained at that time. All telephone interviews were conducted by one of the investigators who was a pharmacy resident at the time of the study. The telephone interview consisted of a 20-item questionnaire capturing the frequency and intensity of hot flashes, as well as other menopausal symptoms such as night sweats and trouble sleeping. In addition, current HT use, formulation and dose, when HT was started in relation to surgery, changes to HT products since surgery or refusal to use HT by the patient were also determined. Intensity of hot flashes was captured as mild (sensation of heat without sweating); moderate (hot flashes with a sensation of heat and sweating) or severe hot flashes (sensation of heat, with sweating, with cessation of activity). These definitions are derived from the Food and Drug Agency (FDA) recommendations for capturing hot flashes and are similarly used in other studies [
      • Gallicchio L.
      • Whiteman M.K.
      • Tomic D.
      • et al.
      Type of menopause, patterns of hormone therapy use, and hot flashes.
      ,

      US Department of Health and Human Services Food and Drug Administration. Non-contraceptive estrogen drug products for the treatment of vasomotor symptoms and vulvar vaginal atrophy symptoms recommended prescribing information for health care providers and patient labelling; 2005.

      ]. Women were identified as being prescribed HT if it was recorded in the patient chart, discharge summary or self-reported by the patient during the telephone interview. HT dosing was converted to the approximate equivalent of conjugated estrogen (CE) dose for comparison [
      • North American Menopause Society
      Prescriptional hormone therapies.
      ].

      2.3 Data analysis

      The primary outcome of the study was the proportion of patients started on HT (e.g. estrogen, progesterone and/or androgen therapy) after surgical menopause. Secondary outcomes include the type and dose of HT initiated, when HT was initiated, frequency and severity of hot flashes, experience of other menopausal symptoms, use of other medications for hot flashes and characteristics of women most likely to receive HT.
      Summary statistics were used to describe the extracted data and characterize the cohort. Chi-square or Fisher's exact tests were used for discrete variable and t-tests for continuous variables to compare the characteristics of women who received HT after surgical menopause with those who did not. A stepwise logistic regression with adjustment for physician correlation using generalized estimating equation was completed to identify patient characteristics associated with receipt of HT, with the dependent variable being receipt of HT and independent variables being patient characteristics including age, time since surgery, BMI, indication for surgery, and use of other medications for hot flashes. A univariate analysis was initially completed, for each variable. Covariates were considered for inclusion in the multiple logistic regression if they were associated with receiving HT (p < 0.1) in the univariate analysis. Analysis was performed using SPSS version 15.0. A p-value of less than 0.05 was considered to be statistically significant.

      3. Results

      Between December 2006 and November 2007, 177 women were identified as having undergone a hysterectomy with BSO at the study site. Of these, 108 women met the initial screen and were sent information letters about the study. Another 9 women were identified as not meeting the inclusion criteria during the telephone interview and were excluded. In total, 70 (71%) women agreed to participate in the telephone interview (Fig. 1). The most common reasons for exclusion were not being able to reach the women (27 patients).
      Respondent characteristics are outlined in Table 1. The mean age of the respondents at the time of surgery was 44.3 years (range 26–50), the mean time since surgery was 10.2 months (range 4–13), and the most common reason for surgery was uterine leiomyoma (34%). The majority of women were non-smokers (70%) and nearly half had a BMI ≥ 30 (44%).
      Table 1Characteristics of women interviewed.
      CharacteristicN = 70
      Age, mean ± SD (range), y44.3 ± 5.2 (27–50)
      Time since surgery, mean ± SD, m10.2 ± 3.8
      BMI, mean ± SD, kg/m229.8 ± 8.1
      Smoker, n (%)21 (30)
      Indication for surgery, n (%)
       Uterine leiomyoma24 (34)
       Endometriosis11 (16)
       Malignancy10 (14)
       Prophylaxis2 (3)
       Other
      Other includes endometrial hyperplasia, ovarian cyst, pseudomyxoma peritonei, menorrhagia/dysmenorrhea, chronic pelvic pain, cervical dysplasia.
      23 (33)
      Medical history, n (%)
       Hypertension10 (14)
       Hypothyroid10 (14)
       Diabetes6 (9)
       Dyslipidemia6 (9)
       Venous thromboembolism2 (3)
       Migraines2 (3)
       Coronary artery disease (CAD)1 (1)
       Cerebrovascular disease (CVD)1 (1)
       Gallbladder disease1 (1)
       Depression12 (17)
      a Other includes endometrial hyperplasia, ovarian cyst, pseudomyxoma peritonei, menorrhagia/dysmenorrhea, chronic pelvic pain, cervical dysplasia.

      3.1 Hormone therapy

      Twenty-eight women of the 70 women interviewed (40%) were prescribed HT after surgical menopause and 23 women (33%) were still taking HT at the time of the interview. Three women had also been offered HT but had decided against using HT and thus never received a prescription. Half of the women (n = 14) were prescribed HT at discharge from the hospital, with 9 (32%) prescribed at or within 6 weeks after surgery, and 5 (18%) more than 6 weeks after surgery. Of the 5 women who were no longer on HT, 2 women had received a prescription for HT but never started and 3 stopped taking HT because they felt it was not necessary. Of the women still taking HT, the median time for women to start HT was 3 days after their surgery; however there was a wide range from 1 to 181 days. Hormone therapy use among the respondents is detailed in Table 2. Estrogen therapy (ET) was the only HT prescribed in all instances, with over half the women prescribed transdermal estrogen (52%). The most common dose for ET use was equivalent to 0.625 mg of conjugated estrogen (CE) (70% of women). After starting HT, 9 women (32%) required a change in product, and 9 (32%) required changes in dose.
      Table 2Hormone therapy (HT) use by women.
      VariableN = 70
      Women prescribed HT, n (%)28 (40)
      Women on HT at time of interview, n (%)23 (33)
      When HT was prescribed
       Before discharge from hospital, n (%)14 (50)
       ≤6 weeks after surgery, n (%)9 (32)
       >6 weeks after surgery, n (%)5 (18)
      Type of HT: n (% of women still on)
       Oral11 (48)
       Patch4 (17)
       Gel8 (35)
      Doses of HT used
      Includes venous thromboembolism, breast and endometrial cancer.
       0.3 mg, n (%)3 (13)
       0.625 mg, n (%)16 (70)
       0.9 mg, n (%)1 (4)
       1.25 mg, n (%)3 (13)
      a Doses of HT calculated by using approximate equivalent to conjugated estrogens: 0.625 mg conjugated estrogens = 1 mg oral 17β-estradiol, 50 mg estradiol patch, 2 pumps estradiol gel (1.5 mg estradiol)
      • North American Menopause Society
      Prescriptional hormone therapies.
      .
      Characteristics of women using and not using HT are reported in Table 3. Overall there were no significant differences noted between the two groups. Five women in the non-HT group were identified as having contraindications to HT (venous thromboembolism, breast and endometrial cancer). Of the respondents, 4 (14%) in the HT group and 7 (17%) in the non-HT group reported using other medications (antidepressants, clonidine, gabapentin) for hot flashes. The multivariable analysis showed no significant association between patient characteristics and HT use.
      Table 3Characteristics associated with hormone therapy use.
      CharacteristicsWomen prescribed HT n = 28 (%)Women not prescribed HT, n = 42 (%)p
      Age, mean ± SD, y43 ± 545 ± 50.13
       <40 y8 (29)4 (10)
       40–45 y6 (21)10 (24)
       >45 and ≤50 y14 (50)28 (66)
      Time since surgery, mean ± SD, m9.7 ± 3.810.6 ± 3.80.35
      BMI, mean ± SD, kg/m229.7 ± 8.130.4 ± 8.30.9
      Current smoker8 (29)13 (31)0.88
      Indication for surgery0.23
       Uterine leiomyoma10 (36)14 (33)
       Endometriosis7 (25)4 (10)
       Malignancy2 (7)8 (19)
       Prophylaxis02 (5)
       Other9 (32)14 (33)
      Contraindications to hormone therapy
      Includes venous thromboembolism, breast and endometrial cancer.
      05 (12)0.078
      Other medications for hot flashes
      Includes antidepressants, clonidine and gabapentin.
      4 (14)7 (16)0.58
      Herbals3 (11)6 (14)0.73
      a Includes venous thromboembolism, breast and endometrial cancer.
      b Includes antidepressants, clonidine and gabapentin.

      3.2 Menopausal symptoms

      The presence of menopausal symptoms, including hot flashes, according to HT use is characterized in Table 4. Overall, 56 women (80%) reported having hot flashes. Women not on HT were more likely to report hot flashes as compared to women on HT (87% vs 65%, p = 0.031). In addition, hot flashes in women not on HT were more likely to be daily (74% vs 30%, p = 0.006) and the intensity classified as moderate or severe (57% vs 47%, p = 0.033). Night sweats and problems with sleep did not differ significantly between both groups.
      Table 4Association of menopause symptoms and hormone therapy use after surgical menopause.
      VariableWomen taking HT, n = 23 (%)Women not taking HT, n = 47 (%)p
      Chi-square or Fisher's exact tests.
      Women reporting any hot flashes15 (65)41 (87)0.031
       Daily hot flashes7 (30)34 (73)0.006
       Moderate to severe hot flashes11 (48)28 (59)0.033
      Other symptoms n (%)
       Night sweats10 (43)26 (55)0.35
       Sleeping problems10 (43)21 (45)0.95
      a Chi-square or Fisher's exact tests.

      4. Discussion

      We found that only 40% percent of women were prescribed HT after a surgical menopause, with the majority prescribed either at discharge or within the first 6 weeks of surgery (82%). The number of women still on HT had declined to only 33% by the time the interviews were completed, a mean 10 months after surgery.
      This is in sharp contrast to other published studies from North America which have reported much higher HT use rates (87–89%) after surgical menopause [
      • Gallicchio L.
      • Whiteman M.K.
      • Tomic D.
      • et al.
      Type of menopause, patterns of hormone therapy use, and hot flashes.
      ,
      • Langenberg P.
      • Kjerulff K.H.
      • Stolley P.D.
      Hormone replacement and menopausal symptoms following hysterectomy.
      ]. However, these studies were completed prior to publication of the WHI in 2002, and may be a reflection of the practice patterns at that time. Since the WHI, there has been a considerable decline in the worldwide use of HT, even after surgical menopause [
      • Parente L.
      • Uyehara C.
      • Larsen W.
      • et al.
      Long-term impact of the women's health initiative on HRT.
      ,
      • Hersh A.L.
      • Stefanick M.L.
      • Stafford R.S.
      National use of postmenopausal hormone therapy: annual trends and response to recent evidence.
      ,
      • Buist B.S.
      • Newton K.M.
      • Miglioretti D.L.
      • et al.
      Hormone therapy prescribing patterns in the United States.
      ,
      • Silverman B.G.
      • Kokia E.S.
      Use of hormone therapy, 1998–2007: sustained impact of the Women's Health Initiative Findings.
      ,
      • Parazzini F.
      Progetto Menopausa Italia Study Group
      Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997–2003.
      ]. Studies examining prescription rates in menopausal women have shown decreases in overall HT use by 28–50% [
      • Parente L.
      • Uyehara C.
      • Larsen W.
      • et al.
      Long-term impact of the women's health initiative on HRT.
      ,
      • Hersh A.L.
      • Stefanick M.L.
      • Stafford R.S.
      National use of postmenopausal hormone therapy: annual trends and response to recent evidence.
      ,
      • Buist B.S.
      • Newton K.M.
      • Miglioretti D.L.
      • et al.
      Hormone therapy prescribing patterns in the United States.
      ,
      • Silverman B.G.
      • Kokia E.S.
      Use of hormone therapy, 1998–2007: sustained impact of the Women's Health Initiative Findings.
      ]. Information from North America on HT practice patterns after the WHI specific to surgical menopause is limited; however in Italy, where HT use has been historically lower than in North America [
      • Manzoli L.
      • Giovanni P.D.
      • Duca L.D.
      • et al.
      Use of hormone replacement therapy in Italian women aged 50–70 years.
      ], HT use in women with surgical menopause dropped from 31% in 1997–1998 to 19% in 2002–2003 [
      • Manzoli L.
      • Giovanni P.D.
      • Duca L.D.
      • et al.
      Use of hormone replacement therapy in Italian women aged 50–70 years.
      ]. Another study from Taiwan conducted after the WHI showed a low rate of HT use after surgical menopause of only 31%. Personal choice was the number one reason cited for not being on HT [
      • Chen R.-J.
      • Chang T.-C.
      • Chow S.-N.
      Perceptions and attitudes toward estrogen therapy among surgically menopausal women in Taiwan.
      ]. The results from the Taiwan study are similar to the low HT use in our study (33%). To our knowledge, our study is the first from North America looking at practice patterns after surgical menopause since the publication of the WHI.
      In our study, women not taking HT were more likely to experience daily and moderate or severe hot flushes as compared to women taking HT. In fact, 74% of the women not on HT reported daily hot flashes. Hormone therapy, particularly estrogen therapy, is appropriate for women who experience moderate to severe hot flashes. As only 5 women had contraindications to HT, the majority of the women not on HT who were still symptomatic would have been candidates for HT.
      In addition, only half of the women less than 45 years of age were started on HT. More of these younger women could have benefited from the long term health benefits of estrogens. Recent evidence has suggested an increased risk of cardiovascular disease in women with BSO at a young age [
      • Rivera C.M.
      • Grossardt B.R.
      • Rhodes D.J.
      • et al.
      Increased cardiovascular mortality after early bilateral oophorectomy.
      ,
      • Atsma F.
      • Bartelink M.L.E.L.
      • Grobbee D.E.
      • van der Schouw Y.T.
      Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis.
      ]. Observational data suggests that women with BSO before age 45 may reduce their risk of cardiovascular disease and subclinical atherosclerosis with the use of ET [
      • Rivera C.M.
      • Grossardt B.R.
      • Rhodes D.J.
      • et al.
      Increased cardiovascular mortality after early bilateral oophorectomy.
      ,
      • Lokkegaard E.
      • Jovanovic Z.
      • Heitmann B.L.
      • et al.
      The association between early menopause and risk of ischaemic heart disease: influence of hormone therapy.
      ,
      • Allison M.A.
      • et al.
      Oophorectomy, hormone therapy, and subclinical coronary artery disease in women with hysterectomy: the Women's Health Initiative coronary artery calcium study.
      ]. As well, despite the increased risk of cardiovascular disease observed in the WHI hormone therapy trial in women treated with estrogen and progesterone, the same risk was not seen in the estrogen alone arm in women with a hysterectomy [
      • Writing Group for the Women's Health Initiative Investigators
      Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principle results from the Women's Health Initiative randomized controlled trial.
      ,
      • The Women's Health Initiative Steering Committee
      Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial.
      ]. A subgroup analysis of younger women (50–59) in this study showed a non-significant decrease in cardiovascular disease (HR 0.63; CI 0.36–1.09), suggesting there is a window of opportunity for women to be treated with HT after surgical menopause [
      • Rossouw J.E.
      • Prentice R.L.
      • Manson J.E.
      • et al.
      Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause.
      ]. Added to this, early menopause before age 45 is associated with lower bone mineral density and increased risk for fractures [
      • Gallagher J.C.
      Effect of early menopause on bone mineral density and fractures.
      ,
      • Melton L.J.
      • Khosla S.
      • Malkasian G.D.
      • et al.
      Fracture risk after bilateral oophorectomy in elderly women.
      ]. Surgical menopause has also been linked to an increase risk of overall death [
      • Parker W.H.
      • Broder M.S.
      • Chang E.
      • et al.
      Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study.
      ]. A recent report from the Nurses Health Study found that bilateral oophorectomy in women who had not used estrogen therapy before the age of 50 had a higher risk of all-cause mortality, primarily from coronary heart disease and lung cancer [
      • Parker W.H.
      • Broder M.S.
      • Chang E.
      • et al.
      Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study.
      ]. Even though at this time, it is unclear if estrogen therapy eliminates all of these risks, HT consultation discussing the efficacy and risks of HT would have been beneficial in our study population [
      • Hickey M.
      • Ambekar M.
      • Hammond I.
      Should the ovaries be removed or retained at the time of hysterectomy for benign disease?.
      ].
      A number of the women on HT continued to experience hot flashes (65%); however, these were reported to be less frequent as compared to woman not taking HT. It is plausible that the HT dose may have been inadequate to treat hot flashes for some of these women and may have required further adjustment. Surgical menopause may require higher doses of HT for effective symptom relief compared to natural menopause [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • Wild R.
      Introduction to special issue on surgical menopause.
      ,
      • North American Menopause Society
      Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
      ,
      • Reid B.A.
      • Gangar K.F.
      • Rogers V.
      • et al.
      Long-term results of bilateral oophorectomy for the treatment of chronic pelvic pain: relief of pain and special hormone replacement therapy requirements.
      ]. Over 80% of the women in our study were on ET doses (range equivalent to 0.3–0.625 mg CE) similar to the recommended starting doses for HT in natural menopause [
      • North American Menopause Society
      Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
      ]. Women on higher ET doses reported lower frequency and severity of hot flashes as compared to women on lower doses. Nevertheless, due to the small number of women on HT, we were unable to make any specific correlations between HT dose and symptoms.
      Non-hormonal therapies like clonidine, gabapentin, antidepressants, and herbal preparations were used by some women in our study. Some of these may be effective in decreasing vasomotor symptoms in women who cannot tolerate or safely use ET [
      • Reid R.L.
      • Blake J.
      • Abramson B.
      • et al.
      SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
      ,
      • Haney A.F.
      • Wild R.A.
      Options for hormone therapy in women who have had a hysterectomy.
      ]. Use of other medications for hot flashes was not associated with use of HT. The use of herbal products by 13% of women suggests that women were seeking relief from hot flashes and sought other alternatives or options that did not require a prescription.
      There are some limitations in this study. Firstly, there may be recall bias due to the retrospective nature of the study. However, other studies of women with surgical menopause have reported low levels of recall bias [
      • Chen R.-J.
      • Chang T.-C.
      • Chow S.-N.
      Perceptions and attitudes toward estrogen therapy among surgically menopausal women in Taiwan.
      ]. In addition, our study is limited by the quality of documentation in the medical charts. Even though some of the patient characteristics captured in the chart review were confirmed in the phone interview, not all were to keep the interviews focused. Another limitation is that women who agreed to participate in the study may have been more or less likely to be prescribed HT or experience hot flushes. Fortunately we had a high survey response rate (71%) from the women who met the inclusion criteria, suggesting that our study group may be a good representation of this patient population. Furthermore, we had a small sample size that may have influenced our results in correlating patient characteristics and HT use or HT dose with symptoms. As well, this cohort was recruited from only one academic teaching hospital; therefore the observed frequency of HT use may not reflect women in other practice settings. Additionally, a validated symptom tool to assess menopausal symptoms was not used in our study nor did we capture all lifestyle factors affecting vasomotor symptoms, such as physical activity. Since our survey was done over the telephone, any of the currently available tools may have been more difficult to administer.
      Finally our study was not set up to capture specific discussions regarding HT, which may have ensued between each woman and her physician. As HT initiation involves shared decision-making between the woman and her health care provider, better insight on this process may have been beneficial in understanding the use of HT after surgical menopause. Further studies in this area are needed.

      5. Conclusions

      Although HT can be beneficial in reducing vasomotor symptoms, as well as preventing cardiovascular disease and osteoporosis in women undergoing surgical menopause, the overall use of HT in this study was low. Over two-thirds of women were not on HT after a surgical menopause and many of these women were still having daily hot flashes at the time of the interview. Targeted patient education prior to surgery or at discharge may help improve the management of menopausal symptoms and reduce the occurrence of long term health consequences in women after a surgical menopause.

      Contributors

      Yuksel, Chubaty, Schuurmans, and Shandro participated in the conception and design of the study and analyses and interpretation of the data. Yuksel and Chubaty acquired the data and supervised the study. All authors critically revised the manuscript for important intellectual content and approved final version submitted to the journal. Yuksel had full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses.

      Competing interest

      None declared for Yuksel, Chubaty, Shandro, and Schuurmans.

      Funding

      No funding was received for this study.

      References

        • Reid R.L.
        • Blake J.
        • Abramson B.
        • et al.
        SOGC clinical practice guidelines: menopause and osteoporosis update 2009.
        J Obstet Gynecael Can. 2009; 31: S1-S46
        • Wild R.
        Introduction to special issue on surgical menopause.
        Menopause. 2007; 14: 556-561
        • Gallicchio L.
        • Whiteman M.K.
        • Tomic D.
        • et al.
        Type of menopause, patterns of hormone therapy use, and hot flashes.
        Fertil Steril. 2006; 85: 1432-1440
        • Gallagher J.C.
        Effect of early menopause on bone mineral density and fractures.
        Menopause. 2007; 14: 567-571
        • Melton L.J.
        • Khosla S.
        • Malkasian G.D.
        • et al.
        Fracture risk after bilateral oophorectomy in elderly women.
        J Bone Miner Res. 2003; 18: 900-905
        • Rossouw J.E.
        • Prentice R.L.
        • Manson J.E.
        • et al.
        Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause.
        JAMA. 2007; 297: 1465-1477
        • Rivera C.M.
        • Grossardt B.R.
        • Rhodes D.J.
        • et al.
        Increased cardiovascular mortality after early bilateral oophorectomy.
        Menopause. 2009; 16: 15-23
        • Lokkegaard E.
        • Jovanovic Z.
        • Heitmann B.L.
        • et al.
        The association between early menopause and risk of ischaemic heart disease: influence of hormone therapy.
        Maturitas. 2006; 53: 226-233
        • Allison M.A.
        • et al.
        Oophorectomy, hormone therapy, and subclinical coronary artery disease in women with hysterectomy: the Women's Health Initiative coronary artery calcium study.
        Menopause. 2008; 15: 639-647
        • Rocca W.A.
        • Bower J.H.
        • Maraganore D.M.
        • et al.
        Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause.
        Neurology. 2007; 69: 1074-1083
        • North American Menopause Society
        Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
        Menopause. 2010; 17: 242-255
        • Haney A.F.
        • Wild R.A.
        Options for hormone therapy in women who have had a hysterectomy.
        Menopause. 2007; 14: 592-597
      1. British Menopause Society Counsel Consensus Statements. Premature menopause; 2007.

        • Writing Group for the Women's Health Initiative Investigators
        Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principle results from the Women's Health Initiative randomized controlled trial.
        JAMA. 2002; 288: 321-333
        • The Women's Health Initiative Steering Committee
        Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial.
        JAMA. 2004; 291: 1701-1712
      2. US Department of Health and Human Services Food and Drug Administration. Non-contraceptive estrogen drug products for the treatment of vasomotor symptoms and vulvar vaginal atrophy symptoms recommended prescribing information for health care providers and patient labelling; 2005.

        • Langenberg P.
        • Kjerulff K.H.
        • Stolley P.D.
        Hormone replacement and menopausal symptoms following hysterectomy.
        Am J Epidemiol. 1997; 146: 870-880
        • Parente L.
        • Uyehara C.
        • Larsen W.
        • et al.
        Long-term impact of the women's health initiative on HRT.
        Arch Gynecol Obstet. 2008; 277: 219-224
        • Hersh A.L.
        • Stefanick M.L.
        • Stafford R.S.
        National use of postmenopausal hormone therapy: annual trends and response to recent evidence.
        JAMA. 2004; 291: 47-53
        • Buist B.S.
        • Newton K.M.
        • Miglioretti D.L.
        • et al.
        Hormone therapy prescribing patterns in the United States.
        Obstet Gynecol. 2004; 104: 1042-1050
        • Silverman B.G.
        • Kokia E.S.
        Use of hormone therapy, 1998–2007: sustained impact of the Women's Health Initiative Findings.
        Ann Pharmacother. 2009; 43: 251-258
        • North American Menopause Society
        Prescriptional hormone therapies.
        in: Menopause practice: a clinician's guide. 4th ed. North American Menopause Society, Mayfield Heights, OH2010: 9.12
        • Parazzini F.
        • Progetto Menopausa Italia Study Group
        Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997–2003.
        Menopause. 2004; 15: 164-170
        • Manzoli L.
        • Giovanni P.D.
        • Duca L.D.
        • et al.
        Use of hormone replacement therapy in Italian women aged 50–70 years.
        Maturitas. 2004; 49: 241-251
        • Chen R.-J.
        • Chang T.-C.
        • Chow S.-N.
        Perceptions and attitudes toward estrogen therapy among surgically menopausal women in Taiwan.
        Menopause. 2008; 15: 517-523
        • Atsma F.
        • Bartelink M.L.E.L.
        • Grobbee D.E.
        • van der Schouw Y.T.
        Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis.
        Menopause. 2006; 13: 265-279
        • Parker W.H.
        • Broder M.S.
        • Chang E.
        • et al.
        Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study.
        Obstet Gynecol. 2009; 113: 1027-1037
        • Hickey M.
        • Ambekar M.
        • Hammond I.
        Should the ovaries be removed or retained at the time of hysterectomy for benign disease?.
        Hum Reprod Update. 2010; 16: 113-130
        • Reid B.A.
        • Gangar K.F.
        • Rogers V.
        • et al.
        Long-term results of bilateral oophorectomy for the treatment of chronic pelvic pain: relief of pain and special hormone replacement therapy requirements.
        J Obstet Gynaecol. 1996; 16: 538-543