HRT and Surgical Menopause

[brungerbulb]

Hi. I’ll be succinct this time, I’m looking to go through surgical menopause as soon as possible (there doesn’t seem to be any other tenable option to alleviate crippling dysphoria and PMDD) and I’m wondering how HRT will factor into this. From what I understand, post menopause women usually take their own type of HRT in the form of estrogen pills. I’ve also heard mentions that some women get orchiectomies because it takes away a lot of the testosterone that the gonads were producing. So I guess what I’m wondering is what will I need to do to maintain my hormone levels post-menopause? Will taking testosterone be enough or will I also need to take estrogen to account for the lack of it? I haven’t really had any luck googling this because of how specific it is, so I think anecdotal evidence has to be my best resource.

[Latha]

Hi there, Brungerbulb

Hold on, I want to make sure we're on the same page about the changes that you're looking for. I understand you want to alleviate dysphoria and PMDD. Could you tell us a bit more about your general transition goals? (Am I correct in understanding that you want to transition?)

About surgical menopause- by this, do you mean surgery to remove the ovaries? You also mentioned that you wanted a hysterectomy in a previous thread- is that still the case?

[brungerbulb]

Hi. The surgery I've looked into specifically is called a full hysterectomy, which involves removal of both ovaries, the uterus, and adjoining structures like the cervix. This produces an effect similar to naturally occurring menopause, which is why it's referred to as surgical menopause. The only other medical step I'm planning on taking transition-wise is going on testosterone, which I hope will be able to grant me changes I look forward to like an increase in body hair, deeper voice, and potentially bottom growth. I'm asking how removal of the ovaries might factor into this because my hormones have always been a major factor in my unstable mental health. An estrogen based endocrine system has failed to work for me my entire life. I'm wondering how my hormones will be processed once the ovaries are removed, since I understand those to be the main producer and processor of hormones in a surgically untouched body.

[Heather]

Hey there, brungerbulb.

So, the very best people for you to talk about this with is going to be your healthcare team, because they have all your medical records and will know things that I can't, and that you can know, but won't have the education and experience to be your own doctor in this capacity. And hysterectomies are something that generally will be considered a last resort, especially for someone so young, with PMDD and dysphoria, rather than an only option. You have a bunch of options, including hormone blockers, if estrogen and/or progesterone are the issues. This may be just one of them. I say may be because it is very, very unlikely a surgeon will okay a hysto for someone your age, and especially if there isn't a medical basis for it and other things haven't been tried first, and it also may be that this actually isn't the right thing for the issues at hand.

That said, having a full, or radical, hysto without any estrogen-based hormone therapy generally isn't a great ideas for anyone, especially someone as young as you are. It's so important for bone mass, for one, and yours won't be complete so early in puberty. It's also important when it comes to keeping your genital tissue, including the tissue around the urethra, robust instead of frail (in fact, even if someone doesn't use systematic HT after a hysto and/or starting T, topical estrogen is usually advised at a minimum to keep you from un-fun things like nonstop UTIs). Lastly, people who have full hystos without any estrogen HT on the other side tend to have a very hard time mental-health wise, especially people with histories of mood disorders like PMDD. (I hear you, though: I'm also someone whose sex hormones gave me a very hard time for decades of my life, and post-menopause myself, it is pretty clear that my hunch that my estrogen levels were just too high for my body was right, because I feel a lot better in a lot of ways now that it's much lower due to menopause.)

Have you already started using T? If not, that would be something generally advised for someone to start well before they have a hysterectomy, because that can start kind of tapering how your body works when it comes to testosterone, estrogen and progesterone. Starting T at the same time as a hysto or right after and also not using any estrogen would be roooooouuuugh going for anyone based on everything I know.

Looking at your post history, it doesn't seem like you've yet started with any gender-affirming healthcare. Do I have that right? If not, I'll circle back to what I said up top here: healthcare providers are going to be the best place to start when it comes to what you're asking. Community care, information services like ours and anecdata can be really useful for lots of things, but aren't the way to go for mapping out a whole medical transition well. For that, you need people working in this kind of care who have all of your very unique information at hand. If you need help finding that care, we can often help out. I'd say the same thing for some of the mental healthcare you're seeking here. You won't actually have had much estrogen (and no progesterone) for most of your life: the former only really starts gearing up once puberty begins and the latter only happens once a person has started ovulating. If you've been having issues since before puberty, your mental health issues may be more complex than just being about these hormones.

Too, to answer your question, the ovaries are not the main production system of all hormones in the body, the endocrine system is. That includes the hypothalamus and a whole bunch of glands: the pituitary gland, the pineal gland, the thyroid gland, the parathyroid glands, and the adrenal glands as well as the pancreas, ovaries and/or testes. The ovaries, however, are the main production source of estrogen and progesterone, specifically. Progesterone will eventually just go away without them, but the body does still produce some estrogens via body fat and the adrenal glands.

Happy to answer any questions, know that was a big info dump!

[brungerbulb]

Hi. I'll correct a point you made in mentioning that I am "early in puberty". I am not. I have been in puberty since I started growing pubic hair at eight years old, and had my first period at nine. I understand that puberty likely will not be ending for me any time soon, but that doesn't mean I've only just started. When I turn sixteen in a few months I will have spent half my life in puberty, and the wrong one at that. So please forgive me if nothing less than mutilation seems comfortable. I understand that "as soon as possible" likely means in a decade or more, but its something I need to tell myself is on the horizon to assure that I'm okay.

My doctors have never even mentioned hormone blockers to me. They've only prescribed me more estrogen in the form of birth control, and both doses have failed to work and resulted in a sort of permanent light flow period until the dose is upped again (I spent about three months bleeding brown the first time around. The second instance of this started about two weeks ago and doesn't appear to be stopping anytime soon, and even turned red at one point). I only recently pushed to get my hormone levels tested during a blood lab, but I haven't been told anything about the results so I assume they look like what should be normal.

I also researched if I should have been prescribed hormone blockers when I first started puberty. Apparently I was just old enough to deserve what happened to me.

[Sam W]

Hi brungerbulb,

There are a few things I want to address in your reply, both in terms of practical, more immediate elements and some bigger picture stuff.

On the practical end, in a previous post you mentioned you were in the process of trying to get onto testosterone. How has that progressed? I ask because you mention wanting to have something on the horizon to look towards to feel okay, and starting T is going to be available to you way, way sooner than any kind of surgical intervention. Too, how is your overall relationship with the healthcare providers you've been seeing? Do you feel like they listen to you, or like they're interested in collaborating with you to alleviate some of the issues you're facing? Or do you feel like you have to get angry or otherwise really lean on them to get help?

In terms of the bigger picture stuff, something that is really coming through in you post is anger; anger at your body, at the healthcare you have--or haven't--received, and even at Heather's response to you. You get to feel however you feel about all this, and you're understandably upset and frustrated by a healthcare system that's not all that great at dealing with one, let alone multiple, of the issues you're facing. But I do want to ask that you steer clear of language like "mutilation" when referring to your body; I know some folks use it hyperbolically or poetically, but for other people who use or read the boards it's tied to some very real, traumatic experiences like FGM.

I also think that, understandable as it is, it might help you in the long run to see if you can take some of the energy going into the frustration and anger you feel about all this and redirect it towards the more immediate steps you can take, rather than putting a lot of emotion and attention onto something--the hysterectomy--that is treated as a last resort by the majority of healthcare providers. There are likely steps you can take towards getting on T, or towards the PMDD management, that are more available to you and may be easier to get your healthcare team to collaborate on.

[brungerbulb]

I don’t mean to be rude. I know I’ve come off that way. I apologize for exaggerating.

I haven’t been in school for over a month at this point because of emotional instability.

I am completely unable to receive any gender related care until January 3rd once I’ve turned sixteen. This is a law Planned Parenthood has in place. UCSF is completely unresponsive. I won’t be able to return to school until even later than this point.

I have never spoken to my physician without my mother in the room. I once asked to see a gynecologist and they both dissuaded me. After bleeding for months on end I returned to the physician to get a depo shot instead, only for her to tell me I wasn’t able to get it because of the effect it has on bone structure. I am now on a new dose of birth control. I have no idea what it’s called, how many milligrams it is, or what is in it. Maybe my mom does.

Isolation has made me lonely and afraid. The urgency of all of this simply doesn’t matter to doctors. They’ve been throwing different medications at the wall to see what sticks. I can’t express how much I really need help without being institutionalized, but I worry that’s the only way to make them understand.

I feel weak for crying over nothing and guilty for wasting volunteer time. None of it matters.

[Amanda B]

Hi brungerbulb,

I can definitely see how isolation may be exacerbating everything going on. Community is so important when everything around us feels like it's failing. So when we feel isolated and lonely on top of additional challenges, it only makes sense to feel the way you're feeling.

Sam and Heather have provided some great practical information so far, so I'd like to get some clarity on where you'd like to go from here in terms of support from us. What feels most helpful at this time? Would you like continued answers about navigating gender-affirming care as a minor and a trans person? Are you more interested in using this space as emotional support, to process some of these feelings?

Too, I'd like to address the mental health support you have access to. How much does your therapist know about your seeking gender-affirming care? Are they aware and familiar with this topic? I am interested in hearing about this so we can best support your mental health as well.