HRT concerns after hysterectoe/oopherectomy

I am 41 years old.  I had my uterus removed when I was 21 due to heavy periods (never thought to get a second opinion - I was young, fortunately I was married with children at the time).  At age 26 I had an ovary removed due a large fluid cyst (benign).  At age 32 my last ovary was removed due to cysts (all benign).  I have been on Premarin 0.9 since I was 32 - nine years now.  I am small boned and now have osteopenia.  How long should I remain on HRT and will it protect my bones enough? I do lift weights and exercise, get plenty of dairy and don't smoke.  I have given up on ever having a normal sex life, ever since the last ooperectomy I have no desire and when I do have an orgasm it is with 1/4 of the intensity it once was.  I live in a rural area without specialists so I am hoping you can give me some advice.  Thanks.

[Machelle Seibel, MD]

Having a hysterectomy as such a young woman can create challenges, even if it corrected a problem. But now you have two concerns. The first is protecting your bones. The best way to follow the condition of your bones is with a bone density. They are typically done every 2 years. The radiation from a bone density is small, about the equivalent to the radiation associated with air travel. Estrogen, especially combined with calcium, is usually very effective in protecting bones. But other medications can also be used either instead of estrogen, or in addition to it. Examples are Fosomax, Actinel and Boneva. If the estrogen is maintaining your bone density after 9 years, there is a good chance it will continue to. Weight lifting and exercise that you are doing is terrific as is getting plenty of dairy. Going off estrogen depends on other risks such as the concern over breast cancer and blood clots. Most of the risk of increased likelihood of blood clots ends after about 4 years on estrogen. The breast cancer risk on estrogen alone (without progesterone) is likely not increased according to some major studies. That doesn't mean a woman can't get breast cancer; it means she her risk is not substantially increased by taking the estrogen.

For your second concern, sex drive, have your doctor measure your testosterone level. If Testosterone is low, a low dose can be added to the estrogen. Also, over the counter products such as Replens can help with vaginal moisture. Use it daily for a week then twice a week afterward. Talk with your doctor about other possible treatments. It might be worth a vacation to a city where there is a good sex therapist and spend one hour of your vacation getting advice about other things you can do to improve your sex drive and the rest of your vacation puting  your new information to work.
Machelle M. Seibel, MD