Menopause — Why Women Are Still Being Under-Treated

• Symptom-level dosing (bare minimum to reduce hot flashes)

• Physiologic replacement dosing (closer to what ovaries produced before surgery)

• Systemic estrogen without local vaginal therapy

• No attention at all to pelvic floor dysfunction

• No attention to androgen loss (testosterone)

When care is incomplete, it’s not surprising that outcomes don’t improve much. That’s not “hormones don’t work.” That’s “the plan wasn’t built for the physiology.”

Why Dosing Matters More in Younger Surgical Menopause

A 35-year-old who loses ovarian function overnight is not the same clinical situation as a 54-year-old transitioning naturally.

This is where many practices accidentally under-treat:

• They prescribe estrogen like it’s routine menopause symptom management

• When what’s often needed is closer to true replacement (individualized, monitored, and adjusted)

Authoritative guidance for estrogen replacement-level therapy exists in adjacent clinical situations like primary ovarian insufficiency (POI), which is also early loss of ovarian function. ACOG describes replacement approaches such as 100 mcg transdermal estradiol or 1–2 mg oral estradiol as examples of achieving replacement levels. ACOG: Hormone Therapy in Primary Ovarian Insufficiency

That doesn’t mean everyone should be on the same dose. It means “starter doses” that might be fine for mild hot flashes may be inadequate for abrupt endocrine loss.

The Missed Workhorse: Local Vaginal Estrogen for Pain and GSM

Genitourinary Syndrome of Menopause (GSM) is the umbrella term for vaginal and urinary symptoms caused by estrogen loss: dryness, burning, recurrent irritation, pain with sex, urinary urgency, and more.

The Menopause Society (formerly NAMS) states hormone therapy is the most effective treatment for vasomotor symptoms and GSM. NAMS 2022 Hormone Therapy Position Statement (PubMed).

In the 2026 RRSO paper, vaginal estrogen use was very low even though pain and discomfort worsened (per the summary you shared and the overall findings about function and distress).

Plain English:

• Systemic estrogen can help, but it’s not always enough for vaginal tissue.

• Local vaginal estrogen is often the missing piece for pain and dryness.

• If sex is painful, “try lube” is not a plan. It’s a shrug.

Androgens: The Conversation That Keeps Not Happening

Ovaries contribute to androgen production, and after removal, some women experience significant drops that can affect sexual desire and responsiveness.

There’s a reason international sexual-medicine groups put real guidance in writing: the International Society for the Study of Women’s Sexual Health (ISSWSH) published a clinical practice guideline on systemic testosterone for women with hypoactive sexual desire disorder (HSDD), including patient selection, dosing principles, and monitoring. ISSWSH Testosterone Guideline (summary page).

This is not a DIY lane. It’s a “carefully prescribed and monitored” lane — but ignoring it entirely leaves a chunk of physiology unaddressed.

Pelvic Floor Support: The Unsexy Fix That Actually Helps

When pain shows up, it’s not always just tissue dryness. Guarding, muscle tightness, and pelvic floor dysfunction can layer on quickly, especially after a big hormonal shift plus anxiety around pain.

A serious plan may include:

• Pelvic floor physical therapy

• Gradual reintroduction strategies (not “push through it”)

• Addressing partner communication (because avoidance spirals are real)

This is the relationship-saving work nobody advertises, but it matters.

The Ethical Problem Nobody Wants to Say Out Loud

Risk-reducing ovary removal can be medically appropriate and even life-saving in high-risk patients. But ethically, you can’t do the “big intervention” and then provide “small support.”

If a patient is pre-menopausal (especially under 40), abrupt endocrine loss is foreseeable. Sexual changes are foreseeable. Bone and cardiometabolic issues are foreseeable.

So a bare-minimum, under-dosed, “see you next year” approach is not neutral.
It’s choosing to accept predictable harm.

What Adequate Care After Surgical Menopause Can Look Like

This is a practical, patient-centered checklist you can use to structure a better standard of care (and a better blog):

Systemic hormone strategy

• Clear goals (symptom relief vs physiologic replacement)

• Appropriate route (transdermal vs oral) based on risk factors and preferences

• Dose titration with follow-up, not a one-and-done

GSM and pain strategy

• Early assessment for dryness, burning, and pain

• Consider local vaginal estrogen when indicated (not as a “last resort”)

• Lubricants/moisturizers as support tools, not the whole plan

Sexual function strategy

• Ask about desire, arousal, and distress directly (most patients won’t volunteer it)

• Consider androgen evaluation and specialist-guided options when appropriate, using established guidance such as ISSWSH’s framework

• Address relationship dynamics and communication (because hormones don’t fix resentment)

Pelvic floor strategy

• Screen for pelvic floor dysfunction early

• Refer to pelvic PT when pain, tightness, or avoidance patterns appear

Ongoing Research and Emerging Evidence

This area is evolving fast, and the headlines often oversimplify. Two things can be true at the same time:

• Studies can show worsening sexual outcomes after RRSO.

• “HRT wasn’t associated with improvement” can reflect treatment variability, under-dosing, limited local therapy, lack of androgen consideration, and inconsistent follow-up — not the inherent failure of hormones.

What we need more of:

• Trials that define “adequate replacement” for younger surgical menopause

• Better data on integrated plans (systemic + local + pelvic floor + counseling)

• Outcomes measured beyond hot flashes (function, distress, relationship impact)

Where My V Clinic Fits In

At My V Clinic, our approach is education-first and individualized. If you’re facing surgical menopause (or already living it), the goal is not to “tough it out.” The goal is to build a plan that matches your biology and your life — with real follow-up and real conversations.

If you want more background reading on menopause care, you can start here.

(And for the clinical backbone behind this discussion:  NAMS 2022 HT Position Statement & ACOG POI HT guidance.