Patients who are considering a hysterectomy commonly have questions about their bodies will respond to the surgical removal of their uterus. Women need to understand the roles of the various organs in their reproductive system and how their removal will affect them.
Hysterectomy refers to removal of the uterus ONLY, the ovaries are not removed with a hysterectomy. Ovaries are responsible for the production of estrogen, the female hormone. Since the ovaries are kept in place in a hysterectomy, they will continue to make estrogen in women who have not entered menopause, regardless of the presence of the uterus. It is estrogen from ovaries, not the uterus, that is responsible for preventing menopause or the change of life.
A women who undergoes a hysterectomy and keeps her ovaries will continue to produce estrogen and ovulate, but will not menstruate or be able to become pregnant on her own. If desired, a women who has had a hysterectomy can produce eggs for in vitro fertilization procedures using a surrogate uterus (another woman to carry the pregnancy). It is important to understand that not having menstrual cycles does not mean your ovaries are no longer making estrogen or that you are no longer female. Removal of the uterus simply eliminates the effect of estrogen on the uterus; estrogen is continually produced if the ovaries are in place, and you will not go into menopause.
What if I have one ovary removed?
It is also important for many women to learn that one ovary is sufficient for the production of hormones. In women who must have one ovary removed, they will experience no changes in their menstrual cycle. Women with one ovary continue to ovulate monthly and can conceive a child. Women who undergo a hysterectomy and retain one ovary will also not enter menopause, just as if they still had both ovaries.
A few thoughts about the uterus, the ovaries, and hormones.
- Estrogen makes the uterus “have a period” or menstrual cycle. It is the estrogen that is produced by the ovaries that drives the reproductive system.
- Without ovaries, a woman would not be female, would not have breasts or female characteristics, would not have a menstrual period, could not have children, and would not need birth control.
- With only ONE ovary in place, normal hormone function will still continue.
- The function of the uterus is to hold a baby and for delivery ONLY.
- If a patient has a hysterectomy and has one or both ovaries left in place she will not go into menopause and will not have hot flashes, night sweats, possible anxiety, mood swings, depression. You will continue to be female, will not gain weight, or experience any of the typical changes that occur with menopause. Since the uterus is removed, you will not have menstrual cycles and cannot become pregnant on your own. You could become pregnant with your ovaries, your partner’s sperm, and a surrogate uterus (someone else’s uterus).
- If your ovaries were removed but your uterus was kept in place, you would enter menopause immediately. Without your ovaries you might have hot flashes, night sweats, possible anxiety, mood swings, depression, vaginal dryness and itching, and the typical changes that occur with menopause.
Should I have my ovaries removed?
Another potentially confusing topic is under what circumstances the uterus alone should be removed compared to removal of the ovaries, as well. Some patients undergoing hysterectomy also require or request removal of the ovaries and fallopian tubes. Patients who are close to menopause are counseled regarding the risk of leaving the ovaries in place, including ovarian cancer and ovarian cyst formation. Both of these conditions are relatively uncommon, but can occur. Since ovarian cancer is such a devastating disease, patients with a family history of ovarian or breast cancer, or those patients who want to eliminate the possible development of ovarian cysts or cancer may have their ovaries removed at the time of the surgery. This adds no increased time or risks to the surgical procedure.
Several factors are important in determining whether a patient’s ovaries should be removed, including the patient’s age and the safety of the procedure. In general, it is in the patient's best interest to minimize your surgical experience, and ovaries should not removed unless completely necessary and after a full discussion of this possibility with your physician before surgery.
Estrogen Replacement Therapy after hysterectomy
Removal of the ovaries at the time of hysterectomy will not affect postmenopausal patients regarding estrogen function. These patients are no longer producing estrogen from the ovaries, but are producing testosterone, the male hormone which helps with libido, from both their ovaries and the adrenal glands, each of which makes 50% of the testosterone produced. In the majority of patients, libido is not affected with removal of the ovaries. For women who experience a decrease in libido, testosterone supplements can be prescribed.
Removal of the ovaries in premenopausal patients, before change of life, will bring about the onset of menopause. Symptoms of menopause include hot flashes, night sweats, possible mood swings, anxiety, depression, and vaginal dryness and itching. Premenopausal patients who require the removal of both ovaries may desire to use estrogen replacement therapy (ERT). This is not the same as hormone replacement therapy (HRT), which refers to using both estrogen and progesterone. Estrogen, if given alone to a patient with a uterus in place, may cause uterine cancer. Progesterone, which typically acts on the uterus to cause a menstrual period, is also an "antiestrogen," that counteracts the effect of estrogen and prevents cancer in women who have a uterus. The sole use of progesterone in HRT is to prevent the development of uterine cancer.
Estrogen Replacement Therapy and the Women’s Health Initiative Study
The Women’s Health Initiative study was a large, powerful study that tested the effect of HRT, hormone replacement therapy with estrogen and progesterone, in patients with a uterus, as well as ERT, estrogen replacement therapy, in patients without a uterus. The study showed a small but definite increased risk of breast cancer, heart disease, and stroke in patients using HRT. Patients who had had a hysterectomy and received ERT or estrogen-only DID NOT have an increased risk of breast cancer or heart disease, but did have a similar, very small increased risk of stroke.
What this means is that if you need to have a hysterectomy but are concerned about menopause, you can safely use estrogen in low doses according to the Women’s Health Initiative study without an increased risk in breast cancer or heart disease. This provides patients with the option of treating menopausal symptoms after hysterectomy safely, and should be considered in patients undergoing hysterectomy. Those patients with a history of breast cancer should talk with their medical oncologist before starting any hormone therapy.