Jwala has had uterine fibroids for 4-5 years now and is experiencing irregular periods with heavy bleeding lately. Her doctor has suggested a hysterectomy as a potential treatment option as it can give permanent relief. However, women in her circle are advising against it for it will lead to the loss of her femininity (in her late 30s) and intimacy with her partner with whom she envisions a long-term commitment, after being single for 6 years following her divorce.
Years of painful periods and multiple doctors later, Vaishali has recently landed the diagnosis of adenomyosis, for which hysterectomy has been advised because of her medical history. She isn’t sure if she should go ahead with it because her previous treating doctors either did not bring it up at all or were against it.
Many women do not have enough information to make a call regarding hysterectomy. The fear of not knowing what to expect, becoming more of a man or feeling handicapped is very common and clout their judgment. Doctors often do not have the privilege of time for a comprehensive explanation to their patients even if they would love to. Therefore, it is often upon us to do some homework and ask specific questions in our limited time with the treating doctor, so it is a win-win.
Let’s explore the possible scenarios that decide the type of hysterectomy and potential impact on hormonal health and menopausal status in this blog as these factors eventually determine the quality of a woman’s life.
Hysterectomy (the surgical removal of the uterus and other reproductive organs, as necessary) is a major gynecological surgery that is recommended for certain conditions when other treatments do not work.
Some of these conditions include but are not limited to
Uterine fibroids
Chronic infection
Gynecological cancers
Endometriosis (the tissue lining the inner uterine wall grows outside the uterus)
Adenomyosis (lining of the uterus growing into the muscle of the uterus)
Childbirth complications (if the surgery can be life-saving)
Uterine prolapse
Gender affirmation (in transgender/ non-binary individuals)
Types of hysterectomies
Depending on the condition and its severity, the different parts of the uterus and other reproductive organs may be removed.
Total hysterectomy: The entire uterus and the cervix are removed.
Sub-total hysterectomy (aka partial or supracervical hysterectomy): the uterus is removed completely or partially while preserving the cervix. If a part of the uterus is retained, regular or occasional menstruation is possible post-surgery.
Radical hysterectomy: the uterus, cervix and the upper part of the vagina are removed.
Note: The cervix is the narrow end of the uterus that connects the uterus and vagina. The uterus, cervix and vagina are not hormone-producing organs.
Does a hysterectomy always lead to menopause?
Ovaries are the main producers of reproductive hormones (estrogen and progesterone) in a female body; some secondary organs produce estrogen too, but at very low levels.
When one or both ovaries are removed (termed oophorectomy) along with the uterus, there is an abrupt interruption of hormone production and circulatory levels.
Unilateral oophorectomy: When one functional ovary is preserved, though the hormone levels dip, the effect is mild to moderate.
Bilateral oophorectomy: When both ovaries are removed, the effect is immediate i.e. the person is considered to be in induced or surgical menopause.
When both ovaries are removed along with the uterus, the sudden decline in estrogen in the body can bring on severe menopausal symptoms as the body would not have time to adjust. Depending on the individual’s health conditions, age and certain other criteria, post-oophorectomy individuals are more likely to be prescribed hormone replacement therapy (HRT). HRT is generally ruled out if the surgery is done in post-menopausal women.
Recommended reading: Understanding Medical Menopause
The removal of ovaries along with the uterus was a norm in the past. With emerging evidence on the significant roles of estrogen and progesterone in the overall health of the individual, current medical policies across the globe strongly recommend the preservation of ovaries as much as possible. This decision is conditional on the pros and cons concerning the individual’s medical needs. For example, in the case of cancers in the fallopian tube or even in parts of the uterus closer to the ovaries, the tube and ovaries (one or both) may need to be removed along with the uterus in a precautionary or life-saving surgery, termed hysterectomy + oophorectomy (or salpingo-oophorectomy).
Read more about the effects of estrogen on the overall health of women
Discussion points with your healthcare provider
When presented with a hysterectomy as a potential treatment option for your condition, it is important to discuss the below points with the treating doctors to gain clarity. Gaining this knowledge can go a long way in mentally preparing yourself for what’s to come.
Need and plan for the surgery: It is essential to understand the reasons for considering a hysterectomy as the best solution to your issues. Some questions to ask before giving consent:
What are the risks involved? Are there alternative treatments that can work as effectively?
How urgent is the surgery?
Will it eliminate all my current symptoms or only some?
What organs are being removed?
Will I get periods after the surgery? Are my ovaries being left behind?
What will be my post-operative treatment modules, if any?
Health status of the ovaries (pre- and post-op): This is the top factor, as you must have gathered from the above sections. Here are some questions you may want to ask if the retention of ovaries is considered:
Is the status of my ovaries appropriate to my age?
How can I follow up on their status post-surgery when I won't get my periods (which is the ultimate indicator of their activity)?
Will I experience menopause immediately after the surgery or earlier than usual?
Mode of the procedure: Hysterectomy can be through a
vaginal incision
abdominal incision or
laparoscopy procedure
The post-operative procedures and recovery will vary accordingly. If presented with more than one option, you may want to discuss the pros and cons of each procedure to arrive at a mutually agreeable decision.
Need for hormone replacement: This will be necessary if you are ovulating (before the surgery) and one or both ovaries are removed during the surgery.
Mental health support: Most women who undergo hysterectomy go through mental struggles both in the decision-making stage and post-surgery. The need for mental health support should also be considered on a need basis.
Pap smear/ HPV vaccination: Post-hysterectomy women with the entire or partial cervix retained are candidates for regular pap smears (at intervals appropriate to age, pre-existing conditions and family history) as anyone else.
Menopause tracking after hysterectomy (without oophorectomy)
When one or both ovaries are preserved during a hysterectomy, the ovarian function (aka hormonal cycles) may
Continue for years until natural menopause: Periods and/or PMS/PMDD can be experienced in a cyclical manner depending on whether the person has a partial uterus or not, respectively.
Stop sooner than usual after the surgery (premature ovarian insufficiency): This usually happens due to disturbance to the blood supply to the ovaries. Recent research on small cohorts of women has shown that women who underwent hysterectomy experienced ovarian failure (menopause) 4 years earlier than their natural menopausal age and with more severe symptoms than those who did not undergo the surgery. However, this need not be true for everyone. There is anecdotal evidence that insufficient blood supply to the ovaries is generally compensated by the formation of new blood vessels in younger women undergoing hysterectomy than in older women. It is possible that the age at which the hysterectomy is performed can be a significant determinant of early ovarian failure. This association is, however, yet to be confirmed by research.
Here are some ways to keep track of ovarian function post-hysterectomy.
Menopause symptoms: Those who menstruate regularly may see variations in frequency and/or volume of bleeding. Those who do not menstruate post-hysterectomy have to rely on other symptoms of menopause- physical and psychological (detailed here).
FSH test: A yearly test of the levels of follicle-stimulating hormone (which would increase with age and steeply during the menopausal transition) can give a fair idea of ovarian function. Your gynecologist can guide you in this regard.
Ultrasound imaging of ovaries: Ovaries with mature eggs can be visualized prominently by ultrasound imaging. The size of your ovaries can indicate if they are functional.
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About the author
With 10+ years of experience in science communication, Dr. Ayshwarya Ravichandran ensures evidence and science-backed information are conveyed to women in understandable and comprehensible language and visualization. She is also a passionate women's health advocate engaging the Miyara community in different ways.
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