The decision to retain or remove healthy ovaries during a hysterectomy requires balancing long-term health risks and benefits. A hysterectomy is the surgical removal of the uterus, which ends menstruation and the ability to become pregnant, but does not automatically cause menopause. An oophorectomy is the removal of one or both ovaries; if both are removed before natural menopause, it immediately triggers surgical menopause due to the abrupt loss of hormone production. Combining a hysterectomy with a bilateral oophorectomy is highly individualized, depending on age, health status, and specific risk factors for ovarian cancer. This determination involves weighing the protective effects of retaining natural hormone function against eliminating the future possibility of ovarian disease.
Preserving Natural Hormone Production
Keeping the ovaries intact allows for the continuation of endogenous hormone production, which offers protective effects for various body systems. The ovaries are the primary source of estrogen before menopause, but they also produce significant quantities of androgens, such as testosterone and androstenedione. Even in postmenopausal women, the ovaries remain hormonally active, contributing to androgens that are converted into a form of estrogen (estrone) in fat and muscle tissues.
Ovarian hormones help maintain long-term health, particularly for the cardiovascular and skeletal systems. Studies show that women who undergo oophorectomy, especially before age 50, have an increased risk of coronary heart disease and all-cause mortality. Estrogen regulates mitochondrial metabolism and insulin sensitivity, and its loss can accelerate the accumulation of chronic conditions. Furthermore, both androgens and estrogens inhibit bone resorption, meaning their sudden decline following removal can lead to a higher risk of developing osteoporosis and fractures.
Ovarian hormones also support neurological and sexual health. Oophorectomy before natural menopause is associated with a higher risk of cognitive impairment, including dementia. Androgens influence sexual desire, energy levels, and overall well-being. The ovaries’ sustained function after menopause provides a low-level hormonal baseline that contributes to systemic homeostasis, making ovarian conservation a preferred option for women at average risk of cancer.
Assessing Cancer Risk Reduction
The main justification for removing healthy ovaries during a hysterectomy is to prevent ovarian cancer, which is often detected at advanced stages. The procedure, known as prophylactic bilateral salpingo-oophorectomy (removal of both ovaries and fallopian tubes), reduces the risk of ovarian and fallopian tube cancer by up to 96% in the general population. For women with a high genetic risk, such as those carrying a BRCA1 or BRCA2 gene mutation, this risk reduction is particularly significant, decreasing ovarian cancer risk by nearly 80%.
For women with BRCA mutations, the surgery is often recommended between ages 35 and 45, after childbearing is complete, to significantly lower lifetime cancer risk. This procedure also provides a protective effect against breast cancer, particularly for premenopausal women, with studies showing a reduction of up to 50%. However, for women not at high genetic risk, the lifetime chance of developing ovarian cancer is relatively low, and removing healthy ovaries for cancer prevention alone may not offer a survival advantage.
The decision must weigh the low lifetime risk of ovarian cancer against the increased long-term risks for cardiovascular disease, lung cancer, and all-cause mortality associated with the loss of ovarian hormones. While ovarian cancer accounts for a smaller number of deaths annually, heart disease and stroke cause significantly more. This underscores the importance of the protective hormonal function of the ovaries for the average-risk patient. Therefore, current guidelines favor ovarian conservation unless a patient has a known genetic predisposition or other compelling risk factors.
Influence of Patient Age on the Decision
A patient’s age and menopausal status are the most influential factors in the decision to conserve or remove ovaries during a hysterectomy. Removing the ovaries before natural menopause (typically before age 51) induces an abrupt hormonal deficiency that carries significantly greater long-term health consequences. For women under age 45 who undergo oophorectomy, there is a higher risk of non-cancer death and a 24% faster accumulation of chronic conditions compared to those who retain their ovaries.
For pre-menopausal women, ovarian conservation is strongly recommended unless there is a high-risk indication, such as a BRCA mutation or existing ovarian disease. The sudden loss of hormones in younger women can lead to an increased incidence of heart disease, osteoporosis, and cognitive decline. The protective effects of endogenous hormones are potent in this younger age group, making preservation of ovarian function a priority for overall health.
For women who are already post-menopausal, the decision changes because the ovaries have ceased their primary reproductive function and the body has adapted to lower hormone levels. Although the postmenopausal ovary still produces androgens, the overall health risks associated with oophorectomy diminish significantly after age 50 to 55. In this older age group, the goal shifts to eliminating the small remaining risk of ovarian cancer without incurring the severe systemic shock experienced by younger patients.
Managing Surgical Menopause
If the decision is made to proceed with an oophorectomy, the resulting surgical menopause is often more severe and sudden than the natural transition. The immediate drop in estrogen and other hormones causes an abrupt onset of symptoms, including hot flashes, mood changes, and sexual dysfunction. This sudden hormonal void also increases the long-term risk of conditions like cardiovascular disease and bone density loss.
Hormone Replacement Therapy (HRT) is the standard treatment to mitigate these effects, especially for women who undergo the procedure before the average age of menopause (around 51). Current guidelines recommend that women under 45 who have an oophorectomy be offered HRT at least until age 51, provided there are no contraindications (such as a history of hormone-dependent cancer). HRT replaces the lost estrogen and can prevent bone loss while helping maintain heart health and cognitive function.
Since a hysterectomy has already removed the uterus, patients who receive HRT only require estrogen, as progesterone is not needed to protect the uterine lining. This estrogen-only therapy is a less complex form of HRT and can be administered via patches, gels, or tablets. In some cases, testosterone may also be considered to address symptoms like low libido, energy, and mood.