Should I Keep My Ovaries?

The rationale for keeping the ovaries, would be to maintain a source of your own sex hormone production. It is possible that your ovaries may continue to produce adequate amounts of estrogen and testosterone until the time you would have had experienced a natural menopause. The normally functioning postmenopausal ovary also may be capable of producing significant amounts of testosterone for several years following menopause. Testosterone is the hormone is closely associated with energy levels, lean body mass, libido and sexual function. In addition, if testosterone levels are present, some of it may be converted to estrogen by a process called, "aromatization". This may be the reason that naturally menopausal women are known to have less severe menopausal symptoms and fewer negative health consequences. as contrasted to women who have had their a surgical removal of benefit in reducing the severity of menopausal symptoms.

However it should be noted, there is an increased incidence of ovarian failure following hysterectomy. This is discussed in some detail in the section of the web site, Ovarian Failure Following Hysterectomy

Is there any reason I might want my ovaries removed? 

There is always the argument that removing the ovary prevents the possibility of ovarian cancer. A woman has a 1 in 70 chance of developing cancer of the ovary during her lifetime. Due to a lack of symptoms initially, the presence of ovarian cancer is typically not discovered to a late stage and for this reason is often fatal. The peak incidence of ovarian cancer is between the ages of 70-80.

There is a type of ovarian cancer that is hereditary. The mutated genes responsible for most hereditary ovarian cancers have been identified, (BRCA1, BRCA2). There is a blood test available to identify carriers of this gene. Woman who are identified as having the mutated gene should consider the option of ovarian removal and non-carriers can be assured that their risk of ovarian cancer is not increased.

I'm concerned about the possibility of ovarian cancer, but I want to keep my ovaries. Is there anything I can do? 

If you were to decide to keep your ovaries, there are strategies that can be and I believe should be implemented by all women, to increase the possibility of discovering a developing ovarian cancer at an early stage and increase one's chance of surviving this disease. (1)A yearly pelvic ultrasound, preferably transvaginal and utilizing one of the more advanced ultrasound technologies. (2)A yearly CA 125 blood test. (3)A yearly pelvic examination. (4)An immediate visit to the doctor for any persistent abdominal symptoms.

What if I have endometriosis?

If the reason for your hysterectomy is endometriosis, there is an additional consideration for removing the ovaries. There is research that documents that patients who were treated for endometriosis with ovarian conservation were at a substantially increased risk of recurrent symptoms and a frequent need for reoperation, as compared to those who had ovarian removal.

Is there an age that you recommended that your patients who needed a hysterectomy have their ovaries removed?

If I was asked, I usually recommended that patients 45 and over consider having their ovaries removed, assuming they planned to use HRT. Not all women respond well to the more frequently used HRT regimens. Accordingly, one important factor in the decision making process is whether you have a physician resource available who is knowledgeable about menopausal issues and skilled in a wide range of HRT treatment options. This is discussed in the section of the web site, Hysterectomy.

If I have my ovaries removed, should I go on HRT?

I would certainly suggest that. I believe that women who are experiencing hormonal deprivation should consider appropriate HRT as a first line strategy for health and quality of life maintenance. Surgically menopausal users of HRT are known to have a lesser incidence of osteoporosis, cardiovascular disease and death, than non-users. In addition surgically menopausal women who are without the benefit of HRT, may experience severe and life altering menopausal symptoms.

What are the risks of going on HRT?

I believe, assuming that HRT is given in a physiologic manner and in my view means a non-oral route of administration, specifically transdermal or subcutaneous, in doses that result in physiologic blood levels of estradiol and testosterone, the risks would be no greater than having your own source of hormone production. I prefer to prescribe non-oral regimens of estradiol and testosterone, utilizing non-oral routes of administration. This has the advantage of avoiding the "bolus, first pass" liver consequences and enzyme alterations associated with oral administration of hormones. Oral administration of HRT, is the most commonly used route of sex hormone delivery used in the world and it has been proven to be effective and safe for most women. However, my sense is that non-oral routes of administration are potentially even safer and more effective. There is more about this in the section of the web site, Methods of HRT.

I would like to share a scenario I often saw repeated in various forms.

I would be speaking to a menopausal woman from whom I had just taken a detailed history. She had related that she smoked 1 1/2 packs of cigarettes daily, drank 3-5 cocktails daily, took over-the-counter and prescription diet medication, did no exercise, was 30 lbs overweight, consumed a high fat diet, had undergone 3 cosmetic surgeries requiring an anesthetic, visited a tanning salon 3 times a week, did not wear a seat belt while driving, did not have regular pelvic exams or mammography and was having unprotected sex.

After I had discussed HRT at length, including the weight of evidence that HRT is an effective health maintenance strategy, she would look at me and say, "but I am afraid of the risks of HRT!"


Hysterectomy Overview
Dr Nosanchuk discusses hysterectomy, a surgical menopause, reasons why the procedure is performed, risks, health effects and advisability of hormone replacement therapy / hrt and contrasts it to a natural menopause...

Ovarian Failure Following Hysterectomy
Hypothetically, if you’re premenopausal and still have your ovaries following a hysterectomy, one would expect continued production of ovarian sex hormones. Unfortunately, it has been well documented that this is often not the case. A number of medical studies have documented that ovarian failure occurs frequently in retained ovaries following a hysterectomy ...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Ovarian Failure following a Hysterectomy

Hypothetically, if you’re premenopausal and still have your ovaries following a hysterectomy, one would expect continued production of ovarian sex hormones. Unfortunately, it has been well documented that this is often not the case. A number of medical studies have documented that ovarian failure occurs frequently in retained ovaries following a hysterectomy ... 

There are reasonable considerations for keeping your ovaries when a hysterectomy is indicated. This is certainly true prior to age 45 and in some cases even after. This may not be possible when the ovaries are diseased, or if there are conditions such as extensive endometriosis, or a malignancy of pelvic organs.

The rationale for keeping the ovaries is that they may to continue to produce estradiol, the naturally occurring female hormone until the age a natural menopause would have occurred. This is usually thought of as being between the ages of 48-52.

In addition, following a natural menopause even if the ovaries no longer produce significant amounts of estrogen, they are capable of producing significant amounts of testosterone, the hormone most closely associated with sex drive, energy levels and maintenance of lean body tissue. When present, some of the testosterone may also be converted to estrogen in tissues of the body, by a process called aromatization. While the levels that result are small, they are nonetheless significant, and at least in a hypothetical sense provide some benefit.

Accordingly, it makes sense to keep your ovaries if possible as it may preclude the need for HRT at least until the time of your expected menopause.

"I had a hysterectomy and kept my ovaries. I have menopausal symptoms, hot flashes, fatigue and no sex drive. I went to my Dr and he says I don’t need HRT, because I still have my ovaries. Can this be true?"

Hypothetically, if you’re premenopausal and still have your ovaries following a hysterectomy, one would expect continued production of ovarian sex hormones. Unfortunately, it has been well documented that this is often not the case. A number of medical studies have documented that ovarian failure occurs frequently in retained ovaries following a hysterectomy.

This frequently presents a dilemma for the woman who is of premenopausal age, has had a hysterectomy, still has her ovaries and has menopausal symptoms.
•First, as she still has her ovaries and expects them to produce adequate amounts of hormone; are the symptoms related to declining hormone levels or do they represent another health-related problem?
•Second, if she realizes that the symptoms are menopausal and she goes to her physician for help, she may be told that since she still has ovaries that this is not possible. I receive frequent e-mail from symptomatic women whose physicians fail to recognize that ovarian dysfunction is the problem and refuse to provide HRT.
•Third, even if the cause of the symptoms is recognized as being related to declining hormone levels, the possibility exists that the more routinely prescribed regimens of HRT will not relieve the symptoms. 

"So, what do I do about this?"

The first strategy is to make reasonably certain that the symptoms are related to ovarian failure. Symptoms such as hot flashes, sweats and vaginal dryness are usually related to lowered estrogen levels. Hyperthyroidism, a condition of an excess of thyroid hormone will cause feelings of warmth and sweats can be tested for and excluded as a cause of the symptoms. A diminished libido is associated with ovarian failure, but can be related to other health problems, relationship issues or situational factors. Symptoms of irritability, or fatigue can be of menopausal origin, or related to other factors as well.

"What if I’m sure that the symptoms are menopausal?"

It may be possible to document that ovarian failure has occurred by having your Dr perform blood tests. If the levels of estradiol and testosterone are low and the FSH, (Follicle Stimulating Hormone), are elevated there is little question that ovarian failure has occurred. FSH, is the hormone secreted by the pituitary gland that signals the ovary to make more estrogen. If the ovary is failing in its ability to do this, the pituitary produces higher levels of FSH in an effort to "whip" the ovary into producing adequate levels of estrogen.

Unfortunately, this strategy although useful is not perfect. If the ovaries are "struggling" to produce adequate hormones levels, the test results may be in the normal range and symptoms may still be present.

"Okay, then what do I do?"

If the blood tests are normal and the symptoms are suggestive of being of menopausal origin, a trial of HRT is indicated if desired. If the symptoms resolve, you have the answer.

"What if the hormones don’t relieve the symptoms?"

There are 2 possibilities.

Either a more effective program of HRT is indicated, or the symptoms are not of menopausal origin.

"What do I do if my doctor tells me that I don’t need hormones because I still have my ovaries and refuses to even provide a trial of therapy?"

You will need to emphasize that you are fully aware that ovarian failure can and does occur in retained ovaries following a hysterectomy and that he/she needs to read the readily available literature that documents this phenomenon.

If it is your desire, you need to insist that you be provided with a reasonable program of HRT.

The alternative is to find a physician who is more knowledgeable regarding these issues.

Hysterectomy Overview
Dr Nosanchuk discusses hysterectomy, a surgical menopause, reasons why the procedure is performed, risks, health effects and advisability of hormone replacement therapy / hrt and contrasts it to a natural menopause... 

I Want To Know If I Should I Keep My Ovaries
There is no right, or wrong decision. The choice in keeping or taking the ovaries ultimately is a personal one...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

 

Hysterectomy Overview

WHAT IS A HYSTERECTOMY?

A hysterectomy is a surgical removal of the entire womb or uterus, which induces a "surgical menopause". Frequently, in addition to the uterus, one or both of the ovaries are removed during the same operative procedure.

IS THERE A DIFFERENCE IF THE OVARIES ARE REMOVED?

Although, we usually refer to premenopausal women who have had a hysterectomy as having experienced a "surgical menopause" they are not menopausal in a "hormonal" sense unless their ovaries have been removed.

HYSTERECTOMY WITH OVARIAN PRESERVATION

Women, in whom the ovaries are retained, although they no longer have monthly periods, will not experience menopausal symptoms or the effects of hormonal deprivation. That is, as long as the ovaries continue to function normally, or until the age an expected natural menopause would have occurred, or sooner if the ovaries have been compromised by the surgery.

Unfortunately, even if the ovaries are preserved, they become dysfunctional up to 50% of the time within 3 years following the surgery. Nevertheless, in women under the age of 45 preservation of the ovaries is an important consideration when reasonable.

HYSTERECTOMY WITH OVARIAN REMOVAL

If both of the ovaries are removed the source of estrogen and testosterone production is lost. The fall in hormone levels is sudden and severe. It is a very different circumstance, than a natural menopause where the decline in estrogen levels may be gradual in onset and ovarian testosterone production may continue for several years.

Women in this category, who are without the benefit of HRT, often have the most severe menopausal symptoms and long-term consequences of sex hormone deficiency. Health, quality of life and longevity are affected. There is a statistically shorter life expectancy, associated with a higher rate of death, mostly from heart attacks, strokes, and osteoporosis. Libido and sexual function deteriorate.

A hallmark study published 1983 in the Journal of the American Medical Association revealed a significantly increased death rate among women 40-50 years of age who had had a hysterectomy and who were without the benefit of estrogen replacement, as compared to those who were estrogen users. For those who had their uterus removed, the rate was 3 times higher. For those who also had both ovaries removed, the rate was 8 times higher. It is apparent that careful consideration should be given to HRT after a surgical menopause.

DOES HRT HELP?

Most of the routinely prescribed programs of HRT are usually effective in preventing the long-term consequences of hormone deficiency and maintaining quality of life.

DOES HRT WORK FOR ALL WOMEN WHO HAVE THEIR OVARIES REMOVED?

Unfortunately, following the surgery, there is a group of women who experience life-altering symptoms, which are unresponsive to the routinely prescribed regimens of HRT. This often presents a dilemma. We have a woman who has undergone a major surgical procedure. She has been told that if she takes HRT, her quality of life, including her libido and sexual function, will be the same, if not better.

If she is fatigued, having symptoms and has no libido in the immediate post-operative period, it may not seem unreasonable to her. After all, she just had a major surgery., didn’t she? A few months go by and she is still fatigued, having flushes, insomnia, problems with her memory and she has no sex drive.

She does the reasonable thing. She returns to her physician, who changes her HRT regimen several times. Months go by, and she feels no better. She returns to the doctor again and restates her concerns. The physician looks at her, shakes his or her head, almost, but not imperceptibly, and speaks.

"You weren’t psychologically ready for this surgery," or " Are you having trouble at home." And then, "This has nothing to do with the surgery … you need to see a therapist."

She looks at the physician in disbelief, just having suffered the indignity of having her legitimate concerns invalidated. She feels betrayed, and wonders what she has to do, after leaving this "jerk's" office to regain her life. So, she goes to several new physicians, and is placed on several additional HRT regimens, without success. Next, she purchases several vitamin and/or herbal preparations and rubs on progesterone cream with no improvement. She reads everything she can that seems to address her problem. Ultimately, if nothing helps, she begins to doubt that she will ever feel like herself again. And, sometimes she even begins to wonder if some of the problem is actually in her mind.

Well, it’s not in her mind. If she felt fine prior to her surgery, and now does not, it is probably related to the surgery. On the other hand, it could be an amazing coincidence, but I keep reading that great detectives don’t believe in coincidences, so why should we.

Does this sound like an unlikely scenario? Well, it’s not. There are many women who feel exactly this way and are desperately trying to regain their quality of life.

SO HOW CAN THEY FEEL BETTER?

They need to find a physician who is knowledgeable in the treatment of menopausal women and who has expertise in the wide range of HRT therapeutic options. Ultimately, if nothing else seems to work, "subcutaneous hormone implants" are almost always effective. The sections of the web site, MENOPAUSAL SYMPTOMS, ABOUT HRT, METHODS OF HRT and REGIMENS, will provide more information about this.

WHAT IF THEY CAN’T FIND A PHYSICIAN LIKE THAT?

It would be helpful to contact a compounding pharmacy, such as College Pharmacy for information about some of the HRT options that are available. They will provide information about their products to patients and their physicians regarding availability and appropriate use. There is a link to their web site on the links page. If necessary they can also provide the names of physicians to whom they provide specialized HRT products.

IF THERE ARE POTENTIAL PROBLEMS, WHY WOULD ANYONE HAVE A HYSTERECTOMY, OR THEIR OVARIES REMOVED?

No one should have a hysterectomy or any surgery if it’s not necessary. In the past far too many hysterectomies were performed. Even today patients need to remain vigilant and consider the benefits and potential consequences before making a decision.

But there are instances when surgery is reasonable. One indication for surgery is the presence a malignant or premalignant involvement of the uterus, cervix or ovaries. Another, is uncontrolled uterine bleeding, which is unresponsive to more conservative therapy. Vaginal bleeding can cause life-threatening anemia and often surgery is the only option. Endometriosis, and a condition called adenomyosis, can be painful and life altering and surgery is still the best option in many cases. Surgery is often the most reasonable option for women who have a ‘uterine prolapse,’ a condition where the uterus protrudes into the lower vagina. The surgery also performed for benign growths of the uterus, called "uterine fibroids," when they are thought to be the cause of bleeding unresponsive to non-surgical therapy, pain or impingement of other organs.

Sometimes, women who have surgery for these indications find that their quality of life is significantly improved. This is particularly true when the problem is endometriosis, vaginal hemorrhage and uterine prolapse.

Ovarian Failure Following Hysterectomy
Hypothetically, if you’re premenopausal and still have your ovaries following a hysterectomy, one would expect continued production of ovarian sex hormones. Unfortunately, it has been well documented that this is often not the case. A number of medical studies have documented that ovarian failure occurs frequently in retained ovaries following a hysterectomy ...

I Want To Know If I Should I Keep My Ovaries
There is no right, or wrong decision. The choice in keeping or taking the ovaries ultimately is a personal one...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.