Is a "Benign" Hysterectomy Truly Benign?
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As a fully-trained, board-certified, licensed and practicing obstetrician-gynecologist, I have performed and assisted many hysterectomies in my career so far.
Why? Because nearly half of women in the United States will have a hysterectomy in their lifetime.
I want to discuss risks that have come to light more recently about these types of surgeries, especially as it relates to menopausal women.
Risks of the surgeries themselves are well-known and vary with the type of procedure: bleeding risk, infection risk, injury risk.
I want to discuss here long-term risks of the surgeries because we often think surgery is to “fix” something, but in some cases it may trade one problem for another.
First, let’s clarify some terminology surrounding pelvic surgery.
Hysterectomy = removal of the uterus
supracervical hysterectomy means the cervix was not removed, this is rare in today’s surgical landscape
total hysterectomy still refers to the uterus only, ovary removal is described below
Salpingectomy = removal of fallopian tubes
Oophorectomy = removal of ovaries
Bilateral = both sides (can refer to both tubes and/or ovaries, versus saying right or left if only one side was removed)
Salpingo-oophorectomy = removal of fallopian tubes and ovaries
Hysterectomies in various routes are required to complete residency training. There are different number requirements for each route:
abdominal (large incision through the belly)
laparoscopic (small incisions in the belly)
vaginal (no incisions in the belly)
There have been some major shifts in how hysterectomies are performed regarding the above routes.
One study shows that in the year 2000, most hysterectomies at one center were performed abdominally. The next most common route was vaginal, followed by a small percentage performed laparoscopically.
By 2010, the majority were performed laparoscopically and the number performed vaginally was dropping. Vaginal hysterectomy is the least invasive route of hysterectomy but cannot always be performed due to technical or medical reasons.
The less invasive laparoscopic approaches have improved outcomes for patients having hysterectomies, even in some cases of cancer. But just because we can do something (and do it well) doesn’t always mean we should.
The Data on Risks
Human studies will be observational, meaning women aren’t randomized into different groups to find out what happens in an experimental manner. That would be unethical. The studies then have to look at women who already had these procedures and follow them through time, or women who have already decided to have the procedures and follow them through time.
A study out of Norway published in 2023 reviewed over 20,000 women who had hysterectomy, hysterectomy plus ovary removal, or none.
They found that women who had hysterectomy had:
30% increased risk of dying from anything (called all-cause mortality).
23% increased risk of cardiovascular mortality (dying from heart or vascular disease)
Women who had both ovaries removed had:
Increased cardiovascular mortality if ovaries removed before age 52
An Australian study found that having a hysterectomy only (ovaries left intact) before age 35 led to increased all-cause mortality. Hysterectomy with ovary removal before age 45 led to increased all-cause mortality.
This tracks with studies of earlier natural menopause having increased cardiovascular mortality.
Why are these risks happening?
Whether menopause is natural or surgical (ovary removal), the decrease of hormone production by natural menopause and elimination of hormone production by surgical menopause causes massive hormonal changes.
Some of estrogen’s effects are:
Helps the release of nitric oxide, which helps relax our blood vessels and ultimately maintains a lower blood pressure than stiffer blood vessels.
Increasing receptors for cholesterol particles on the liver, maintaining the natural cycle of cholesterol metabolism
Increases insulin sensitivity by increasing insulin secretion by the pancreas and improving glucose uptake in the muscles (pulling sugar out of the bloodstream and into the muscle)
Maintains lower visceral fat (fat found around the abdomen and organs).
After menopause and loss of estrogen, these effects are lost, resulting in:
Stiffer blood vessels
Disrupted cholesterol cycling
Insulin resistance
Increased visceral fat (which increases systemic inflammation)
Combined, these effects lead to increased cardiovascular risk of women after menopause.
If we’re no longer reproducing, why keep the ovaries?
The post-menopausal ovaries (ovaries in a woman who has gone through menopause) are still producing hormones, though very little compared to the reproductive years.
I think there’s a misconception that the ovaries are producing zero after menopause. I was actually under this impression during my training. It’s not true.
The menopausal ovaries are hormonally active, producing some estrogens and testosterone.
What You Can Do
1. If you’ve had any pelvic surgery, know exactly what was done and removed. If you don’t know or can’t remember, you can request medical records from the hospital where it was performed. Surgeons make an “operative note” after every procedure or surgery stating what was done. Pathology reports in your medical record will show what was found on inspection of removed organs.
2. If you are considering pelvic surgery, deeply consider the risks not just of the surgery itself, but of the long-term effects of organ removal. Surgeries can be necessary and life-changing in a good way if it’s done for the correct reasons, with an experienced surgeon, with realistic expectations, and fully-informed consent.
3. Try to improve conditions without surgery if possible and medically acceptable. This may be through lifestyle changes or medication, or both.
4. Use hormone replacement therapy if you are a good candidate, which can be assessed by talking to a knowledgable, qualified provider. Hormone replacement therapy if started early in menopause can decrease mortality and heart risk.
This is not medical advice. Hysterectomy, any surgery and medical treatment is individual and should be discussed with your healthcare provider.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
https://www.sciencedirect.com/science/article/abs/pii/S0002937820305226
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/aogs.14531
https://www.sciencedirect.com/science/article/abs/pii/S104727979700207X
https://www.sciencedirect.com/science/article/abs/pii/S0002937813000690
https://onlinelibrary.wiley.com/doi/full/10.1155/2021/6636856
https://journals.lww.com/menopausejournal/abstract/2014/10000/ovarian_estradiol_production_and_lipid_metabolism.15.aspx
