Every year, thousands of Australian women officially hit the Big Change, complete with menopause's signature hot flushes, night sweats, mood swings, and more. But for a smaller group of women, those and other tortures aren't simply nature running its course: Around 600,000 will be going through what's called surgical menopause, because they've had their ovaries removed.
For some, it's done to minimise risk of ovarian cancer. For others, there's something already wrong with the ovaries, like cysts, pain, or even an emergency situation that involves twisting (you do not want to Google it; we promise). But no matter why you get the surgery, one thing's certain: Menopause comes on immediately, with all its bells and whistles, because the ovaries are the hormone hub of the reproductive system. Without them, you'd no longer produce much oestrogen, leading to the very same symptoms as a more natural menopause-hot flushes, vaginal dryness and discomfort, problems sleeping, mood changes, skin changes, weight gain, you name it, says gynaecological surgeon Dr Matthew Siedhoff.
The benefits of ovary removal-called an oophorectomy-can be enormous. Emergency situations can be averted; pain can be minimised. Among women who are carriers of the BRCA1 and BRCA2 gene mutations, ovary removal can reduce the risk of breast and ovarian cancer by around 80%, according to a review of preventive surgery.
But that doesn't mean ovary-removal surgery is an easy decision. Here are a few things to keep in mind.
Surgery may be less complicated than you'd think.
The least invasive way to remove the ovaries is laparoscopically, meaning a teeny camera is inserted through a small incision in the belly button to guide removal, Siedhoff says. "There's a decrease in risk of complications like a blood clot or an infection, and you'll spend less time in the hospital," compared with an open surgery, he explains. A laparoscopic procedure also makes for a "better cosmetic effect," he says, while open surgery leaves a scar much like one from a C-section. Open surgery can take a little longer to recover from but may be necessary for some women.
Your hormone levels will drop-and you'll probably want to do something about it.
Yes, the benefits, like a lower risk of both ovarian and breast cancer, are big, but that doesn't mean ovary removal is without risks. In fact, it's been linked to a seriously higher risk of heart disease, osteoporosis, dementia, and death by any cause, likely due to that drastic drop in oestrogen. Research suggests that premenopausal women who have their ovaries removed at age 35 or younger have nearly twice the risk of developing cognitive impairment or dementia, a seven times higher risk of heart disease, and an eight times higher risk of a heart attack, explains gynaecologist Dr Philip Sarrel.
Experts believe reintroducing some of that missing oestrogen can make all the difference. However, by 10 months after their procedure, just 25% of women without their ovaries are taking any oestrogen at all, Sarrel says. Like many women entering non-surgical menopause, women having their ovaries removed have also been scared away from taking hormone replacement therapy (or more accurately, hormone therapy) because of controversial data from the Women's Health Initiative study published in the early 2000s. We won't rehash all the details here, but suffice it to say the results were largely overstated, and consequently a lot of women shied away from hormones. Many women could stand to benefit from hormone therapy, though, with or without their ovaries, before and after menopause, Siedhoff says, but he especially recommends that women who have their ovaries removed in their 30s or 40s take it until they are at least closer to the natural age of menopause, typically 50 or 51.
Ideally, you'd start taking hormone therapy right after ovary removal (or even right before), Sarrel says, to avoid acute hormone withdrawal. The timing matters, he says, because the older you are when you start hormone therapy, the riskier it can be, as the WHI findings show, and the more damage to your health is already done. For example, starting hormone therapy 6 years after oophorectomy led to greater decline in bone health than starting it 3 years after surgery, which in turn was linked to weaker bones than starting it within 2 months.
You can keep your ovaries even if you don't have a uterus.
Should you need your uterus removed due to concerns like fibroids or endometriosis, your ovaries can definitely stay put. In fact, considering the risks of losing your oestrogen, you probably want them to stay. Yes, Siedhoff says, a hysterectomy is a natural time to bring up ovary removal, and the two were frequently done simultaneously in premenopausal women in years past. "Now most women elect to keep their healthy ovaries for the benefit of the hormones," he says.
However, if you do have a hysterectomy, you need to monitor those hormone levels afterward, Sarrel says. He published a study that found 6 months after surgery, 25% of women's ovaries had stopped functioning due to lack of blood flow. Three years after surgery, that was the case among 40% of the women. The other 60% were totally fine, he says. "You can assume ovaries are going to continue to function, but we need to make sure they are producing regular amounts of oestrogen," he says. A surefire sign that they're not, he says, would be the beginnings of menopause-related symptoms like hot flushes, sleep problems, and feeling depressed. "All you need to do is replace estrogen, and that's the end of the symptoms."
You don't necessarily have to get rid of both ovaries.
If cancer prevention is your main objective, you'll need to have both ovaries removed. But if your concern is with one single ovary, like a cyst, it's perfectly safe and even advised to leave the healthy ovary be. "One ovary is enough to avoid changes in fertility potential and hormonal function," Siedhoff says, which means you'll keep menstruating, avoid the health risks of early menopause, and may even still be able to get pregnant.
But your fallopian tubes are coming out.
If you're getting your ovaries removed, say good-bye to your fallopian tubes. That's because there's really no good reason to keep them, since no eggs will be traveling down the tubes from the ovaries anyway. Plus, there's evidence, Siedhoff explains, that ovarian cancer doesn't always start in the ovaries, but can first grow in the fallopian tubes. Women who have had their tubes tied have a lower risk of ovarian cancer, so doctors are mostly convinced that removing the fallopian tubes is required for optimal cancer risk reduction.