Keep Your Ovaries or Remove Them? (Make the Right Decision)

[00:00:00]If you're scheduled for a hysterectomy, you're going to want to watch this video. One of the questions I get asked all the time is, "Should I remove my ovaries when I have a hysterectomy?" And the answer is, well, it depends. And it's because there's a lot of factors to take into consideration.

[00:00:16]In fact, this is one of the most important decisions you'll make before surgery because there isn't one right answer for everyone. Today, I'm going to walk you through the pros and cons of removing your ovaries versus keeping them. So, that way you can make a more informed decision and have a better conversation with your surgeon. And make sure you stay till the end because I'm going to tell you how to get my checklist. This checklist can help you be prepared for one of the most overlooked parts of surgery, so [music] stay tuned. I'm Dr. Erica Montes, a gynecological surgeon, and I performed hundreds of hysterectomies, and my goal is to help you feel informed, confident, and in control of the decisions you make about your body. Let's get into it.

[00:01:01]>> [music] [music] >> So, before we dive into the pros and cons, here's something many women don't realize. Just because you're having a hysterectomy doesn't automatically mean your ovaries need to come out. In fact, for many women, keeping their ovaries may be beneficial, but for others, removing them may absolutely be the right choice.

[00:01:29]And that's why this decision deserves more than a quick discussion right before surgery.

[00:01:34]>> [music] >> So, here's a little bit of history. For decades, removing the ovaries during hysterectomy became increasingly common, especially for women over age 45. And I'm sure you all know some women who had their ovaries removed, and their doctor told her, "This is what we recommend," and it was done. And the reason why is the thought process was simple. If the ovaries aren't there, then they can't develop cancer. And that makes sense, right? But over time we've learned that ovaries do much more than just make babies. Even after menopause, they continue producing small amounts of hormone that can affect the entire body.

[00:02:16]And that's why the conversation has evolved. So, let's break it down.

[00:02:20]So, I will review I made this board because it can get a little bit complicated, but I'll review the pros and cons of removing the ovaries and also the pros and cons of keeping your ovaries. And we'll go through each of these sections on the board. That way you can make a good decision. So, first let's review the advantages or pros of removing your ovaries. And there's two reasons. Number one, reducing ovarian cancer risk. Now, the average woman's lifetime risk of ovarian cancer is about 1 in 70. Removing both ovaries will definitely significantly lower your risk. And this is especially important if you have a strong family history of ovarian cancer or carry a genetic mutation such as a BRCA1 or BRCA2 mutation. Now, here's something else that's important that many people don't know. And you're going to want to tell your friends about this one. Many women can actually reduce their ovarian cancer risk just by removing their fallopian tubes during hysterectomy even if they keep their ovaries. And this is something that we call an opportunistic self-injectomy because we have the opportunity to remove them because we're already in the pelvis and working or doing some type of surgery.

[00:03:36]>> [music] >> And growing evidence suggests that it may reduce ovarian cancer risk substantially because many ovarian cancers are now believed to start actually in the fallopian tubes. [music] And I do this routinely on all of my hysterectomies. If you want to visualize this, go to my steps of a hysterectomy video for more information.

[00:03:56]>> [music] >> And number two, the second reason or advantage of removing your ovaries would be for treatment of certain chronic gynecological conditions. For example, women with severe endometriosis, recurrent ovarian cysts, chronic ovarian pain, those who have undergone repeated ovarian surgeries, removing an ovary or both may be the best option for that patient. And I actually remember one patient who came to me, she had already undergone three surgeries on the same ovary, and when I saw her, unfortunately, she had developed yet another large cyst and was planning for a hysterectomy for fibroids. And so, we had a long discussion about her goals, what she wanted moving forward, and at that point, removing the problematic ovary made sense for her in her situation.

[00:04:45]>> [music] >> And she felt informed, prepared, and comfortable with the decision, and she understood that she would likely need hormone therapy sooner rather than later, but she was okay with that possibility because she knew that that ovary wasn't going to give her any problems [music] anymore. Now, let's talk about the downsides of removing [clears throat] your ovaries, and this is where many women are surprised. If you're premenopausal, removing your ovaries can can cause an immediate surgical menopause.

[00:05:15]There's nothing gradual about it. Your estrogen, progesterone, and testosterone levels drop dramatically overnight, and unlike a natural menopause where hormones gradually decline over years, surgical menopause happens >> [music] >> all at once.

[00:05:31]And that's when this can lead to the symptoms such as hot flashes, night sweats, sleep disturbances, mood changes, vaginal dryness, brain fog, decreased libido, and without appropriate hormone therapy, studies have shown increased risk of osteoporosis and cardiovascular disease, >> [music] >> particularly when ovaries are removed before the natural age of menopause. And here's something else that often gets overlooked. Even [music] if you keep your ovaries, some women notice worsening hormone symptoms soon after hysterectomy because surgery can actually reduce the blood flow or blood supply to the ovaries. So, if you're already experiencing perimenopausal symptoms, this is an important conversation to have before surgery.

[00:06:18]I remember one of my patients, she was around 45. She was already dealing with symptoms like insomnia, night sweats, mood swings, and vaginal dryness before her hysterectomy.

[00:06:29]>> [music] >> But, the difference is is that we made a hormone plan before surgery. She started hormone therapy the day after surgery, and she actually did really well. And that's exactly why I'm such a big believer in having a plan before surgery rather than scrambling afterwards. You don't need to suffer. Again, if you're interested in my pre-hysterectomy hormone plan checklist, click on the link in the comments to go to my Instagram, comment hormones, and I'll DM you the list. Now, let's talk about the advantages of keeping your ovaries.

[00:07:01]Even after menopause, ovaries continue producing small amounts of hormone, including testosterone and hormone precursors that can be converted into estrogen or estradiol. And as we all know, those hormones still matter.

[00:07:15]Keeping your ovaries has been associated with benefits for bone health, heart health, sexual health, and overall longevity, which is so important, particularly in women under age 50.

[00:07:28][music] And that's one reason why current evidence generally supports ovarian conservation or keeping ovaries for average-risk women who have normal appearing ovaries at the time of hysterectomy. I've actually checked hormone levels on some patients well into menopause and surprisingly their ovaries are still producing some measurable amounts of hormone. Of course, that's not going to be true for every woman, but it is a good reminder that ovaries don't suddenly become useless after menopause. And you could ask me or sometimes even patients ask me, "Well, couldn't I just remove my ovaries and you give me hormone therapy and everything will be fine?" [music] And of course, that's a reasonable question. And while hormone therapy can absolutely be beneficial and I discuss and prescribe this every day in clinic, we still don't know if replacing or giving hormones back to you perfectly recreates everything a naturally functioning ovary does.

[00:08:30]Some women feel great on hormone therapy, others need adjustments from time to time, and unfortunately, some continue to have symptoms despite treatment. For example, I recently had a patient who chose to remove her ovaries at the age of 56 [music] at the time of her hysterectomy. We started hormone therapy the day after surgery and at about the 6-week mark, she still didn't feel quite like herself. And we're continuing to work together to optimize her treatment and I think she'll get there, but this is why informed consent is so important because we can never guarantee that hormone therapy would help you just like if you kept your natural hormones.

[00:09:12]>> [music] >> And finally, let's talk about the downsides of keeping your ovaries. The biggest one is that you still have some residual risk of ovarian cancer. [music] And you may also later in life develop ovarian cysts, ovarian [music] some other type of ovarian pathology, pain, or something that may require a future surgery. And yes, while some women will eventually need another surgery, the good news is is most won't.

[00:09:40]The risk of needing future ovarian surgery after hysterectomy >> [music] >> is estimated to be between 3 to 9%. And personally, I can count on probably two hands the number of patients I've had to take back to surgery for a new ovarian cyst after hysterectomy. So, while it does happen, it's pretty [music] uncommon.

[00:10:01]So, what's the bottom line here? If you're having a hysterectomy, don't automatically assume your ovaries should come out, and don't automatically assume that they should stay in. Remember, both options have pros and cons, and as you can remember from my board at the beginning of the video, you can see that there really isn't one right answer.

[00:10:22]Again, I'll quickly just review the pros and cons. If you remove your ovaries, a pro is it reduces your risk of cancer, it can treat chronic conditions. If you take them out, then you will undergo a surgical menopause. That's why hormone therapy plan is definitely so important.

[00:10:41]If you keep them, you still have uh natural hormone benefits, >> [music] >> and you can still be on hormone therapy if you keep them, so that is that may even help you even more. And then if you [music] keep them, a con is there's still a residual cancer risk, and there's a small risk of needing a reoperation.

[00:11:02]Again, the best decision depends on your age, your gynecological history, what symptoms [music] you currently have, your family history, your genetic risk, and your personal goals.

[00:11:13]Current trends generally favor keeping normal ovaries in average-risk women through about the age of 65, but every patient's different, and there is absolutely a role for ovarian removal in some women, particularly those with an increased genetic risk for for ovarian cancer, but for many women who are average risk, the benefits of prophylactic ovarian removal are less clear than we once thought decades ago.

[00:11:42][music] The most important thing is that you understand your options and make a decision that aligns with your health goals.

[00:11:49]So, let me know in the comments. Did you keep your ovaries or did you remove them during your hysterectomy?

[00:11:55]>> [music] >> And looking back, are you happy with your decision? If this video helped you, save it or share it with someone who's preparing for a hysterectomy, and subscribe for more women's health information that you can actually use, and I'll see you on the next one.