Hysterectomy: Should Your Ovaries Come Out Too?

If a hysterectomy has been advised, there is a second decision hiding inside the first one: whether your ovaries come out at the same time. It is often presented as a detail, or as sensible housekeeping — while we are in there, we may as well — and it is neither. For most women under 60 having surgery for a benign condition, keeping healthy ovaries is the better default.

This article explains what the evidence actually shows, why age changes the answer, and the middle path that most women have never been offered.

What do the ovaries actually do after childbearing is over?

This is the misunderstanding the whole conversation rests on. Most women are told, in effect, that the ovaries make eggs and hormones for having babies, so once the family is complete they are spare parts.

They are not. Before the menopause, the ovaries are the body's main source of oestrogen, which acts on blood vessels, bone, brain, skin and the urinary tract. And they do not switch off at menopause either — the post-menopausal ovary continues to produce androgens, some of which the body converts into oestrogen, for years afterwards. Removing them is not the same as letting the menopause happen; it is an abrupt, total and permanent withdrawal.

What does the evidence actually show?

The most useful data come from a very large study that followed around thirty thousand women for twenty-eight years after hysterectomy for benign disease — roughly seventeen thousand who had their ovaries removed and thirteen thousand who kept them.

The women who had their ovaries removed had a 13% higher risk of dying from any cause over the follow-up period. Coronary heart disease was higher, at around 23%. Lung cancer death was higher too. Set against that, ovarian cancer was very substantially lower — unsurprisingly, since the organ was gone.

The pattern that matters most is what happened to younger women. Among those who had the surgery before the age of 50 and never took oestrogen afterwards, the increases in death from heart disease, from cancer overall and from all causes were clearest. Where oestrogen was taken through to the average age of natural menopause, much of that excess was offset.

In other words: the harm is real, it is concentrated in women operated on before their natural menopause, and it is substantially mitigated — but not abolished — by replacing what was removed.

But doesn't removing the ovaries prevent ovarian cancer?

It does. The question is how much cancer you are preventing, and at what price.

For a woman at ordinary risk, the lifetime chance of ovarian cancer is around 1.4%. After a hysterectomy with the ovaries left in, the risk is lower still. In the long-term study above, the chance of actually dying of ovarian cancer among women who kept their ovaries was around three in ten thousand.

That is a small number, and it has to be weighed against a considerably more common set of consequences: earlier heart disease, weaker bones, and the symptoms of an abrupt menopause. Preventing a rare cancer by accepting a common harm is not automatically a good trade, and for most women under 60 it is not.

This arithmetic changes entirely if you carry a high-risk gene such as BRCA, or have a strong family history of ovarian or breast cancer. In that situation removing the ovaries is a genuinely protective operation and is recommended. The point is that it is a decision driven by your risk, not by convenience.

What is surgical menopause, and how is it different?

Natural menopause happens over years. Hormone levels drift down, the body adjusts as it goes, and symptoms usually build and fade gradually.

Surgical menopause happens in an afternoon. Oestrogen goes from normal to negligible between one day and the next, with no run-up. Women describe hot flushes that begin within days and are more intense than they expected, sleep that falls apart, mood changes, joint aches, vaginal dryness and a loss of libido that is often not warned about at all.

It is manageable, and hormone replacement makes an enormous difference when it is started promptly. But it is a different experience from the menopause your body would have arranged for itself, and women who were not told to expect it feel misled — reasonably.

Is there a middle option?

Yes, and it is the most useful thing in this article. It is now recommended practice to remove the fallopian tubes while leaving the ovaries in place.

The reasoning comes from a genuine shift in understanding. A large share of what we call ovarian cancer does not begin in the ovary at all — it begins in the fallopian tube and spreads to the ovary. That is why removing the tubes reduces the risk of ovarian cancer substantially: one large population study found around a 65% reduction after the tubes were removed.

Crucially, taking the tubes does not appear to affect ovarian function. The hormones keep coming. So you get most of the cancer-prevention benefit without the heart, bone and menopausal cost of removing the ovaries themselves.

It does not reduce the risk to zero, and it should not be described as though it does. But for a woman having a hysterectomy for a benign reason, removing the tubes and keeping the ovaries is the option that most often makes sense — and it is the one least often explained.

So when should healthy ovaries be removed?

What is not on that list: being over 40. Having completed your family. Being already in theatre. Or the sentence that gets used most often of all — so that you never have to worry about it again.

Does keeping my ovaries mean I could still need another operation?

It is possible, and it is a fair question to ask. A small proportion of women who keep their ovaries later develop an ovarian problem needing surgery — a cyst, or pain. The number is low, and importantly a second operation, should it ever be needed, does not undo the years of hormonal protection you had in the meantime.

If a cyst does turn up on a future scan, our page on ovarian cysts and how to read your scan report explains what the findings mean and what usually happens next.

Do the ovaries fail earlier if the uterus is removed?

Sometimes, and it is worth knowing. Hysterectomy can slightly disturb the blood supply to the ovaries, and on average women who have had one reach the menopause a little earlier than they otherwise would — often quoted as a year or two. This is a reason to preserve the ovaries with care during surgery, and a reason to mention new menopausal symptoms afterwards rather than assuming it is unrelated.

What should I actually ask before the operation?

That last point matters more than it should have to. A great many women discover after the operation that their ovaries were removed, and discover it from the discharge summary. The consent form usually said so. Nobody read it aloud.

Does the uterus itself need to come out at all?

That is the prior question, and it is worth asking before this one. Hysterectomy is the right answer for some women, and for many others there are steps that come first — the hormonal coil, tablets, hysteroscopic treatment, embolisation, or a uterus-preserving operation. Our pages on heavy and irregular periods, fibroids and hysterectomy itself work through the ladder.

If a hysterectomy has been advised and you have not been through those options, that alone is a reason for a second opinion, quite apart from the question of the ovaries.

Getting a straight answer in Gurugram

How this is handled here is simple enough: the two decisions are separated, they are made before the operation rather than during it, and what is planned is written down. If the ovaries are healthy and you have not reached the menopause, the default is to keep them and to discuss removing the tubes. If there is a genuine reason to remove them, you will hear the reason, and the hormone replacement plan will be agreed before the surgery rather than after.

Second opinions are actively welcomed, including on operations advised elsewhere. Bring your scan reports and the consent form you were given.

Where to see us

Dr. Anam's Women Health Clinic, Sector 51 (Mayfield Garden) and Sector 56, Gurugram. Open seven days a week, including Sundays.

The bottom line

Removing the uterus and removing the ovaries are two decisions, not one. For a woman under 60 having surgery for a benign condition, with no high-risk gene and healthy-looking ovaries, keeping them is usually the better choice — and removing the tubes while keeping the ovaries gets most of the cancer benefit without the cost.

Whatever is decided, it should be decided by you, before the operation, with the numbers in front of you. Not on the table, and not in the discharge summary.