One gynecological topic that I get a lot of questions about is relating to hysterectomies. More specifically, how does having a hysterectomy impact a woman’s hormones and what can women do to reduce side effects and lingering symptoms after having a hysterectomy procedure; but also, should a woman even have a hysterectomy in the first place?
I want to acknowledge, first of all, that a hysterectomy can be life saving and when I was starting out in private practice as a gynecologist, obstetrician and surgeon, back decades ago… a hysterectomy was considered “standard of care” (the typically recommended treatment that is also most often covered by insurance) for uterine cancer as well as many non-cancer-related conditions (fibroids, heavy bleeding, cramping, etc.)…but after seeing so many women suffer from lingering symptoms AFTER a hysterectomy I started drilling down into the research. I asked myself, “What were the underlying causes that led to the hysterectomy to begin with and how could I address those sooner?”
I soon realized that a repetitive sequence was occurring; and this sequence seemed to almost always end in a hysterectomy. Outside of cancer, I thought this was fixable, and that’s when I started to advocate for addressing the root cause of these symptoms, often an issue of hormone imbalance, where the uterus was the “victim”, notthe cause of symptoms, and there might be a better way rather than resorting to invasive surgery.
The sequence went this way. Female patients in their 30’s would start to have worsening PMS symptoms, irritability and mood swings. The conventional “standard of care” treatment for the “witchy” behavior might be a prescription such as Prozac, an SSRI, or other anti-anxiety or antidepressant.. Along with that prescription, PMS symptoms such as a heavy period, break-thru bleeding and cramping (and other uterine issues such as ovarian cysts) would be addressed by simply shutting down the uterus and ovaries! This is often accomplished by putting women on birth control pills in order to do that.
We now know that birth control pills can cause a whole variety of incremental hormone imbalance and health issues, including estrogen dominance (bringing with it many quality of life affecting symptoms), reductions in healthy levels of thyroid hormones, deficiencies in vital nutrients (such as magnesium) and impacts to emotional well-being, just to name a few. (learn more about the side effects from taking birth control pills on my good friend Dr. Jolene Brighten’s website).
In most cases the pill didn’t resolve the core symptoms or may even have made them worse, so next came the standard of care procedures; often starting with an ablation (a procedure that destroys the lining of the uterus with a goal to reduce menstrual flow), and then a hysterectomy. Often the ovaries may be removed at the same time as well.
Low and behold, though, even after a hysterectomy a woman’s symptoms often continued to linger, or new ones appeared (including early onset menopause, low libido, pain with sex, incontinence, vaginal dryness, pelvic prolapse and more).
Recent research has also shown linkages between having a hysterectomy and an increased risk for heart disease and possibly even dementia. (1,2)
While it is true that a hysterectomy may still be the best strategy for certain health scenarios such as cancer, most of the hysterectomies that occur today are not about cancer. By the age of 60, more than one-third of all women have had a hysterectomy (estimate by the National Women’s Health Network), most for conditions unrelated to cancer. This is a staggering number and made worse when you reflect on the fact that many of the women are still in their reproductive years when they have their hysterectomy. Approximately 23.3% of women ages 18 years and older in the US have had a hysterectomy. (3)
"I also want to emphasize that when I started my practice as an OB/GYN I was doing 2-3 major surgeries every 1-2 weeks, but as I became skilled at addressing and fixing the root cause I went to 2-3 surgeries per year!"
So what do you need to know about the pros and cons of having a hysterectomy,and what do you need to know should you have already had one?
In this 2-part series I’ll be talking to you about,
The word hysterectomy originates from the latin root “hyster”, which stands for womb.
A hysterectomy is the surgical removal of part of or the entire uterus; it also sometimes includes the removal of the cervix, fallopian tubes and the ovaries. The uterus is where a baby develops (referred to as the womb) and as you’ll see in the graphic is co-located with a number of important organs such as the ovaries, cervix, vagina, bladder and pelvic floor. This is an important point as ligaments and nerves are tightly interconnected to create a well-supported set of organs.
Medical practitioners used to think the uterus was basically about two things: carrying a baby or a location for common cancers in women. Note that this philosophy meant that if a woman had already had children the mentality was that she no longer needed her uterus…or ovaries for that matter…and that they “could” be a potential site for cancer. So if you don’t need them, go ahead and get rid of them!
In the past 25 years or so, however, we have learned so much more. We now know that many hormones and chemicals specifically target the uterus (not to mention the ovaries), and we know there are many important hormone receptors in the uterus (beyond reproductive hormones, including thyroid hormone receptors and even my favorite hormone, oxytocin). The ovaries also produce oxytocin and hormones such as testosterone even over the age of 65.
The uterus has influence on the state of the ovaries; we know that removing the uterus expedites a woman going into premature menopause. We also know that having a uterus is associated with fewer issues in heart health, immunity, blood-pressure, mood and more. Oh, and let’s not forget that there is something called a uterine orgasm, too!
Even with all of the knowledge about the importance of a woman’s uterus, hysterectomy is one of the most common major surgeries among women of reproductive age. Approximately 600,000 hysterectomies are performed annually (as of 2013) in the US, second only to cesarean sections (C-sections), which are the most common (don’t get me started on those either, in terms of women having them when not truly a medical necessity…we’ll talk about that in a future blog…major impacts to the baby’s gut microbiome and more…).
Today, a lot of hysterectomies are not for cancer or for life-threatening reasons. They are for what is referred to as “benign” reasons. Benign conditions are definitely still quality-of-life affecting, and insurance covers treatment of most of the conditions. Don’t get me wrong, these conditions need to be addressed, but there is a wide variety of non-surgical alternatives or less invasive surgical procedures available. We’ll talk about these alternatives to hysterectomy (also helpful in reducing symptoms in the aftermath of a hysterectomy) in Part 2 of this series. These less invasive alternatives focus on the underlying root cause of many uterine conditions, which is hormone imbalance.
So what are the types of conditions that have been historically addressed with a hysterectomy?
Benign (quality-of-life affecting) conditions include:
Medical (life-threatening) conditions include:
The good news is that more recently the trend is for fewer hysterectomies for benign conditions among reproductive-aged women. But we want to see that number decrease even more! There are still too many hysterectomies performed today for benign conditions. (If we are being faced with the recommendation of a hysterectomy, we must think to ourselves, have all the underlying issues been resolved? Whether we have the hysterectomy or not, we must still address the root causes.)
Whether the entire uterus is removed, just parts, or whether the cervix, fallopian tubes or ovaries are also removed, has implications relating to,
A partial hysterectomy (referred to as a subtotal hysterectomy or a supracervical hysterectomy) removes the upper part of the uterus but leaves the cervix in place. A total hysterectomy not only removes the entire uterus but also the cervix (we’ll talk later about the ramifications of this, but it can include incontinence as well as impacts to sexual function).
Often when uterine cancer is present a radical hysterectomy is performed, which removes the entire uterus, the tissues along the sides of the uterus, the cervix and even the top part of the vagina.
In 2015, according to the CDC, 54,644 cases of uterine cancer were reported in the US. That means that out of 100,000 women, 27 new cases were reported (and 5 died).
Other organs can also be removed, such as the ovaries (known as an oophorectomy), even a woman’s fallopian tubes (salpingectomy). Having both of these removed is called a salpingo-oophorectomy. Some women remove these as a pre-emptive strike against the risk of ovarian cancer. Ovarian cancer is the second most common gynecologic cancer, and although it causes more deaths than other types of gynecologic cancer it isn’t as commonly seen, accounting for only about 3% of all cancers. In 2015 there were 21,429 reported cases of ovarian cancer in the US. That means that out of 100,000 women, 11 new cases were reported (and 7 died).
There are a few different types of hysterectomy that are performed.
Abdominal hysterectomy, considered an open surgical procedure, refers to removal of the uterus through an incision made in the abdominal wall/belly area. Historically it has been the most common hysterectomy performed. Recuperation may take 2-3 days and there is a scar. This is considered the most invasive hysterectomy procedure.
There are two less invasive approaches as well: Vaginal hysterectomy and Laparoscopic hysterectomy. In general these surgeries provide for a faster recovery, can reduce the length of hospital stays, reduce the time a woman needs to rest in order to recuperate, result in less pain and scarring, and may lower the chance of infection. A surgeon needs to evaluate each case based on the individual woman and her health, to determine whether she is a good candidate for a less invasive procedure. Underlying health issues, obesity, uterus size, previous surgeries and other health factors may come into play.
Vaginal hysterectomy is the removal of the uterus through the vagina.
Laparoscopic hysterectomy is where a tube, surgical tools and camera are inserted through small cuts made around the belly button. The surgeon views the insertion of the tube and surgical tools on a video screen. Laparoscopic surgery can also be used to assist in vaginal hysterectomies. These were my personal favorite to perform because I could observe more non-invasively. There are also robot-assisted laparoscopic surgeries.
The trend is for a greater number of hysterectomies to be performed as same-day outpatient surgery (in 2008 approximately 13.3% of hysterectomies were outpatient versus 57.5% in 2014) (5)with fewer abdominal surgeries (most invasive) and more vaginal or laparoscopic surgeries.Abdominal surgery was still the most common approach within the inpatient setting, but overall that more invasive procedure dropped from 49.5% (of all surgeries) in 2008 to 28.1% in 2014. This is fantastic progress.
While more women are opting for minimally invasive surgery, I’d like to see more women opting out of surgery all-together for benign conditions, assuming she and her doctor can agree on an alternative plan. At the very least, I’d like to see more education (for patients, but frankly, we could use additional training within the medical community) relating to the effectiveness of non-surgical treatment. In the meantime, I’m happy to at least see a downward trend for the most aggressive hysterectomy surgeries for benign conditions.
A patient once told me, “Hysterectomies run in my family!”. She said it as if it was diabetes or heart disease. This was actually really intriguing. While a hysterectomy is a surgical procedure so is not itself something that is influenced by genes, some of the conditions or risk factors that may result in the decision for a hysterectomy are definitely influenced by genetics, including cancer, fibroids and endometriosis. (6)
One example of a possible “genetics” role leading to hysterectomies can be seen with African – American women and fibroids. African-American women were found to be more predisposed to larger and more symptomatic fibroids (more pain, etc.) requiring surgical remedies at an earlier age than Caucasian women, and researchers concluded there was a racial difference in the development of fibroids. (7) Among over 95,000 premenopausal women included in the Nurses Health Study II, African-American women had three times the odds of a diagnosis of fibroids compared to Caucasian women. If you’re interested, you can read more about ethnic differences, benign conditions and hysterectomy rates.
Cancer is another genetically linked condition where women may choose to have some form of hysterectomy or may have only their ovaries removed (while not having a hysterectomy and leaving the uterus intact). This is often referred to as “risk-reducing surgery” (RRS). Hereditary gynecological cancers where this surgery may be performed include hereditary breast cancer (women having mutations in the breast cancer susceptibility BRCA1 and BRCA2 genes), hereditary ovarian cancer and a condition called Lynch syndrome (associated with ovarian and endometrial cancers). The challenge, today, is that there isn’t a reliable approach for early detection for ovarian cancer (and it has a generally poor prognosis), so many women opt to have at least their fallopian tubes and ovaries removed.
While genetics can come into play (again relating to a heritable condition), for many benign conditions it is likely that demographics, environment, lifestyle, nutrition, and attitudes play a more major role than genetics in whether a given woman has a hysterectomy.
Certainly where you live (rural or urban, for example…and there are regional differences too) may influence the attitude, expertise and recommendations of your physician. Rates of hysterectomy have traditionally been higher in the South and Midwest versus rates in the West and Northeast.
It has actually been reported that younger gynecologists or those in an academic setting are less likely to choose a hysterectomy for their patients. Training is important, as are the appropriate surgical resources, especially for the more minimally invasive surgery options. And in an interesting survey – given to practicing gynecologists and surgeons, one of the biggest concerns relating to hysterectomy decisions was technical difficulty. Simply put, the less invasive surgeries like laparoscopic surgery requires a surgeon have training, but also,surgical volume such that they gain surgical expertise. (8)
Both the physician’s attitudes about hysterectomy (and whether to remove the ovaries at the same time, I might add) as well as a patient’s family history of hysterectomy, are two of the defining factors relating to many women’s decision to have a benign condition corrected via hysterectomy. It’s hard to say “no” to a procedure if all the women in your family have always had it.
Lifestyle and clinical factors such as BMI, diet, diabetes, smoking, alcohol intake, exercise, and hypertension have also been reported in some studies to increase the risk of fibroids. Women who are obese have been found to have an increased risk for developing a variety of gynecological conditions such as heavy menstrual bleeding and endometrial hyperplasia. As an aside, being obese increases surgical time and may also increase a woman’s risks for having complications during the procedure as well. (9)
Exposure to toxins has also been associated with fibroids, such as exposure to bisphenol A (found in your kitchen!). (10) Poor diet (such as exposure to endocrine disruptors in our meat supply) and environmental toxins can further throw off hormone balance. All of these factors can increase the incidence of fibroids and other uterine conditions which can lead to higher rates of hysterectomy, but fortunately…lifestyle modifications to avoid these risk factors can help you avoid a hysterectomy. (11)
I’ll talk about alternatives to hysterectomy in Part 2 of this series, “Is Hysterectomy Optional?” But prior to a woman deciding to have a hysterectomy she should understand the known side effects and potential risks associated with the particular type of hysterectomy her surgeon is recommending. Be your own advocate!
Outcomes are generally good with a fairly low risk of immediate complications (again, that risk goes up with obesity or other underlying health issues such as diabetes, etc.). But many women find that some of their initial issues aren’t resolved, and additional symptoms can often be seen.
Some of the potential side-effects of a hysterectomy are noted below.
Along with impacts to estrogen (should a woman go into premature menopause after her hysterectomy or should she have her ovaries also removed) the reduction in androgens (which can convert to estrogens) can cause additional impacts to a woman’s mood and libido. (13)
Think back to the graphic of the pelvic region. Many of the long-term effects that are frequently seen as a result of hysterectomy relate to the pelvic floor area, including conditions such as: pelvic organ prolapse, structural pain, urinary incontinence, bowel dysfunction, pelvic organ fistula formation and impacts to sexual function. This is because hysterectomy distorts pelvic anatomy and may disrupt local nerve supply.
There are many nerve endings, tendons and ligaments around the vagina and uterus, and throughout the pelvic region. During a hysterectomy many of these attachments are cut. Even with re-attachments made there is opportunity for some of the supporting structure to be damaged or weakened.
Clearly there are many potential side effects of a hysterectomy, so we really don’t want to have one if we can safely avoid it. Again I am specifically referring to benign conditions, not cancer or emergency situations.
There are alternative medical treatments (procedures, less invasive surgeries, and hormones) as well as many lifestyle interventions that can help women avoid more aggressive surgery (diet, exercise, supplements, detox strategies, adrenal support, etc.). Women need to be sure to discuss their own particular health situation – and safest alternatives – with their physician.
Note that most of these therapies can also help you should you already have had a hysterectomy and are dealing with some of the symptoms and side-effects I’ve mentioned earlier.
In Part 2 of this series, “Is Hysterectomy Optional?” I’ll be discussing,
Don’t forget you can also read my book, “The Hormone Fix”, for the latest on woman’s health! Learn all about my Keto-Green diet and lifestyle which can be key to addressing “all that ails a woman” (for real!)
Looking for a healthy dish that’s both tasty and easy to make? Try my Cruciferous Veggie Bake recipe from The Hormone Fix.It’s sure to please any crowd!
Cruciferous Veggie Bake
MAKES 4 TO 6 SERVINGS
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