Aside from C-sections, hysterectomies are still the most common surgical procedure among women, but most women who undergo the procedure don't understand their full range of options before going under the knife – or leave the operating room not knowing exactly which of their organs remain.
But, reports The Washington Post, that is exactly what happens to many hysterectomy patients today.
Dr Emily Von Bargen, a urogynecologist at Massachusetts General Hospital, often sees women who have undergone a hysterectomy but don’t know exactly which of their organs were removed. “I would say 50% of patients don’t know the specifics around their surgery,” she said. “It really is mind-blowing.”
Much of the confusion boils down to two words often used to describe a hysterectomy: “total” and “partial”.
A total hysterectomy removes both the uterus and the cervix, the muscular doughnut at the base of the uterus. A partial, or supracervical, hysterectomy leaves the cervix in place. (A radical hysterectomy, a rarer procedure performed in cases of cancer, removes the uterus, cervix, surrounding tissue and sometimes the upper part of the vagina.)
The key distinction is this: a hysterectomy refers only to the uterus and cervix. Removal of the ovaries is a separate procedure, known as an oophorectomy. That means no matter what kind of hysterectomy you are getting, the ovaries may also be removed – or not.
Yet many patients still believe a total hysterectomy automatically includes ovarian removal, said Catherine (78) a moderator of the hysterectomy support forum HysterSisters who asked to be identified by her first name.
Therefore, they think a partial hysterectomy means the removal of the uterus and the cervix, but not of the ovaries or the fallopian tubes.
Adding to the confusion, some surgeons also use these terms incorrectly, said Von Bargen. “I always say, what does a hysterectomy mean to you?” she said. “Because to some people, a partial hysterectomy means keeping my ovaries.”
Dr Cheryl Iglesia, a urogynecologist in Washington, said it was also common for women to believe they had undergone a total hysterectomy, only to learn later upon examination that they still had a cervix. This means they may still need regular Pap smears.
“Some people are shocked when you tell them,” she said. In addition, “they don’t necessarily always know what happened with the tubes or ovaries”.
A 2009 survey of women in Washington who had undergone hysterectomies found that “a substantial proportion” believed they had one ovary removed, when in fact both were”.
Among more than 700 Norwegian patients who thought their ovaries had been removed, one-third actually still had ovaries, a 2024 survey found.
In 2019, a study in Michigan found that even after consulting a doctor, a “considerable proportion” of women undergoing hysterectomies did not understand which organs would be removed. Of 144 women who reported they were having a partial hysterectomy, only 15 actually did; others actually had a total hysterectomy.
“That’s crazy,” said Dr Zeinab Kassem, a fellow in maternal and foetal medicine at Tufts University and the lead author of the Michigan study. “You’re forced to speculate, why?”
One reason for the confusion, she said, could be that other common surgeries – gallbladder removal, hip replacement – typically involve a single, obvious body part. With reproductive organs, “you see them as all just one big organ, lumped together, with one purpose”, she said. “But the reality is, no, the ovaries serve a specific purpose on their own.”
Compartmentalised thinking
Historically, surgeons considered the uterus and the ovaries a package deal. The ovaries produced eggs and hormones that supported nearby reproductive organs; the uterus was where a fertilised egg implanted.
Both were thought of as essential for pregnancy, but expendable if a woman had finished having, or did not intend to have, children.
“It was a compartmentalised way of thinking,” said Dr Walter Rocca, a neurologist and epidemiologist at the Mayo Clinic who studies the consequences of ovarian removal. “The people concerned about reproduction, fertility and women’s health were not, at the same time, considering the possible effects on heart, bone, brain and other organs.”
By the 1990s, doctors were trained to remove the ovaries virtually any time they were taking out a uterus. “It was kind of the rule,” said Dr Jonathan Berek, a gynaecological oncologist who directs the Stanford Women’s Cancer Centre. “When in doubt, take the ovaries out.”
The rationale was to prevent ovarian cancer, a silent killer. Before 2008, more than half of women who underwent a hysterectomy for reasons other than cancer had their ovaries removed as well.
“At a certain point in history, it seemed everyone was just getting everything out for the most minor of indications,” said Dr Karen Tang, a gynaecological surgeon in Philadelphia. “They just didn’t realise how severe the health risks were.”
In the end, it was a layperson who challenged obstetrician-gynaecologists to look at those risks more closely. Around 2000, Janine O’Leary Cobb, a Canadian women’s health activist who ran an early menopause newsletter, grew worried about the consequences of ovary removal.
Her readers had been writing in to describe severe menopause symptoms after the procedure. Research was scarce, but there were hints in the literature that removing the ovaries increased the risk of heart disease.
It did not take having a medical background to find this practice alarming, said O’Leary Cobb, now 91. “The human body evolved a certain way for certain reasons, and taking things out willy-nilly – it just doesn’t make sense that it would have no consequences,” she said.
She shared her concerns with Dr William Parker, an Ob-Gyn and clinical professor at the University of California, Los Angeles.
Parker had written a book on women’s health in which he suggested – conservatively, for the time – that women over 45 consider having their ovaries removed as “good prevention” for ovarian cancer.
Now he wondered if he had been right. Parker called up a former student who had trained in statistical analysis and assembled a team to find out.
Working without funding, the researchers developed a mathematical model that would weigh survival rates for women who kept their ovaries or had them removed, drawing on data from 200 published studies.
The results were sobering. Parker and his colleague found that ovarian cancer, while deadly, was also rare: a woman was 35 times more likely to die of cardiovascular disease, and about three times as likely to die of hip fracture. Both ailments were risks of early menopause, an unavoidable consequence of removing the ovaries.
The decision to remove ovaries as a cancer prevention measure “should be approached with great caution”, they concluded in an initial study in 2005.
Soon, Rocca and colleagues at the Mayo Clinic added to this evidence, linking the removal of the ovaries before menopause to a higher risk of cognitive decline and dementia.
Parker, however, was not finished. He realised he could compare the long-term health outcomes for thousands of women who had had hysterectomies with or without ovarian removal, using data from almost 30 000 women in the national Nurses’ Health Study who had been tracked for decades.
By 2009, the consequences were clear: removing the ovaries was associated with an array of disease risks, including heart disease, osteoporosis, stroke, lung cancer, Parkinson’s disease and dementia. Those who lost their ovaries before menopause lived shorter lives and fared worse in almost every category compared with those who kept them. (Hormone therapy lowers some but not all of these risks.)
In fact, Parker’s 2005 model suggested that women could benefit from keeping their ovaries even after menopause, a finding supported by a secondary analysis of data from the Women’s Health Initiative. After menopause, the ovaries still produce androgens, some of which are converted into oestrogen by fat and muscle and continue to confer a protective effect.
“This is a big deal,” Parker recalled thinking. “We’re talking about women’s ovaries that are taken out by the carload.” He himself had been performing at least one hysterectomy with oophorectomy per week.
Removing essential organs
Seemingly overnight, the practice of removing healthy ovaries became “one of the most incredible controversies in the practice of gynaecology”, in Rocca’s words.
Some doctors initially resisted the idea that they had been removing essential organs without good reason. Nevertheless, over the next decade, the hysterectomy was – quietly – decoupled from ovarian removal. In one county, Rocca and colleagues documented an 80% decline in the rate of oophorectomies among premenopausal women from 2005 to 2018.
No longer were the ovaries viewed as solely reproductive organs whose purpose was limited to pregnancy and childbirth. They were also batteries that powered the body’s health, contributing to skin elasticity, heart health, brain health and bone density.
These days, instead of the ovaries, surgeons performing a hysterectomy usually remove the fallopian tubes, where most ovarian cancer is believed to originate. Yet while even the American College of Obstetricians and Gynaecologists now recommends that surgeons leave the ovaries intact, that standard has not been uniformly adopted.
In many regions of the US, for example, hysterectomy rates are declining faster among white women than black women. Compared with other groups, black women and women in the South are the most likely to have had a hysterectomy, with or without ovarian removal.
The fact that black women are more likely to have fibroids – the top reason for a hysterectomy – doesn’t fully explain this disparity, said Whitney Robinson, an epidemiologist at the University of North Carolina at Chapel Hill who studies hysterectomy rates.
“There’s not a clear sense… is this being delivered at the appropriate rate in an equitable manner?” she said. Practice also varies by surgeon, and some of these professionals trained long before the ovarian paradigm changed.
Just as the ovaries have been reconceptualised as endocrine organs that affect far reaches of the body, the uterus, too, may play a key role in overall health beyond childbearing, said Dr Elizabeth Stewart, an Ob-Gyn at the Mayo Clinic.
As a result, true hysterectomies – those limited to removing only the uterus – may still be performed too liberally. “Even among healthcare providers, there is still a perception that as long as you leave the ovaries, hysterectomy is a no-risk solution,” she said.
Removing the uterus is known to cause temporary hot flushes, night sweats and other menopausal symptoms, probably because the procedure severs a blood vessel that connects this organ with the ovaries.
Women with hysterectomies also experience menopause on average four years earlier and are at greater risk for mental health conditions, cardiovascular diseases and obesity, for reasons not fully understood.
For Stewart, this raises an important question: beyond its connection to the ovaries, is there some intrinsic, unstudied quality of the uterus that confers overall health benefits?
Her hunch is that the uterus, too, is an endocrine organ in its own right. During pregnancy and labour, it is known to produce hormones such as prolactin and prostaglandins.
“But does it play that role during the reproductive years?” she wonders. “And even more importantly, does it play that role in post-reproductive years?”
See more from MedicalBrief archives:
Alternatives to hysterectomy are underused
Increased health risks with hysterectomy alone
Prevent ovarian cancer by removing fallopian tubes, urge experts
Less invasive hysterectomy supported in stage-1 endometrial cancer
Hysterectomy may affect cognition — animal study