Surgical Menopause

What happens in surgical menopause

The ovaries make most of the body's estrogen and progesterone, and about half of its testosterone before menopause. In natural menopause, levels fall gradually over several years (perimenopause). When both ovaries are removed, levels drop within days.

Removing the uterus alone (hysterectomy) with the ovaries left in place does not cause immediate menopause, though periods stop and menopause may come slightly earlier. Removing only the fallopian tubes (salpingectomy) does not cause menopause.

Why ovaries are removed

• ovarian, fallopian tube or uterine cancer
• risk reduction in people with BRCA1 or BRCA2 mutations or Lynch syndrome, usually recommended between ages 35 and 45 depending on the gene
• severe endometriosis
• ovarian cysts or masses
• pelvic infection or abscess
• sometimes at the time of hysterectomy for other reasons, though keeping healthy ovaries is now generally recommended before natural menopause

Symptoms

Symptoms often begin within days to weeks and can be more severe than in natural menopause:

• hot flashes and night sweats
• sleep disturbance
• mood changes, irritability, anxiety and depression
• difficulty concentrating and memory problems
• vaginal dryness, itching and pain during sex (genitourinary syndrome of menopause)
• low libido, partly from loss of ovarian testosterone
• joint aches
• urinary urgency and recurrent urinary infections
• dry skin and hair changes

Long-term health risks

The risks are greatest when surgical menopause happens before age 45, and especially before 40, without hormone replacement:

Treatment

Hormone therapy

For most people with surgical menopause before the average age of natural menopause (about 51), guidelines recommend hormone therapy unless there is a reason not to use it. Benefits include relief of symptoms and protection of bones and possibly the heart and brain.

• estrogen alone if the uterus has also been removed
• estrogen plus a progestogen if the uterus remains, to protect the uterine lining
• transdermal patches, gels or sprays carry a lower risk of blood clots than tablets
• doses needed by younger women are often higher than those used in natural menopause
• testosterone may be considered for low libido

The risks of hormone therapy that apply to older women after natural menopause (such as breast cancer and clots) do not appear to apply in the same way to younger women replacing hormones their bodies would naturally make.

When hormones are not suitable

People with hormone-sensitive breast cancer, some other cancers or a history of blood clots may not be able to take estrogen. People with BRCA mutations without breast cancer can usually use hormone therapy until natural menopause age after discussion with their specialists. Non-hormonal options include:

• SSRIs or SNRIs such as paroxetine, venlafaxine or escitalopram
• gabapentin
• fezolinetant, a non-hormonal medicine for hot flashes
• vaginal moisturizers and lubricants; low-dose vaginal estrogen may be acceptable even for some cancer survivors after specialist discussion
• cognitive behavioral therapy for hot flashes, sleep and mood

Lifestyle

• weight-bearing exercise and strength training for bones
• calcium and vitamin D
• not smoking and limiting alcohol
• cooling measures: layered clothing, fans, cool bedroom
• heart health checks: blood pressure, cholesterol, blood sugar

Monitoring

• bone density scan (DEXA), often within a few years of surgery
• regular cardiovascular risk assessment
• review of hormone therapy at least yearly

Frequently asked questions

What is surgical menopause?

It is menopause that begins immediately after both ovaries are surgically removed. Because hormone levels fall suddenly, symptoms are often more intense than in natural menopause, and long-term health risks are higher if it happens before 45.

How soon do symptoms start after oophorectomy?

Symptoms such as hot flashes and night sweats often begin within a few days to weeks after surgery as estrogen levels fall rapidly. Some people start hormone therapy right after surgery to prevent or reduce symptoms.

Should I take HRT after surgical menopause?

For most people who have surgical menopause before about age 51 and have no contraindications, hormone therapy is recommended until the average age of natural menopause to relieve symptoms and protect bones, heart and brain. Discuss your individual risks with your doctor.

Does a hysterectomy cause menopause?

Removing the uterus alone stops periods but does not cause immediate menopause if the ovaries are left in place. Menopause happens immediately only if both ovaries are removed.