According to the CDC, “In 2021, the age-adjusted percentage of women age 18 and older who had received a hysterectomy was 14.6%,” making it one of the most common procedures for women. With around 129 million adult women in the US (per the 2020 census), that puts us in a ballpark estimate of 19 million “uterus-less” women in the US alone. Since millions and millions of women have experienced a hysterectomy, it must be a procedure that we understand forwards and backwards. Right? Maybe not.
Hysterectomy is a controversial topic, and we’re still learning more about how the uterus interacts with the rest of the body, revealing new information about the risks involved with the procedure. Proponents argue that it is a permanent solution to serious reproductive conditions like large uterine fibroids, adenomyosis, endometriosis, and pelvic organ prolapse with few downsides. Opponents argue that the removal of an entire organ should be considered a last resort and reserved for cancer, emergency situations, or when less invasive treatment options have already failed. So how serious is hysterectomy? After childbearing years are past, is there any harm in removing a now “useless” organ, or is prioritizing saving the uterus more important than we once thought?
What is a hysterectomy?
A hysterectomy is the removal of the uterus. A partial hysterectomy removes the upper portion of the uterus and leaves the cervix intact, while a complete hysterectomy removes the entire uterus and cervix. Sometimes hysterectomy is paired with salpingectomy (removal of the fallopian tubes) and oophorectomy (removal of the ovaries).
Because having all the reproductive organs removed comes with more complications than removal of the uterus alone, this article will simply focus on the long-term risks of hysterectomy.
Hysterectomy and heart health
According to a 2018 Mayo Clinic study published in Menopause, “Women who underwent hysterectomy with ovarian conservation were at higher risk of developing de novo (meaning new onset) cardiovascular and metabolic conditions compared with age-matched referent women.” The study compared over 2,094 women who had undergone hysterectomy, and compared their medical records to 2,094 women with intact uterus, randomly selected from the same geographical region. The study found that women in the hysterectomy group had a 14% higher risk of hyperlipidemia, 13% higher risk of high blood pressure, 18% higher risk of obesity, 17% higher risk of cardiac arrhythmia, and, concerningly, 33% higher risk of coronary artery disease, which can lead to heart attack. The study noted that women undergoing hysterectomy were more likely to have pre-existing cardiovascular issues than their healthy-uterus counterparts (perhaps because fibroids and endometriosis are both linked to cardiovascular issues), and the researchers adjusted the statistical analysis to account for this difference. Additionally, cardiovascular risk was much higher for women younger than 35 years who underwent hysterectomy; these women had a 4.6-fold increased risk of heart failure, and 2.5-fold increased risk of developing coronary heart disease [1].
The study found that women in the hysterectomy group had a 14% higher risk of hyperlipidemia, 13% higher risk of high blood pressure, 18% higher risk of obesity, 17% higher risk of cardiac arrhythmia, and, concerningly, 33% higher risk of coronary artery disease, which can lead to heart attack.
Lonely ovaries can cause problems
So, why would removing the uterus cause problems for the heart? While the uterus has no direct impact on the heart that we know of, the ovaries do have a big impact on the cardiovascular system.
Estrogen, mainly produced by the ovaries, is a key hormone for heart health. Without the uterus there to (literally) support the ovaries, ovarian health suffers.
How the uterus supports the ovaries
The uterus connects to the ovaries through blood vessels and the ovarian ligament. Without these vessels, blood flow to the ovaries is decreased. Additionally, some studies suggest that the uterus and ovaries share two-way communication to coordinate ovulation, and ovulation may suffer without the uterus present (as evidenced in this 2001 study on uterine receptors, and this even older 1994 study on capuchin monkeys that found that separating the ovary from the ovarian ligament impaired ovulation [2] [3]). When ovulation is impaired, estrogen and progesterone production is impaired, affecting the rest of the body.
Let’s take a closer look at how the ovaries respond to the abduction of their dear neighbor:
- A 2005 study that followed 259 premenopausal women for five years after hysterectomy found that menopause occurred nearly four years earlier for the hysterectomy group than in the control group [4]. (And early menopause is associated with its own health risks.)
- A 2012 study following 406 women after hysterectomy for five years found a 92% higher risk of ovarian failure compared to the control group [5].
- A 2016 study that followed 1,129 women after undergoing hysterectomy for 17 years found that lacking a uterus nearly doubled the risk of having “constant hot flushes compared to minimal hot flushes” and more than doubled the risk of constant night sweats [6].
Clearly, and as discussed in the above-mentioned Menopause article, “ovary-saving” hysterectomy procedures don’t spare the ovaries entirely. The increased risk of ovarian failure, early menopause, and severe menopausal symptoms after hysterectomy highlight the important role the uterus has on long-term ovarian (and therefore whole-body) health.
Clearly, “ovary-saving” hysterectomy procedures don’t spare the ovaries entirely. The increased risk of ovarian failure, early menopause, and severe menopausal symptoms after hysterectomy highlight the important role the uterus has on long-term ovarian (and therefore whole-body) health.
Mental health
The effects of hysterectomy don’t stop with cardiovascular risks and early menopause. Some women also experience negative mental health after hysterectomy as well.
A 2020 national study from South Korea found that hysterectomy increased the risk of depression by 16% overall, and 18% in patients under 50 [7]. A Mayo Clinic study from the same year found that hysterectomy increased the risk of de novo (new) depression by 26%, and the risk of anxiety was increased by 22%. The study followed health data for 2,094 women over a span of 23 years. In patients who were 35 or under at the time of their hysterectomy, there was a 1.5-fold increased risk of depression and 1.7-fold increased risk of anxiety [8]. Presumably, the high risk of depression for young women following hysterectomy is connected to grief over their loss of fertility. However, even women past their reproductive years can face grief following the loss of their uterus as a symbol of their femininity and motherhood.
What happens when you remove the door from the pelvic floor
Whether a hysterectomy helps or hurts your pelvic floor will largely depend on your starting point. Did your hysterectomy take place because of a grapefruit-sized fibroid that overtook your uterus? Then your pelvic floor is probably doing much better without all that weight and pressure bearing down on it! Did you have severe uterine prolapse that physical therapy failed to help? Then your urinary and bowel pelvic floor issues related to prolapse are probably much improved.
However, it’s important to note that your organs are not just floating in the body (like the ancient Greek belief that hysteria was caused by the uterus literally roaming around). The pelvic organs (bladder, uterus, and rectum) are held in place by connective tissue like fascia and ligaments, and supported by the muscles of the pelvic floor. The uterus sits in the center of these pelvic structures and provides support to the bladder and rectum. Taking out the middle of this pelvic set-up will change how weight and strain are distributed.
Additionally, this 2013 review on how hysterectomies can harm the pelvic floor highlights that hysterectomy can lessen ligament support of the vagina, leading to prolapse, and there is also the potential for nerve damage that can affect pelvic function. The authors cite pelvic organ prolapse, urinary incontinence, bowel dysfunction, decreased sexual function, and pelvic organ fistula (in which two pelvic organs become connected via a new opening) as possible complications of hysterectomy [9].
Supporting pelvic health after a hysterectomy
According to Dr. Sara Reardon (aka the Vagina Whisperer), there are simple exercises that can be added to your daily routine to help with any pelvic floor symptoms that may arise or persist after a hysterectomy. (Note: these are also great to try both before and after childbirth!)
- Low-impact activities like walking with good posture
- Coordinated breathing, focusing on expanding the ribs and diaphragm on the inhale and relaxing on the exhale
- Cat-cows (hands-and-knees position, alternate arching and relaxing the back)
- Pelvic tilts
- Kegels
Increase your level of activity at a slow-and-steady pace that feels good.
One upside is that exercise is also beneficial for cardiovascular health, mental health, and managing menopause symptoms—all the key areas that hysterectomy can affect long term.
The bottom line
Some women feel a great deal of relief after having a hysterectomy, and may only experience the benefits with none of the side effects or risks. And for many women with a variety of issues, hysterectomy may truly be the best option. But while there will likely always be cases where hysterectomies are medically necessary, continuing to learn about the body as an integrated system rather than a collection of independently-functioning parts will hopefully push less-invasive treatment options to the forefront. And, in cases where hysterectomy is still the best way forward, understanding the need to monitor ovarian health, explore additional hormone support, and support recovery through physical therapy can help women live healthier lives after surgery.
It must be a lot worse when a woman undergoes an oophorectomy with a hysterectomy.
The sudden removal of endogenous hormones (and attempt to replace them with synthetic hormones) must have massive repercussions on a woman’s mental and physical health.