Should I have a hysterectomy and oophorectomy to treat endometriosis?

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

If you have endometriosis, you probably already know that estrogen "feeds" endometriosis growth. This is why endometriosis only affects women during their high-estrogen adult years. When your menstrual periods stop around age 50 (menopause) and your estrogen levels drop, endometriosis growth and symptoms will probably also stop (in some cases, endometriosis scar tissue remains after menopause and can cause problems).

Consider the following when making your decision about having your ovaries and uterus removed to control endometriosis:

• There is no cure for endometriosis. Hormone therapy or surgical removal of endometriosis tissue are commonly used to relieve pain. But pain commonly returns within a year or two after treatment.¹
• The ovaries produce most of your body's estrogen. Removing the ovaries (oophorectomy) along with the uterus (hysterectomy) is a last-resort treatment for endometriosis. It does not offer a guaranteed cure-up to 15% of women have pain that returns after this surgery.¹
• Hysterectomy with oophorectomy is a major surgery with short-term and long-term risks. Recovery takes 4 to 6 weeks.
• The sudden drop in estrogen after oophorectomy causes more severe menopause symptoms than you would have with natural menopause. The low estrogen also starts bone-thinning at a younger age. This increases your risk of osteoporosis later in life.
• Some doctors remove only one ovary when treating a younger woman with hysterectomy and oophorectomy.
• You have a second decision to make if you plan to have an oophorectomy: whether to take estrogen therapy. Taking estrogen therapy will protect your bones and prevent menopause symptoms after your ovaries are removed. But it may also cause endometriosis to grow back again.²
• Hysterectomy and oophorectomy may be a good option if you do not plan to be pregnant in the future, are not approaching menopause, have severe symptoms, and feel that your symptom relief will outweigh the risks and side effects of having the surgery.

For more information about whether to take estrogen therapy, see:

Should I use estrogen replacement therapy (ERT) after a hysterectomy or oophorectomy?

Medical Information

What is endometriosis?

The endometrium is the tissue that lines the uterus. During each menstrual cycle, a new endometrium grows, getting ready for a possible pregnancy. If you don't become pregnant during that cycle, the endometrium sheds, which you know as your menstrual period.

Endometriosis is endometrium tissue that grows outside of the uterus, usually on the ovaries or fallopian tubes or on the outer surface of the uterus, the bowels, or other abdominal organs. In rare cases, it can affect other organs and structures in the body.

Endometriosis growths are called 'implants.' These implants grow, bleed, and break down with each menstrual cycle, just like the endometrium does. This can cause pain and can make it difficult to become pregnant (infertility). In some cases, scar tissue forms around implants. Scar tissue can also cause pain and infertility and can interfere with an organ's normal function.

What are the risks of endometriosis?

While some women never have symptoms, others have severe pain. In some cases, endometriosis interferes with other organs, such as the bowels or bladder.

When is hysterectomy and removal of the ovaries an option for the treatment of endometriosis?

Hysterectomy and oophorectomy are considered a last-resort treatment for endometriosis. This is because it is a major surgery that results in permanent infertility, and removing the ovaries causes a sudden drop in estrogen. This causes sudden, usually severe menopause, difficult side effects, and bone-thinning. Normally, a woman takes low-dose estrogen to prevent these problems after having an oophorectomy. But taking estrogen may also increase the risk that endometriosis will return.

Hysterectomy and removal of the ovaries may be a treatment option when:

• Endometriosis symptoms decrease your quality of life.
• Scar tissue impairs the function of abdominal organs (although scar tissue can usually be surgically removed without also taking the uterus and ovaries).
• You have tried treatment with hormone therapy and continue to have pelvic pain or other symptoms.
• You have no future plans for childbearing.
• Your symptoms outweigh the risks and long-term effects of the surgery. This includes the long-term risks of taking estrogen therapy to protect against bone-thinning after your ovaries are removed versus the risk of osteoporosis if you don't take estrogen therapy.

How effective is hysterectomy and removal of the ovaries for the treatment of endometriosis?

Oophorectomy and hysterectomy is highly effective in relieving endometriosis pain.² But pain does return for up to 15% of women.¹ Your risk of recurring endometriosis increases if you take low-dose estrogen to protect your bones and prevent menopausal symptoms after surgery.² This is because estrogen "feeds" endometriosis.

What are the risks of having an oophorectomy and hysterectomy?

After oophorectomy

Perhaps the most important long-term issue to consider is your body's early drop in estrogen after an oophorectomy. Without estrogen, you have difficult menopausal symptoms (hot flashes, vaginal dryness, moodiness, depression), and your bones begin to thin. This increases your risk of osteoporosis in later life. Taking estrogen therapy can prevent these effects.

If you don't want to take estrogen, you can take another type of bone-strengthening therapy to protect your bones after oophorectomy. For more information on prevention, see the topic Osteoporosis.

Risks of estrogen replacement therapy

Estrogen replacement therapy (ERT) increases your risks of:³

• Stroke. ERT use slightly increases the risk of stroke during the first year of use.⁴
• Blood clots. ERT slightly increases the risk of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism), which can be life-threatening. This risk is greatest in the first year of use.⁵
• Breast cancer. Research is mixed on breast cancer risk, although a slightly increased breast cancer risk after 10 years of use is possible.^{6, 7}
• Uterine (endometrial) cancer (only if you have a uterus). Taking progestin with estrogen eliminates this risk.⁶
• Gallstones. Women who use estrogen replacement therapy are 2 to 3 times more likely to have gallstones than women who do not use it.⁸
• Asthma. Newly diagnosed asthma appears to be more common among women taking estrogen than women who are not. (Estrogen is thought to be a factor that causes asthma or makes it worse across the life span.)⁹
• In some cases, a worsening of endometriosis.
• Ovarian cancer (which is rare). In women using ERT over 5 years, the number of ovarian cancers is slightly higher. Using ERT causes ovarian cancer in about .4 per 1,000 women. (This is the same as 1 in 2,500 women.)¹⁰

After hysterectomy

Most women do not have complications after a hysterectomy. But complications can include:

• Fever. A slight fever is common after any surgery.
• Difficulty urinating.
• Continued heavy bleeding. Some vaginal bleeding within 4 to 6 weeks after a hysterectomy is expected. But call your health professional if bleeding continues to be heavy.
• Continued pain. Pelvic pain that was present before surgery may not be relieved by surgery.
• Change in sexual function.
• Rare complications. These include infection; blood clots in the legs (thrombophlebitis) or in the lungs (pulmonary embolus); the formation of scar tissue; injury to other organs, such as the bladder or bowel; a collection of blood at the surgical site (hematoma); heart problems; breathing problems; and problems from anesthesia. In very rare cases, complications from surgery lead to death.

If you need more information, see the topic Endometriosis.

Your Information

Your choices are:

• Have a hysterectomy and oophorectomy to treat symptoms caused by endometriosis.
• Continue to use more conservative measures, such as hormone therapy to treat endometriosis or laparoscopic surgery to remove endometriosis and scar tissue.

The decision about whether to have a hysterectomy takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having an oophorectomy and hysterectomy to treat endometriosis. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have an oophorectomy and hysterectomy.

Check the box below that represents your overall impression about your decision.

Return to the topic Endometriosis.

References

Citations

1. American College of Obstetricians and Gynecologists (1999). Medical management of endometriosis. ACOG Practice Bulletin No. 11. Obstetrics and Gynecology, 94(6): 1-14.

2. Speroff L, Fritz MA (2005). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1103-1133. Philadelphia: Lippincott Williams and Wilkins.

3. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321-333.

4. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Stroke. Obstetrics and Gynecology, 104(4, Suppl): 97S-105S.

5. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Venous thromboembolic disease. Obstetrics and Gynecology, 104(4, Suppl): 118S-127S.

6. Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419-427.

7. Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701-1712.

8. Hammond C (1999). Climacteric. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 8th ed., pp. 677-697. Philadelphia: Lippincott Williams and Wilkins.

9. Barr RG, et al. (2004). Prospective study of postmenopausal hormone use and newly diagnosed asthma and chronic obstructive pulmonary disease. Archives of Internal Medicine, 164(4): 379-386.

10. Beral V, et al. (2007). Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet, 369(9574): 1703-1710.