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HYSTERECTOMY INFO

Should You Keep One Or Both Ovaries?

To Ooph or Not To Ooph: As more information becomes known about reproductive organ health in transmasculine people, we are seeing patients given new options for retaining either one or both ovaries with their Hysterectomy surgery. What are the benefits and drawbacks of this? This rundown of the pros and cons of removing or retaining ovaries will help trans men and non-binary individuals understand what they need to know before making this important decision.

Removing Ovaries

Hysterectomy surgery removes the uterus, and may also include the removal of the cervix, one or both ovaries (oophorectomy, bilateral oophorectomy) as well as the fallopian tubes (bilateral salpingo). Current recommendations from the American College of Obstetrics & Gynecology are to remove fallopian tubes during Hysterectomy, even if ovaries are preserved, since they provide no function other than to transport eggs, can be a source of cancer, and do not produce any hormones.

Pros of Removing Both Ovaries:

  • Decrease the risk of subsequent gynecological tumours, especially if there is a family history of the BRCA gene, and because transmasculine people have increased risk factors and historically have had difficulty getting gynecological preventative care—removing the ovaries may be the best way to decrease risk for some. (Although a recent study concluded that some types of ovarian cancer may originate in the fallopian tubes, not in the ovaries, it also noted that around 30% of ovarian cancers may not originate in the fallopian tubes.)
  • Eliminate development of ovarian cysts
  • Drastic reduction of estrogen production eases dysphoria for some people.
  • Correction of high estrogen in those for whom hormone replacement therapy (HRT) has not resulted in a balanced hormone profile.
  • Because estrogen levels may drop after surgery, some people can reduce their Testosterone dosage post-op. (If you are taking testosterone and not having any bleeding, you are effectively suppressing estrogen to very low levels, possibly almost zero. For this reason, some do not experience a change in estrogen levels post-op.)

Cons of Removing Both Ovaries:

  • Loss of fertility
  • Some people may be required to include low dose estrogen with their HRT to maintain hormonal balance.
  • Increased risk of osteoporis, if not on HRT

Isn't life long HRT required if the ovaries are removed?

"Long term HRT is not required. There is a whole population subset of patients not taking hormones. Yes, they are susceptible to osteoporosis but there are other non-hormonal medications for prevention and/or treatment. If a patient wants estrogen on board then keep the ovaries, but if estrogen causes dysphoria, then using hormone replacement therapy with preferred testosterone would be better. Testosterone helps prevent osteoporosis. I ask patients that if they were without hormones, which one would they prefer to be on. If it's testosterone then they should continue testosterone. The ovaries would not provide any benefit." — Dr. Heidi Wittenberg

Retaining Ovaries

Many transmasculine people are not aware that they can choose to keep one or both ovaries, even if opting for Metoidioplasty or Phalloplasty (with or without vaginectomy.) Current methods for detecting ovarian cancer include blood tests and ultrasound, neither of which would be prevented by bottom surgery. When the ovaries are retained, the body keeps its primary source of estrogen production, which is seen as a plus for some people. However, the benefits of ovarian conservation decrease with age, and there is little benefit after age 65.

Pros of Retaining One or Both Ovaries:

  • Retaining fertility. The biggest reason to keep ovaries is if you are not sure if you want to be permanently sterile and you want the option of future fertility.
  • While there are no long term studies on the long-term risks for transmasculine people and the removal of both ovaries (bilateral oopherectomy), studies that investigated this in cis female populations concluded that there are negative health implications involving bone, heart, cognitive and sexual health. (Although it is believed that testosterone may prevent the adverse effects associated with the decreased level of estrogen, not all transmasculine people take testosterone.)
  • Natural hormone production, for those who voluntarily choose no HRT or involuntarily need to halt HRT due to loss of insurance, health issues, drug shortages, etc.
  • Prevention of osteoporosis, especially when there's a family history of severe osteoporosis and/or HRT is not used.
  • Prevention of vaginal dryness and discomfort, caused by lack of estrogen, without needing to supplement with vaginal creams or tablets.

Cons of Retaining One or Both Ovaries:

  • If one stops taking testosterone, the ovaries will no longer be suppressed and estrogen production will return, with feminizing effects.
  • Treating cysts and fibroids is more difficult.
  • Removing ovaries after hysterectomy becomes technically difficult as they fall and stick to the pelvic side walls directly over ureters and major blood vessels. There is a risk of damage to ureters and blood vessels with their removal at a later date.

What about cancer?

"In both cis and trans folks, ovaries are hard to feel on exams. Ultrasounds and blood tests have a lot of false negatives and false positives, and cannot be relied on solely for diagnosis. Even with exams, ultrasounds and blood tests, ovarian cancers are usually found once they are advanced at Stage 3 or Stage 4, usually with poor prognosis. Overall, we need better tests to detect ovarian cancer." — Dr. Heidi Wittenberg

The choice to remove one or both ovaries with Hysterectomy is very subjective and dependent on one's transition goals, personal health and family history. As this list of pros and cons reveals, there's much to consider, and speaking with a trans-knowledgeable urogynecologist or gynecologist about your needs and concerns is highly recommended before making a final decision.