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Losing last ovary, do I keep my uterus? Losing last ovary, do I keep my uterus?

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Unread 02-12-2006, 09:54 PM
Losing last ovary, do I keep my uterus?

I am scheduled for surgery on Feb. 20th to have a dermoid cyst removed on my remaining ovary. (first was removed 20 years ago). My ObGyn tells me it is unlikely she will be able to save my ovary. She recommends I leave my uterus in tact. The ObGyn I went to for a second opinion says I should have it removed because HRT is less complicated without a uterus.

I can find lots of info about removing ovaries along with uterus, but what about leaving your uterus in place, but having no ovaries? Any advice?
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Unread 02-13-2006, 06:49 PM
Losing last ovary, do I keep my uterus?

Boy, that's a tough question. I did find this website that talks about uterine function in the absence of ovaries or ovarian function. Here is an exerpt:

"Does the uterus secrete proteins or hormones independent of ovarian function?
The uterus secretes hormones and proteins but they are almost always in response to the cyclical hormonal changes from the ovaries or the prolonged high levels of hormones during pregnancy. Various prostaglandin hormones, cellular growth factors and other compounds are made in response to the changing hormones and the lining of the uterus (endometrium). After the ovaries are non functional such as with surgical or natural menopause, there are no hormones or proteins that are secreted into the body's blood stream that I am aware of. Certainly the muscle cells of the uterus secrete enough local substances that have to do with keeping the cells alive but those substances are pretty much confined locally and do not have any systemic effect.

With the above general comments about the lack of any general hormone secretion from the uterus after menopause already expressed, there are some notable exceptions. It is likely that the local effects of some of the uterine proteins are perceived under special circumstances after menopause. The main one I am aware of is in response to sexual stimulation and intercourse. The physiologic response of blood vessels swelling full of blood during sexual arousal is likely a systemic response of nerves going directly to the blood vessels and not from secretions of the uterus, however there are more blood vessels to become swollen if the uterus is still in place. The substances that cause uterine contractions during orgasm probably do come from the uterus even after menopause. If the uterus is removed, not only do the secreted substances fail to be produced but also their target organ, the muscles of the uterus are gone. Thus the feeling of light uterine cramps during orgasm is gone after hysterectomy.

Does the uterus contribute to sexual response or desire?
As described above, the uterus definitely plays a role in sexual response. It undergoes vascular congestion during arousal and then rapid drainage of the vascular congestion after orgasm (climax). Also there are rapid small amplitude contractions of the uterine muscle during orgasm as well as contractions of the vagina and urethral muscles. After hysterectomy those uterine contractions with orgasm disappear although some contractions are still present in the lower genital tract. Most women will report a difference in orgasm after hysterectomy but not necessarily less enjoyable. There is a current trend among some physicians and patients to perform or request a subtotal hysterectomy in which the main uterine muscle and lining are removed (body of uterus) while leaving the cervix. As you can imagine, it is very difficult to study whether the small amount of muscle in the cervix (it is mostly just connecting tissue and not as much muscle) preserves any degree of uterine contractions during orgasm. I would guess that the cervix alone would not contribute that much.

The genital changes that take place during a sexual response according to the Masters and Johnson classification are:

Excitement phase - vaginal lubrication, vasocongestion, separation of the lips of the vaginal opening (labia majora), vaginal walls thicken, early uterine elevation, lengthening of the vagina
Plateau phase - uterine elevation, clitoral elevation, vaginal expansion, maximum lubrication, outer third of vagina forms orgasmic platform
Orgasm phase - uterine contractions, tenting effects of vagina, orgasm contractions
Resolution phase - sexual flush disappears, changes go in reverse
As you can see, most of the same changes will take palce after hysterectomy as before hysterectomy except uterine elevation and uterine contractions and the vasocongestion that takes place in the pelvis above the vagina.

The problem with most of the scientific studies that have been done on the effect of hysterectomy on sexual response, is that the investigators often lumped together many situations which confuse whether or not a postoperative change is due to the removal of the uterus alone or due to other factors. For example it is well known that menopause itself reduces sexual desire and sexual response because of the loss of estrogen. Even if estrogen is replaced, it can be less than perfect at restoring preoperative sexual desired and response.

One study (1) looked at body image and sexuality in three groups, a control group with no surgery, a hysterectomy group and women having removal of the ovaries with and without hormone replacement. They found NO differences in mood (measured by patient questions) or vaginal blood flow (measured by instruments) and a woman's subjective arousal to an erotic stimulus. They did however find that women who had had an oophorectomy and either had no estrogen replacement or estrogen replacement without testosterone had significantly lower self-reported desire and arousal than any of the remaining groups. This study and others (2, 3) imply that the main problem after hysterectomy is lack of desire (libido) if the ovaries are removed, but not the ability to undergo sexual arousal in response to an erotic stimulus. This may be able to be overcome by adequate testosterone replacement along with estrogen replacement. (See also testosterone article)

Another factor often forgotten in clinical studies is what was the degree of satisfaction with one's sexual partner and sexual desire prior to the surgery. An interesting Scandinavian study (4) looked at 104 women having subtotal hysterectomies. Sexual desire, activity, satisfaction and dysfunction were compared between women without, with a poor, and with a good partner relationship prior to the surgery. They found an improved sexuality, one year post hysterectomy, in 61% of women with a good partner relationship, in 17% of those with a poor relationship but no improvement was seen in women who had no regular partner relationship. Therefore it is extremely important in your judging of medical data that purports to show either positive or negative change with hysterectomy, that the study took into account preoperative partner satisfaction. This study concluded that "women with no or with ambivalent partner relationships are more at risk for deterioration of sexuality after hysterectomy. "

Does the uterus help support the pelvic structures and its removal cause prolapse?
The uterus and top of the vagina are supported in the pelvis by several attachments to the strong tendons and ligaments of the pelvis bone. I do not know if the scientific names of these areas are important to you -- pubovesicocervical fascia, rectovaginal fascia, uterosacral ligaments and cardinal ligaments -- but the concept is important to grasp (5). All of these attachments are cut during hysterectomy and as long as they are reattached to the end of the vagina, prolapse should not occur very frequently. You would think that this is a very easy task surgically but those support ligaments are not visable most of the time. They are below a layer(s) of tissue and there may be breaks in those connections at invisible places other than their attachments to the uterus and vagina.

For example a common instance of prolapse occurs after hysterectomy for uterine fibroids. The uterus is enlarged and the size alone may support the uterus in the pelvis so that breaks in the ligaments are not appreciated before surgery. Then within 3-12 months after surgery, the vaginal vault and the bladder drop down. This causes many women to conclude that hysterectomy "causes" prolapse when in fact a better term would be that potential prolapse was being prevented by the enlarged uterus. This can happen to all surgeons such that even with appropriate surgical repair, the abdominal pressures shift from the repaired points to the weakest anatomical points in the lower pelvis. Thus different areas seem to "fall down" even after successfull surgical repair. "

Here is the link it came from:

I personally had everything removed so I don't have any personal experience to contribute here, but I thought the above info might help you some. Hopefully someone will come along with more insight. I hope this helps at least a little.
Unread 02-14-2006, 05:25 AM
Losing last ovary, do I keep my uterus?

HI JulieGator

I'm so sorry you are faced with this tough decision.

I'm sure it is even harder when you have different opinions from different doctors. I'm glad you are doing your research ahead of time.

If your ovaries are removed, you would go in to instant surgical menopause. You would probably need to use some form of estrogen to help ease your menopause symptoms. I believe the main difference with HRT and keeping your uterus would be that you would need to use a progestin or natural progesterone along with estrogen in order to protect your uterus.

Women that go through natural menopause and still have a uterus can not use only estrogen because there is an increased risk of uterine cancer. They have found that adding a progestin or natural progesterone protects the uterus from the unopposed estrogen.

Women without a uterus can use only estrogen. They do not have to use a progestin or progesterone because there is no risk to the uterus involved. (Although many women in surgical menopause without a uterus still choose to use progesterone to help balance their hormones.)

A great example would be that women without a uterus can use premarin = estrogen only.

Women with a uterus need to use
Prempro = estrogen/progestin.

It may be helpful to do some reading about hormones before making your decision. Some women find there are more side effects while using a progestin verses natural progesterone. The problem is that not all doctors are aware that there is a difference between the two and are not as knowledgeable in prescribing natural progesterone.

Here are some links that may be helpful.

Hormone jungle articles

Hormone resources

It may also be helpful to visit the Ovaries Only forum and talk with some women who there who have had to make the same decision.

Ovaries only

It may be helpful to speak with both doctors are length about the pros and cons to keeping your uterus and their HRT choices after your surgery. A third opinion may even be helpful so you have a better understanding.

Best wishes

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Unread 02-14-2006, 09:01 PM
Losing last ovary, do I keep my uterus?

Troubled Tabby and Nature Bound -
Thank you both for your thorough and helpful replies! I so appreciate it.

I met with another Dr. today for a 3rd opinion and feel so much calmer now. He was incredibly helpful, great bedside manner, answered all my questions and more.

I've cancelled my surgery for Monday and am going to reschedule with him for mid-March. I am glad to have the extra time for additional research - this Monday date (just 10 days from the date my Dr. discovered the cyst) felt too fast.

This new Doc is recommending I have my uterus removed, (easier HRT, less bleeding, no chance of uterine cancer, etc.) but was understanding and supportive of my desire to keep it.

I am still not sure what I will do - but just feel so relieved to have a little more time to think it through.

Thanks again to both of you for listening and answering. You are blessings!

Unread 02-14-2006, 09:48 PM
Losing last ovary, do I keep my uterus?

Hey JulieGator!
Glad to see you posted here and it looks like you got some good feedback. I love this website and learn so much from reading on the forum. Even though I got to keep both ovaries I still worry about losing them in the future and also about adhesions etc... so I think I'll hold on to the new support system I have found between hystersisters and dermoidsisters (that is what I am calling our other forum). Take care!

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