What is causing weight gain and hot flashes in a patient 3 months after robotic-assisted total laparoscopic hysterectomy (RALH) with bilateral tubal ligation (BTL), who retained her ovaries?

Ovarian Insufficiency Following Robotic-Assisted Total Laparoscopic Hysterectomy

The patient's weight gain and hot flashes 3 months after robotic-assisted total laparoscopic hysterectomy with bilateral tubal ligation, despite ovarian preservation, are most likely due to compromised ovarian blood supply leading to decreased ovarian function or premature ovarian insufficiency. 1

Pathophysiology of Post-Hysterectomy Ovarian Dysfunction

When a hysterectomy is performed, even with ovarian preservation, there can be disruption to the ovarian blood supply that may lead to decreased ovarian function. This occurs because:

• The uterine artery provides approximately 30% of the blood supply to the ovaries
• Surgical manipulation during hysterectomy can disrupt collateral blood flow to the ovaries
• Bilateral tubal ligation further compromises blood supply to the ovaries

Clinical Presentation

The patient's symptoms are classic for decreased ovarian function:

1. Hot flashes - Vasomotor symptoms due to estrogen withdrawal 1
2. Weight gain - Studies show women who undergo hysterectomy have higher risk of weight gain (mean 1.36 kg or ~3 pounds) in the first year after surgery compared to controls 2

Diagnostic Considerations

To confirm this diagnosis:

• Check FSH and estradiol levels to assess ovarian function
• Evaluate for other causes of hot flashes (thyroid dysfunction, medication side effects)
• Rule out other causes of weight gain (dietary changes, decreased physical activity)

Management Algorithm

1. Confirm diagnosis with hormone levels

   • FSH >40 IU/L and low estradiol would confirm ovarian insufficiency

2. Treatment options based on severity:

   • For mild symptoms:

     • Lifestyle modifications (cooling techniques, layered clothing)
     • Regular physical activity to help manage weight gain
     • Dietary modifications to prevent further weight gain

   • For moderate to severe symptoms:

     • Consider hormone replacement therapy (HRT) since the patient has no contraindications (no history of breast cancer) 1
     • Non-hormonal options include selective serotonin reuptake inhibitors (SSRIs) or gabapentin if HRT is declined

3. Nutritional interventions:

   • Ensure adequate calcium and vitamin D intake for bone health
   • Consider plant-based supplements like Lepidium peruvianum (maca) which has shown effectiveness for menopausal symptoms 3

Important Considerations

• Women who undergo hysterectomy appear to be at higher risk for weight gain in the first year after surgery, even with ovarian preservation 2
• Bilateral tubal ligation alone has been associated with unfavorable lipid profiles and higher frequency of hot flashes during perimenopausal years 4
• The combination of hysterectomy with bilateral tubal ligation likely compounds the risk of ovarian dysfunction

Prevention of Further Complications

• Regular monitoring of bone density if ovarian insufficiency is confirmed
• Cardiovascular risk assessment, as hysterectomy has been associated with elevated risk of cardiovascular disease even with bilateral ovarian conservation 1
• Weight management strategies to prevent further weight gain

Follow-up Recommendations

• Reassess symptoms and hormone levels in 3 months
• Adjust treatment based on symptom response and hormone levels
• Consider long-term management plan if ovarian function does not recover

This presentation of menopausal symptoms despite ovarian preservation is not uncommon after hysterectomy with tubal ligation and requires prompt management to improve quality of life and prevent long-term health consequences.