Does undergoing a total hysterectomy increase the risk of developing depression?

Does Undergoing a Total Hysterectomy Cause Depression?

Hysterectomy is associated with an increased risk of depression, but the relationship is complex and depends heavily on pre-existing psychological factors, hormonal changes, and the clinical context in which the surgery is performed. 1

Evidence from Guidelines

The most authoritative guidance comes from international consensus guidelines, which explicitly recognize that hysterectomy can induce psychological effects including depression, particularly in the context of gynecological cancer treatment. 1 The interdisciplinary team should be aware of the possible psychological effects of hysterectomy, including depression, loss of sexual pleasure and future childbearing. 1

The American College of Radiology (2024) acknowledges that even with bilateral ovarian conservation, hysterectomy alone is associated with elevated risk of subsequent mood disorders. 1

Key Risk Factors for Post-Hysterectomy Depression

Pre-Surgical Factors

• Pre-existing depression or anxiety is the strongest predictor of post-hysterectomy depression, more important than the surgery itself. 2
• High pre-operative anxiety scores correlate with both pre- and post-operative depression. 3
• Financial toxicity and public insurance status are associated with worsening depressive symptoms after surgery. 4
• Higher baseline pain levels predict increased depression risk post-operatively. 4

Surgical and Hormonal Factors

• Bilateral oophorectomy substantially increases depression risk due to acute estrogen and androgen deprivation. 5
• Emergency hysterectomies are associated with higher rates of post-operative depression compared to elective procedures. 3
• Premature ovarian failure following hysterectomy (even without oophorectomy) may contribute to mood disturbances that often go unrecognized without routine endocrine monitoring. 5

Population-Level Evidence

A large Taiwanese population-based cohort study (2018) found that hysterectomy increased the risk of depression with an adjusted hazard ratio of 1.35 (95% CI = 1.22-1.50), with incidence rates of 1.02 per 100 person-years in the hysterectomy group versus 0.66 in controls. 6 The risk was further amplified when hysterectomy, oophorectomy, and hormone use were considered jointly. 6

Trajectory Patterns

Recent research (2025) identified three distinct depression trajectory patterns following hysterectomy: 4

• 15.6% experience high and increasing depressive symptoms (highest risk group)
• 27.7% have high but decreasing symptoms (improve over time)
• 56.7% maintain persistently low symptoms (majority)

Important Clinical Nuances

When Depression Improves

For many women, depression actually improves after hysterectomy, particularly when the surgery treats chronic conditions causing prolonged heavy bleeding, chronic pelvic pain, or severe premenstrual syndrome. 5, 2 Depression, anxiety, body image, and gynecological symptoms improved in prospective studies at 1 and 4 months post-surgery. 2

When Depression Worsens or Persists

Depression may persist or worsen in: 5, 3, 2

• Women with pre-existing psychiatric illness or personality problems
• Those with high pre-operative anxiety about sexual function changes
• Women experiencing premature ovarian failure without hormone replacement
• Those with poor body image, worsening sexual function, or high stress at 1 month post-surgery

Critical Management Recommendations

Pre-Operative Screening

Screen for depression and anxiety before surgery, as pre-operative psychological status is the strongest predictor of post-operative outcomes. 3, 2 Identify women with high anxiety, financial stress, chronic pain, and concerns about sexual function changes. 3, 4

Hormonal Monitoring

Routine endocrinologic monitoring following hysterectomy is essential to detect the need for estrogen replacement, as the cyclical nature of hormone-related depression often remains unrecognized in the absence of menstruation. 5 Combined estrogen and testosterone replacement following bilateral oophorectomy has been shown to reduce the incidence of depressed states. 5

Psychosocial Support

Psychologists should be included in the interdisciplinary team of caregivers, with counseling offered to both the affected woman and her partner. 1 Extensive education about the surgery and its implications should be provided. 1

Common Pitfalls to Avoid

• Failing to screen for pre-existing depression and anxiety, which are the strongest predictors of poor psychological outcomes 2
• Missing premature ovarian failure after hysterectomy without oophorectomy, as symptoms may be subtle without menstruation 5
• Overlooking the need for androgen replacement after bilateral oophorectomy, which significantly affects mood 5
• Assuming all post-operative mood changes are purely psychological when hormonal deficiency may be the primary driver 5
• Not addressing pre-operative fears about sexual function, which predict post-operative depression 3