Will hormone levels be affected in a patient who has undergone a hysterectomy with ovaries left in place?

Hormone Levels After Hysterectomy with Ovarian Conservation

Hormone levels can be affected after hysterectomy even when both ovaries are preserved, though the ovaries typically continue to produce hormones and most women maintain normal ovarian function.

Expected Hormonal Changes

Ovarian Function Generally Preserved

• The postmenopausal ovary remains a critical source of androgen throughout the lifespan when conserved during hysterectomy 1
• Women with hysterectomy and ovarian conservation typically maintain estradiol levels comparable to women with intact uteri, particularly after age 55 2
• For women under 55 years, those with hysterectomy and ovarian conservation may have slightly higher estradiol levels (ratio 1.24) compared to women with intact uteri 2

Potential Alterations in Ovarian Function

• Some women experience altered ovarian function after hysterectomy, manifested by elevated FSH levels and reduced ovarian stromal blood flow 3
• Approximately 22% (14 of 62) of women with conserved ovaries who were not on hormone replacement had FSH levels ≥20 IU/L, suggesting ovarian insufficiency 4
• Women with hysterectomy show significantly lower ovarian stromal blood flow indices (vascularization index, flow index, and vascularization flow index) compared to controls, despite similar ovarian volumes and antral follicle counts 3

Androgen Levels

• Testosterone levels are intermediate in women with hysterectomy and ovarian conservation—lower than intact women but higher than those with bilateral oophorectomy 1
• Total and bioavailable testosterone levels are reduced by approximately 40% in women with bilateral oophorectomy compared to intact women, with intermediate levels in those with ovarian conservation 1
• Androstenedione levels are approximately 10% lower in hysterectomized women regardless of ovarian conservation status 1

Clinical Implications

Who Needs Hormone Assessment

• Women under age 50 with conserved ovaries should be systematically reviewed for potential hormone deficiency 4
• Assessment is particularly important for women experiencing menopausal symptoms (hot flashes, night sweats, mood changes, sexual dysfunction) despite ovarian conservation 4

Recommended Screening Approach

• Check FSH, estradiol, and progesterone levels in symptomatic women or those under 50 with conserved ovaries 3
• FSH ≥20 IU/L with low estradiol suggests ovarian insufficiency requiring hormone replacement consideration 4
• Consider three-dimensional ultrasound with power Doppler to assess ovarian stromal blood flow if available, though this is not standard practice 3

Hormone Replacement Considerations

When to Consider HRT After Hysterectomy

• Women with hysterectomy and conserved ovaries who have elevated FSH (≥20 IU/L) and menopausal symptoms are candidates for hormone replacement 4
• Approximately 84% (16 of 19) of women identified as potentially benefiting from estrogen replacement after systematic review initiated and continued treatment at 6 months 4

HRT Regimen for Hysterectomized Women

• Estrogen-only HRT should be prescribed to hysterectomized women, as there is no therapeutic advantage in prescribing progestins without a uterus 5
• The exception is women with residual intra-peritoneal endometriosis, who may require progestin 5
• Transdermal 17β-estradiol (50-100 micrograms daily) is preferred as it avoids hepatic first-pass effect and has better safety profile than oral formulations 5

Common Pitfalls to Avoid

Assumption of Normal Function

• Do not assume all women with conserved ovaries maintain normal hormone production—systematic screening identifies a significant subset requiring replacement 4
• The absence of menstruation after hysterectomy masks the typical indicator of ovarian failure, making biochemical assessment essential 4

Timing of Assessment

• Ovarian function changes may not be immediately apparent; some women develop insufficiency months to years after surgery 3
• Even with bilateral ovarian conservation, hysterectomy alone is associated with elevated risk of cardiovascular disease and mood disorders, suggesting subtle hormonal alterations 5

Long-term Monitoring

• Women with conserved ovaries after hysterectomy should have ongoing assessment of menopausal symptoms and consideration of hormone levels if symptoms develop 4
• The decision regarding hormone replacement should consider individual patient preferences and risk factors 6