Question 1

Did the surgery do this?

Accepted Answer

I started with India's menopause guideline, which the Indian Menopause Society rewrote this February. It defines a menopause caused by treatment as one that comes from removing both ovaries, pelvic radiation, chemotherapy, or shutting the ovaries down with drugs. A hysterectomy with the ovaries kept is not on the list. The ovaries make most of a woman's oestrogen and progesterone. They're beside the uterus, so when the uterus is removed and the ovaries are left in, they keep working. A hysterectomy ends your periods. On its own, it doesn't give you menopause. By the guideline's definition, then, the surgery didn't cause menopause. Her symptoms are still there.

Question 2

Then why does it feel like it?

Accepted Answer

The next thing I found surprised me. After a hysterectomy, the ovaries may stop working sooner than they would have. A study in North Carolina followed 406 women who had a hysterectomy and kept at least one ovary, and 465 women who had no surgery. Blood tests every year, for up to five years. The women who kept both ovaries reached ovarian failure at 1.74 times the rate of the women with no surgery. The gap came to about two years. That's an average across the group, and it can't predict what happens to one woman. A study in Auckland found menopause came 3.7 years earlier in women whose hormone levels were normal before surgery. It used a single blood test to decide menopause, which is unreliable in your forties. It found the same direction of effect, with less certainty about its size. India's guideline agrees. A hysterectomy for a non-cancer reason, even with the ovaries kept, leads to earlier ovarian failure than in women who keep their uterus. Why? One idea is blood supply: surgery near the ovaries may change how much blood reaches them. Another is that whatever led to the surgery may also contribute. The North Carolina researchers call it unresolved. Then there's age. India's average age at natural menopause is 46.6, about four to five years earlier than in white women, whose average is about 51. The guideline calls that an approximation. In her late forties, she's past India's average. She may be in menopause, and the surgery may have brought it a little earlier.

Question 3

How would anyone know?

Accepted Answer

Most women can track the transition through their periods: cycles change length, a month is skipped, and then a year passes without one. She has no periods to track. STRAW+10, the system researchers use to stage the transition, says women who've had a hysterectomy can't be staged by bleeding, so they can only be assessed on hormone tests. For natural menopause, the Indian guideline says FSH, oestradiol and AMH blood tests are not recommended for diagnosis, at its strongest grade. Doctors go by age, symptoms and the pattern of periods. Further in, the guideline has a table of tests to be done "solely on indication", and women who have had a hysterectomy are listed on it for both FSH and oestradiol. That means a doctor may order these tests when there's a reason to. A related recommendation in the same guideline is worded differently and is based on expert opinion. So a test is something she can ask her doctor about. STRAW+10 adds two things: wait at least three months after surgery, because surgery can raise FSH for a while, and repeat the test, because one reading can be misleading. The UK's NICE guideline differs. For women 45 and over who've had a hysterectomy, it identifies menopause from the type and combination of symptoms, without a blood test. And the shrunken ovaries on her scan? Neither guideline uses ovary size to stage a woman after a hysterectomy, so the scan can't tell her what stage she's in.

Question 4

What about the bloating, the BP and the TSH?

Accepted Answer

I found less on these. I went looking for a study that tied bloating to menopause. The closest was a review of ten small human studies on menopause, sex hormones and the gut. Five found less variety in gut bacteria. None followed the same women through the transition, and none showed that menopause causes bloating or new reactions to food. For blood pressure, there's SWAN, a long-running US study of women through the transition. It looked at which heart risk factors change with menopause and which change with age. Cholesterol changed with menopause. Blood pressure, sugar and insulin changed with age. There were no Indian women in it. For the thyroid, an eight-city study in India found about one adult in ten with an underactive thyroid. Women had it three times as often as men. That's four symptoms that could go to four specialists: a gastroenterologist, a physician, an endocrinologist and a gynaecologist. Each could be right about their part without seeing the other three.

Question 5

What if hormone therapy comes up?

Accepted Answer

She'd also told me she wants to stay away from medicines where she can. If it ever comes up, one thing changes without a uterus. For women with a uterus, hormone therapy pairs oestrogen with a progestogen, which is there to protect the lining. Without one, the standard is oestrogen on its own. India's guideline names three exceptions where a progestogen is still added after a hysterectomy: Lining tissue left behind, for example after a partial hysterectomy or an ablation A history of endometriosis An early-stage cancer of the womb lining Adenomyosis isn't on the list, though adenomyosis and endometriosis often occur together, so this one is a question for her doctor rather than something a guide can settle. The guideline also says the evidence for these exceptions is limited.

Question 6

What will she find online?

Accepted Answer

Searching online, she'll find long-term studies of women after a hysterectomy. The main one is from a single county in Minnesota. About 2,000 women who had a hysterectomy with their ovaries kept, followed for a median of 22 years, each matched to a woman of the same age without surgery. The women who had surgery had higher rates of five heart and metabolic conditions, from 13% higher for high blood pressure to 33% higher for coronary artery disease. New depression was more common by 6.6 percentage points over 30 years. New anxiety by 4.7. The raised rates were concentrated in the women who had the surgery youngest, at 35 or under. The study is observational. The women were mostly white, with surgeries between 1980 and 2002. An earlier study by the same group found obesity was already more common in these women before surgery. And the authors note that low mood may have been part of why some of them had the operation. On memory, large studies found no higher dementia risk for women who kept their ovaries. The higher risk was linked to early menopause itself, before 40, whatever the cause.

Question 7

How many women is this?

Accepted Answer

In India's latest national family health survey, 3.3% of women aged 15 to 49 had had a hysterectomy. By their forties, it's closer to one in ten. The median age at surgery was 36 in cities and 34 in villages. The most common reason women gave was heavy bleeding or pain, named by about half of them. Like her, none of them have periods to track.

Question 8

What could she ask?

Accepted Answer

Here are five questions she could take to her next appointment. Were both my ovaries kept? Was there any sign of endometriosis during the surgery? Would an FSH and oestradiol test, repeated, help in my case? Could my TSH be its own thing? Can one person look at all of this together? If you've had a hysterectomy and kept your ovaries, what were you told about what comes next? Write to me at hello@spotyellow.com.

“I had a hysterectomy. Am I in menopause?”