Should I Keep My Ovaries During Hysterectomy?

For most people having a hysterectomy for a benign condition, keeping your ovaries is the better choice. Large studies consistently show that removing the ovaries before menopause raises the risk of heart disease, bone loss, cognitive decline, and earlier death, and the younger you are at the time, the steeper the toll. But this is not a one-size-fits-all answer. Your age, your reason for surgery, your cancer risk, and whether you carry certain genetic mutations all shift the calculus in ways worth understanding before you sign a consent form.

Why Your Ovaries Still Matter After a Hysterectomy

Ovaries do more than release eggs. Even after menopause, they continue producing meaningful amounts of testosterone and smaller quantities of estrogen. Research measuring hormone levels directly from ovarian veins has confirmed that this contribution persists for at least a decade past menopause.¹ Those androgens matter for bone density, muscle maintenance, mood, libido, and cardiovascular protection. When both ovaries are removed before the body would have naturally stopped relying on them, the hormonal drop is sudden and complete, unlike the gradual decline of natural menopause.

A review of androgen biology in women underscored that postmenopausal ovaries produce significant androgens for many years, meaning that removing them eliminates a hormone source the body has no other way to fully replace.² This is why the consequences of ovary removal ripple across so many organ systems and why the conversation with your surgeon should go well beyond the uterus.

The Mortality Picture and Why Age Is the Biggest Factor

The largest and most cited study on this question followed nurses for 28 years. Among those who had their ovaries removed during hysterectomy, about 17% died from any cause over that period, compared with about 13% of those who kept their ovaries.³ That gap is meaningful, but it hides an important detail: the harm concentrates in younger women.

A large population-based study published in The BMJ broke the results down by age. Women under 45 who had their ovaries removed faced about a 30% higher risk of death over 20 years compared to those who kept them. For women aged 45 to 49, the increased risk was smaller but still present. By age 50 to 54, there was no significant increase in death, and for women 55 and older, the risk was actually slightly lower, though the reduction was modest.⁴ In concrete terms, for every 71 women under 45 who had their ovaries removed, one extra death occurred within 20 years that would not have happened with ovarian conservation.

Not every study agrees perfectly. A Norwegian cohort study found no significant link between bilateral oophorectomy and all-cause or cardiovascular mortality in its total population.⁵ Differences in population, follow-up length, and how hormone therapy use was tracked likely account for the discrepancy. But the overall weight of evidence, especially from studies with longer follow-up, points in the same direction: premenopausal ovary removal carries real risks, and those risks shrink as you approach natural menopause age.

Heart Disease, Stroke, and Metabolic Changes

The cardiovascular system is one of the clearest casualties of early ovary removal. A study of premenopausal Chinese women who had both ovaries removed during hysterectomy found roughly an 18% higher risk of cardiovascular disease overall, including similar increases in stroke and ischemic heart disease.⁶ The Nurses’ Health Study II echoed this, finding that hysterectomy combined with bilateral oophorectomy carried about a 27% higher risk of cardiovascular disease.⁷

The metabolic fallout extends beyond the heart. Women who had both ovaries removed before age 50 showed higher rates of metabolic syndrome, the cluster of conditions including high blood sugar, abnormal cholesterol, and excess abdominal fat that predisposes to diabetes and heart attacks. In one controlled study, about 47% of women who had bilateral oophorectomy before 50 met the criteria for metabolic syndrome, compared with 36% of controls.⁸ Interestingly, hysterectomy itself, even without ovary removal, appears to raise diabetes risk somewhat, so having the uterus removed is not metabolically neutral either.⁹

Brain Health and Dementia Risk

One of the more unsettling findings in this field involves the brain. A long-running study from the Mayo Clinic found that women who had either one or both ovaries removed before natural menopause faced roughly a 46% higher risk of cognitive impairment or dementia, and the risk climbed the younger they were at the time of surgery.¹⁰ A subsequent meta-analysis confirmed that surgical menopause at any age was linked to faster decline in verbal memory and processing speed, while early surgical menopause, before age 45, was associated with about a 70% higher risk of dementia specifically.¹¹

Beyond cognition, mood takes a hit. A prospective study following women for a year after premenopausal ovary removal found that clinically significant depressive symptoms doubled within three months, and anxiety symptoms nearly tripled, even among women who started hormone therapy afterward. The depression persisted at 12 months, while anxiety returned to baseline.¹² These are not vague complaints about feeling “off.” These are measurable increases in diagnosable depression.

Bone Loss After Ovary Removal

Estrogen is central to maintaining bone density, so removing the ovaries predictably accelerates bone loss. A systematic review and meta-analysis found that bilateral oophorectomy was associated with about a 17% higher risk of fractures compared with keeping the ovaries.¹³ The speed of loss can be dramatic. In one study of premenopausal women who had their ovaries removed for cancer prevention, bone density at the spine dropped by about 3.5% per year and at the hip by about 2.2% per year. Women who took hormone therapy lost bone roughly half as fast, but the loss still happened.¹⁴

Sleep Disruption

Sleep is another system affected by the abrupt hormonal shift. A study comparing surgically menopausal women with those who went through natural menopause found that the surgical group had significantly worse sleep quality, shorter sleep duration, and worse sleep efficiency. They were about twice as likely to meet criteria for insomnia.¹⁵ A prospective study tracking women after premenopausal ovary removal found that sleep disturbance increased within three months and remained elevated at 12 months, with hot flashes, obesity, and smoking identified as risk factors for the worst disruption.¹⁶ For most women, sleep problems existed at some level before surgery, but ovary removal worsened them sharply. Roughly 18% of women in one trajectory analysis had persistently elevated sleep disturbance that did not resolve in the year after surgery.¹⁷

Sexual Function Depends on Timing

Concerns about sexual function after ovary removal are common, and the evidence is somewhat reassuring for older women but less so for younger ones. A study of women who had their ovaries removed later in life found no significant differences in sexual problems compared with women who kept their ovaries. Rates of issues like low desire, difficulty with lubrication, inability to climax, and pain during intercourse were statistically similar between the two groups.¹⁸

But for women who had premenopausal ovary removal, the picture is different. A study looking at sexual functioning more than 15 years after premenopausal surgery found that those women reported about three times more discomfort during intercourse and roughly 2.6 times more vaginal dryness than women who had the same surgery after menopause.¹⁹ That is a lasting effect, not something that fades with time. Again, the pattern holds: the younger you are when the ovaries come out, the greater the consequences.

When Removing the Ovaries Makes Sense

Despite all the above, there are clear situations where the balance tilts toward removal. The most straightforward is carrying a BRCA1 or BRCA2 mutation. A meta-analysis found that risk-reducing removal of the ovaries and fallopian tubes in BRCA carriers cut ovarian and fallopian tube cancer risk by about 80% and breast cancer risk by about 50%.²⁰ For these women, the cancer risk is high enough that the trade-offs of early menopause are worth accepting, typically by age 35 to 40 for BRCA1 carriers and 40 to 45 for BRCA2 carriers.

Severe endometriosis is another scenario where ovary removal comes up. When hysterectomy is performed for advanced endometriosis but the ovaries are left behind, recurrent pain has been reported in as many as 62% of cases, with about a third needing another operation. Ovarian conservation carried roughly a sixfold higher risk of pain recurrence and an eightfold higher risk of reoperation compared with removing the ovaries.^{21 22} For women with extensive disease who have already exhausted other treatments, ovary removal can be the difference between being done with the problem and facing another surgery years later.

The Reoperation Question if You Keep Them

One argument sometimes made for removing the ovaries during hysterectomy is that you might need another surgery later for an ovarian cyst, torsion, or suspected mass. How real is that risk? A study following women for up to 30 years after hysterectomy found that the cumulative chance of eventually needing oophorectomy was about 3.5% at 10 years, 6.2% at 20 years, and 9.2% at 30 years. Women who kept both ovaries had about double the reoperation risk of those who had one removed at the time of hysterectomy.²³ So the risk exists, but it is modest. Roughly 9 in 10 women who keep their ovaries will never need another operation for them, and the benefits of conservation for most women outweigh the small chance of a future procedure.

Removing the Tubes but Keeping the Ovaries

An increasingly popular middle-ground strategy is removing the fallopian tubes (salpingectomy) while leaving the ovaries intact. Research now suggests that many ovarian cancers, especially the most aggressive serous subtype, actually originate in the fallopian tubes rather than the ovary itself. A meta-analysis of 77 studies found that salpingectomy was associated with about a 49% reduction in ovarian cancer incidence.²⁴ A follow-up study from British Columbia’s cancer registry found zero serous ovarian cancers among women who had undergone salpingectomy, compared with 15 in a control group, even though several such cancers were statistically expected in the salpingectomy group based on their age profile.²⁵

A cost-effectiveness study estimated that if salpingectomy were performed routinely during hysterectomy and sterilization surgeries, ovarian cancer cases could be reduced by about 5.5%, and if extended to any eligible abdominal surgery, the reduction could reach about 15%.²⁶ This approach preserves the ovaries’ hormonal output while addressing the cancer risk that used to be the main reason surgeons offered to take the ovaries out. Many gynecologic societies now recommend discussing opportunistic salpingectomy at the time of any pelvic surgery.

The trend is already visible in practice. Among younger women with cervical cancer, the rate of ovarian conservation during hysterectomy climbed from about 55% to about 64% over just a few years, reflecting a broader shift in how surgeons weigh the risks and benefits.²⁷

What if Your Ovaries Do Come Out? Hormone Therapy Matters

For women who do have their ovaries removed before natural menopause, whether by choice or medical necessity, hormone therapy becomes a critical piece of follow-up care. A modeling study estimated that current patterns of underuse of estrogen therapy after premenopausal oophorectomy led to hundreds of additional heart disease and stroke cases over five years, with the toll growing into the thousands over longer follow-up.²⁸ A review of hormone replacement after risk-reducing surgery found that it reduces the detrimental impact on bone health, improves quality of life, and in low-risk women reduces ischemic heart disease and associated cardiovascular mortality.²⁹

A common concern, especially for BRCA carriers, is whether taking hormone therapy after ovary removal might raise breast cancer risk and undo the preventive benefit of the surgery. A large study found that hormone therapy after oophorectomy did not increase breast cancer risk in BRCA carriers. In fact, each additional year of estrogen-only therapy was associated with a modest reduction in breast cancer risk.³⁰ That is reassuring news, because many BRCA carriers have been reluctant to use hormone therapy out of fear it would cancel out their decision to have the surgery. The current evidence suggests it does not.

Still, hormones do not fully replicate what intact ovaries do. They help, sometimes substantially, but studies on bone loss, mood, and sleep all show residual effects even with hormone use. Hormone therapy is damage control, not a perfect substitute for your own ovaries.

Regret and Decision-Making

A prospective study tracking regret after hysterectomy found that about 79% of women had consistently low regret, while about 7% had high regret that did not improve over a year. The remaining group started with high regret but felt better over time.³¹ Age plays into this: women 30 or younger were nearly three times more likely to regret the surgery and about three times more likely to regret loss of fertility than women aged 31 to 49.³² While these studies focused on hysterectomy rather than oophorectomy specifically, the pattern reinforces a broader point: the younger you are, the more careful you should be about removing anything you do not strictly need to remove. Taking time to understand the trade-offs and asking your surgeon pointed questions about why the ovaries would or would not come out is one of the highest-value conversations you can have before pelvic surgery.

The Broad Effects of Early Ovarian Loss

A clinical review cataloging the consequences of early or surgical menopause described the damage as spanning virtually every major system: cardiovascular, neurologic, skeletal, connective tissue, plus quality-of-life effects involving hot flashes, mood, sleep, and sexual function.³³ This is not a single risk to weigh against a single benefit. It is a cascade that touches your bones, your brain, your heart, your sleep, and your sex life. For the average premenopausal woman having a hysterectomy for fibroids, heavy bleeding, or another benign condition, removing healthy ovaries means trading a small reduction in future ovarian cancer risk for measurable increases in several other serious health problems. For most, that trade is not worth making. The evolving strategy of removing the tubes and keeping the ovaries offers a way to address the cancer concern without triggering surgical menopause, and it is rapidly becoming the standard of care.