A bilateral salpingo-oophorectomy, commonly abbreviated BSO, is a surgical procedure that removes both ovaries and both fallopian tubes. It is one of the most consequential operations in gynecologic surgery because, in premenopausal women, it triggers immediate and permanent menopause by eliminating the body’s primary source of estrogen and progesterone. BSO is performed for a range of reasons, from cancer prevention to treatment of chronic pain conditions, and its ripple effects on a person’s hormonal health, bone density, heart, and brain can last decades.
Why a BSO Is Performed
The reasons for removing both ovaries and fallopian tubes vary widely, but they generally fall into a few categories. The most well-known is cancer risk reduction. People who carry inherited mutations in the BRCA1 or BRCA2 genes face a sharply elevated lifetime risk of ovarian and fallopian tube cancer, and preventive BSO is one of the most effective ways to lower that risk. A prospective study of BRCA mutation carriers who underwent risk-reducing BSO found that the surgery led to the diagnosis of early-stage tumors that might otherwise have gone undetected, reinforcing the value of the procedure in this population.1CrossRef. Outcome of Preventive Surgery and Screening for Breast and Ovarian Cancer in BRCA Mutation Carriers Beyond BRCA carriers, BSO is also performed alongside hysterectomy in women being treated for gynecologic cancers such as ovarian, endometrial, or fallopian tube cancer.
Benign conditions account for another large share. Severe endometriosis, for example, sometimes responds poorly to more conservative surgeries, and adding hysterectomy with BSO can produce meaningfully better pain relief. One study found that patients who had excisional endometriosis surgery combined with hysterectomy and BSO experienced roughly two to two-and-a-half points more improvement in non-cyclical pelvic pain on a 10-point scale, compared to those who had excisional surgery alone, with gains holding through two years of follow-up.2Facts, Views & Vision in ObGyn. Excisional endometriosis surgery with hysterectomy and bilateral salpingo-oophorectomy versus excisional endometriosis surgery alone for pelvic pain associated with deep endometriosis Other benign reasons include large or recurrent ovarian cysts, ovarian torsion that has compromised both ovaries, and chronic pelvic inflammatory disease.
BSO also plays a role in gender-affirming care for transgender men and transmasculine individuals. When performed as part of a gender-affirming hysterectomy, the decision about whether to include oophorectomy involves weighing dysphoria reduction against the consequences of surgical menopause. A survey of clinicians found that about 41% encouraged removal of the ovaries at least some of the time in patients on gender-affirming hormone therapy who were undergoing hysterectomy.3Europe PMC. Gender-Affirming Hysterectomy and Oophorectomy Counseling Practices for Transmasculine Adolescents Retaining the ovaries avoids surgical menopause but carries a small ongoing cancer risk and may require continued monitoring.
How the Surgery Is Done
BSO can be performed through open surgery (a traditional abdominal incision), laparoscopically (through several small incisions using a camera and thin instruments), or robotically assisted. The laparoscopic and robotic approaches have become standard for most non-cancer cases. Compared to open surgery, laparoscopic BSO involves a longer time in the operating room, but patients leave the hospital sooner, use less pain medication afterward, and return to full activity faster.4Wiley Online Library. A comparative study of outcome of laparoscopic salpingo-oophorectomy versus open salpingo-oophorectomy Open surgery is still used when cancer is suspected and the surgeon needs direct visualization, or when adhesions from prior operations make minimally invasive access difficult. In most straightforward cases, the procedure takes between one and two hours, and patients go home the same day or the next morning.
The Hormonal Shift After BSO
For anyone who still has functioning ovaries, BSO causes an abrupt hormonal change unlike anything the body experiences in natural menopause. In natural menopause, hormone levels taper off over several years. After BSO, ovarian hormones drop within hours. Research measuring blood levels before and after ovary removal confirms rapid decreases in estradiol, progesterone, and the inhibin proteins that help regulate the reproductive hormone cycle.5Oxford Academic. Serum inhibins, estradiol, progesterone and FSH in surgical menopause: a demonstration of ovarian pituitary feedback loop in women For women who are already postmenopausal, the ovaries still produce small amounts of androgens, so BSO has a subtler hormonal impact but is not hormonally neutral.
The suddenness of this shift matters. Rather than the gradual adjustment that happens over the years leading up to natural menopause, surgical menopause hits all at once, and symptoms tend to be more intense. In a study of women who had risk-reducing BSO, about 69% reported moderate or severe menopausal symptoms an average of nearly eight years after surgery. More than half of those women reported severe urogenital symptoms like vaginal dryness and urinary problems, and roughly a quarter described severe psychological or body-wide symptoms such as sleep disruption and joint pain.6PubMed Central. Severity and duration of menopausal symptoms after risk-reducing salpingo-oophorectomy The persistence of these symptoms years later underscores that surgical menopause is not just a rough few months but a long-term health event.
Cardiovascular Consequences
Estrogen has protective effects on blood vessels, and the loss of ovarian estrogen at a young age is associated with higher cardiovascular risk. A large observational study found that women who had both ovaries removed before age 45 had roughly 44% higher cardiovascular mortality compared to women who kept their ovaries. Critically, this elevated risk appeared only in women who did not take estrogen therapy afterward. Women who used estrogen through at least age 45 did not show the same increase.7PubMed Central. Increased cardiovascular mortality following early bilateral oophorectomy
The picture gets more complicated in women who have BSO specifically for cancer prevention. A study comparing cardiovascular risk in women who had preventive oophorectomy with matched reference women found no meaningful difference in 10-year cardiovascular event risk between the groups. In fact, when the researchers extrapolated the risk out to age 60, the reference group’s risk was actually higher.8PubMed Central. Risk of cardiovascular disease after preventive salpingo-oophorectomy The difference between these findings likely comes down to population and management. Women who have BSO for cancer prevention tend to receive close medical follow-up and are frequently offered hormone therapy, which may buffer the cardiovascular impact.
Bone Density Loss
Estrogen is essential for maintaining bone density, and losing it abruptly accelerates bone breakdown. The speed of this loss after BSO is striking. In a study of high-risk women who had oophorectomy, lumbar spine bone density dropped by about 8.5% within just 18 months, with hip bone density declining by roughly 5.7% over the same period.9PubMed Central. Bone Loss Following Oophorectomy Among High-Risk Women: An NRG Oncology/Gynecologic Oncology Group study Another study of BRCA mutation carriers found annual bone density declines of about 3.5% at the lumbar spine and 2.9% at the femoral neck in women who were premenopausal at the time of surgery. Women who used hormone therapy after surgery lost bone at roughly half that rate.10JAMA Network Open. Changes in Bone Mineral Density After Prophylactic Bilateral Salpingo-Oophorectomy in Carriers of a BRCA Mutation
A systematic review and meta-analysis examining oophorectomy and bone outcomes across multiple studies found that bilateral oophorectomy was associated with a higher risk of fractures and a modestly increased risk of osteoporosis, though some individual comparisons did not reach statistical significance.11Oxford Academic. Hysterectomy, oophorectomy, and bone health: a systematic review and meta-analysis The takeaway is clear: anyone who has BSO before natural menopause should have bone density monitored and should discuss preventive measures with their doctor.
Effects on the Brain and Cognition
Some of the most concerning research on BSO involves its potential effects on brain health. Estrogen receptors are densely distributed in brain regions involved in memory, and removing the ovaries before natural menopause appears to alter cognitive trajectories. One study found that women who had BSO without estrogen replacement performed similarly on brain function tests to women roughly 10 years older who had gone through natural menopause, suggesting early estrogen loss may prematurely age certain brain networks.12SpringerOpen. Women’s Brain Health: Midlife Ovarian Removal Affects Associative Memory
Research tracking cognitive changes after premenopausal oophorectomy has found that memory decline can begin within six months of surgery. Both verbal memory and working memory were affected, but only working memory appeared to be maintained by estradiol replacement. The decline seemed to persist in women who did not take estradiol.13PubMed Central. Cognitive markers of dementia risk in middle-aged women with bilateral salpingo-oophorectomy prior to menopause This research is still evolving, and having BSO does not mean a person will develop dementia. But the pattern suggests that estrogen replacement after premenopausal BSO may be doing more than managing hot flashes.
What BSO Means for Lifespan
The question of whether BSO shortens life depends heavily on the age at surgery and whether estrogen is replaced. A large population-based study found that BSO was associated with increased all-cause mortality in women under 45 and those aged 45 to 49, but not in women aged 50 and older. In fact, for women who had BSO between ages 50 and 54, there was a trend toward lower mortality.14BMJ. Association of bilateral salpingo-oophorectomy with all cause and cause specific mortality: population based cohort study Data from the long-running Nurses’ Health Study told a similar story: among women under 50 who never used estrogen therapy, BSO was associated with about 41% higher all-cause mortality, but the increase disappeared in women who used estrogen.15PubMed Central. Long-term Mortality Associated with Oophorectomy versus Ovarian Conservation in the Nurses’ Health Study A nationwide cohort study corroborated this pattern, finding higher 10-year mortality in women with BSO, with the statistically clearest differences in women aged 45 to 54.16Annals of Internal Medicine. Long-Term Health Consequences After Ovarian Removal at Benign Hysterectomy
These findings have reshaped clinical thinking. The old practice of routinely removing healthy ovaries during hysterectomy “just in case” has fallen out of favor for most women. Current guidance generally recommends keeping the ovaries unless there is a specific reason to remove them, like a known genetic mutation, and providing estrogen therapy to younger women who do undergo BSO.
Sexual Health After BSO
Concerns about sexual function are common before the procedure, and the evidence here depends on timing. In older women who are already postmenopausal, BSO does not seem to make sexual problems significantly worse. A study comparing sexual function in older women with prior BSO to those who still had their ovaries found no meaningful differences across a range of measures including desire, lubrication, pain with intercourse, and ability to reach orgasm.17PubMed Central. Sexual function in older women after oophorectomy
Premenopausal BSO is a different story. More than 15 years after surgery, women who had BSO before natural menopause reported about three times the odds of discomfort during sex compared to women who had BSO after menopause, along with roughly two-and-a-half times the odds of vaginal dryness complaints.18Elsevier. Sexual functioning more than 15 years after premenopausal risk-reducing salpingo-oophorectomy These effects are driven by the loss of estrogen and androgens that the ovaries produce, and they can persist even with systemic hormone therapy, sometimes requiring additional local vaginal estrogen treatment.
Mental Health and Mood
The psychological toll of surgical menopause deserves its own attention. A prospective study following women for 12 months after premenopausal risk-reducing BSO found that clinically significant depressive symptoms roughly doubled by three months post-surgery and stayed elevated at 12 months. Anxiety symptoms nearly tripled at three months before gradually returning toward baseline by about a year. Overall, women who had BSO were at about three-fold increased risk of chronic depressive symptoms compared to a control group.19PubMed Central. What happens after menopause? (WHAM): A prospective controlled study of depression and anxiety up to 12 months after premenopausal risk-reducing bilateral salpingo-oophorectomy
A large cross-sectional analysis using U.S. national health survey data found that women who had hysterectomy combined with bilateral oophorectomy scored consistently higher on depression measures compared to women who had no surgery, and the association remained after adjusting for age, income, and other health factors. Interestingly, bilateral oophorectomy without hysterectomy did not show the same clear link to depression, suggesting the combination of both procedures and their associated hormonal and identity-related impacts may be particularly challenging.20Scientific Reports. Bilateral oophorectomy amplifies depression risk following hysterectomy NHANES 2006–2017
Managing Life After BSO
For premenopausal women, hormone therapy after BSO is not about comfort alone. As the mortality and cardiovascular data suggest, estrogen replacement in younger women appears to offset many of the long-term risks of ovary removal. A key concern for BRCA carriers is whether taking hormones after preventive BSO might increase breast cancer risk, since these women are already at elevated risk. The evidence on this has been reassuring. A study of BRCA1 mutation carriers found that estrogen-only hormone therapy after oophorectomy was not associated with increased breast cancer risk, and each additional year of estrogen-only use was actually associated with a small reduction in risk.21JAMA Network Open. Hormone Therapy After Oophorectomy and Breast Cancer Risk in Women With BRCA Pathogenic Variant An earlier study of BRCA1 carriers similarly concluded that hormone replacement after oophorectomy did not increase breast cancer risk and that the findings should reassure women considering preventive surgery.22American Medical Association. Hormone Replacement Therapy After Oophorectomy and Breast Cancer Risk Among BRCA1 Mutation Carriers
For women who cannot or prefer not to take hormones, several non-hormonal options exist for managing hot flashes and other vasomotor symptoms. Certain antidepressants and anti-seizure medications have been tested in randomized trials and found effective, including venlafaxine, paroxetine, gabapentin, and pregabalin.23Europe PMC. Nonhormonal management of hot flashes for women on risk reduction therapy Side effects at higher doses are more common, so finding the right medication and dose involves some trial and error.24SpringerLink. Adverse effects of non-hormonal pharmacological interventions in breast cancer survivors, suffering from hot flashes: A systematic review and meta-analysis A newer class of drug targeting a brain receptor involved in temperature regulation, called a neurokinin 3 receptor antagonist, has also shown promise. A phase 2b trial of fezolinetant found it rapidly reduced moderate-to-severe hot flashes and was well tolerated.25PubMed Central. A phase 2b, randomized, placebo-controlled, double-blind, dose-ranging study of the neurokinin 3 receptor antagonist fezolinetant for vasomotor symptoms associated with menopause Fezolinetant has since been approved for treating menopausal vasomotor symptoms and represents a genuinely new approach for people who need to avoid estrogen.
An Alternative Gaining Ground
One of the more interesting developments in ovarian cancer prevention is the idea of removing the fallopian tubes first and delaying ovary removal until closer to natural menopause. This “salpingectomy with delayed oophorectomy” approach is based on growing evidence that many ovarian cancers actually originate in the fallopian tubes, not the ovaries themselves. An observational study of women who had their tubes removed for other reasons found no serous ovarian cancers in the group, compared to the roughly five cases that would have been expected statistically.26JAMA Network Open. Outcomes From Opportunistic Salpingectomy for Ovarian Cancer Prevention
A pilot study tested this staged approach specifically in BRCA mutation carriers, removing the fallopian tubes first and planning oophorectomy for later, to see whether it was safe and acceptable to patients.27PubMed Central. Bilateral salpingectomy with delayed oophorectomy for ovarian cancer risk reduction: A pilot study in women with BRCA1/2 mutations A follow-up from a larger preference trial comparing this approach to standard BSO found differences in menopause-related quality of life at five years, supporting the idea that delaying ovary removal preserves hormonal function and its associated benefits for a meaningful stretch of time.28Oxford Academic. Menopause-related quality of life 5 years after salpingectomy with delayed oophorectomy vs salpingo-oophorectomy This strategy is not yet standard practice for BRCA carriers, and long-term cancer outcomes from the ongoing trials are still needed. But for women who are struggling with the idea of losing their ovaries at 35 or 40, it offers a middle ground that many find appealing.
Helping Patients Decide
Given everything BSO involves, the decision is rarely straightforward. For high-risk women facing preventive surgery, the calculus involves weighing a real cancer threat against the long-term costs of surgical menopause. For people with severe endometriosis, the question is whether the added pain relief justifies permanent hormone loss. For transmasculine patients, it involves balancing dysphoria, ongoing surveillance, and hormone management.
Patient decision aids have been developed to help people weigh these trade-offs. In a study evaluating one such tool for women considering salpingectomy for ovarian cancer prevention, the majority of users reported low decisional conflict, suggesting they felt clear about their values and the information they had received. About one in five, however, still reported intermediate or high conflict, a reminder that even with good information, these decisions can be genuinely difficult.29PubMed Central. Evaluation of a patient decision aid for opportunistic salpingectomy and salpingectomy as sterilization method to prevent ovarian cancer The best outcomes tend to come when people have time to understand not just the procedure itself, but the full arc of what comes after it: the hormonal changes, the treatment options, the monitoring they will need, and the real scope of both the risks and the benefits.