Menopause after hysterectomy: symptoms with ovaries intact, surgical menopause and HRT

You've had a hysterectomy, and now something feels different. Maybe you're waking up hot in the night. Maybe your mood has dipped, or you just don't feel like yourself. Yes, you can have symptoms of menopause after hysterectomy with ovaries intact. And without periods to go by, it's hard to know what's going on.

So does a hysterectomy cause menopause? It mostly depends on your ovaries. If both ovaries were removed, menopause starts straight away. This is called surgical menopause. If your ovaries were kept, you won't go into menopause straight away, but it may come sooner than it would have done.

This guide explains the difference, the symptoms to look out for, how you can tell when you've reached menopause, and the treatments worth talking through with your GP.

The first point comes from the NHS guide to recovering from a hysterectomy. The second is from the NHS page on bleeding after menopause, which says to see a GP even if it's only a small amount or only happened once.

Does a hysterectomy cause menopause?

A hysterectomy is an operation to remove the womb. Your periods come from the womb, so they stop. The NHS says that if you haven't already gone through menopause, you'll no longer have periods, whatever your age.

But menopause isn't really about periods. It's about your ovaries, which make the hormone oestrogen. So what happens next depends on which type of operation you had. The NHS describes four main types:

Type of hysterectomy	What's removed	Menopause
Total	Womb and cervix	Not straight away, but may come sooner
Subtotal	Main body of the womb (the cervix stays)	Not straight away, but may come sooner
Total with bilateral salpingo-oophorectomy	Womb, cervix, fallopian tubes and both ovaries	Straight away
Radical	Womb and nearby tissue, including the tubes, ovaries, part of the vagina and lymph glands	Straight away

If you're not sure what you had, your discharge letter or your GP can tell you.

Why your ovaries matter

The NHS page on things to consider before a hysterectomy says healthy ovaries help protect your bones and support your sex drive. It says ovaries should only be removed if there's a significant risk of disease, such as ovarian cancer.

If you haven't had your operation yet and would like to keep your ovaries, the NHS suggests telling your surgeon before the operation.

Surgical menopause: when your ovaries are removed

If both ovaries are removed, the NHS says you'll go through menopause straight after the operation, whatever your age. This is surgical menopause.

It can feel very different from a natural menopause. Normally, oestrogen falls slowly over several years. Women's Health Concern, the patient arm of the British Menopause Society, explains that this slow drop is why natural symptoms often come and go. With surgery, the change happens all at once.

The NHS recovery guide says you'll usually get severe menopause symptoms after the operation. It lists:

• hot flushes
• sweating
• anxiety
• weepiness

On top of this, you're healing from a big operation. It's no wonder many women feel knocked sideways. You're not imagining it, and you're not being weak.

Symptoms of menopause after hysterectomy with ovaries intact

If your ovaries were kept, they carry on making hormones for now. You won't have periods, but your hormones still follow their own path towards menopause.

The NHS says there's a chance this will happen sooner than it would have done. How much sooner isn't clear. A 2011 US study followed women aged 30 to 47 for up to five years. Women who'd had a hysterectomy, without both ovaries removed, were nearly twice as likely to have their ovaries stop working during that time as women who hadn't had the operation. The researchers estimated it happened about two years earlier. But they said it's not clear whether the surgery causes this, or the health problem that led to it. It's one study, so it's a guide, not a promise.

The symptoms are the same as at any menopause. The NHS page on early menopause lists:

• hot flushes and night sweats
• vaginal dryness
• poor sleep (our guide to menopause insomnia can help)
• low mood, or mood swings
• problems with memory or concentration, often called brain fog

The tricky part is that you can't use your periods as a clue. So the symptoms themselves become the main sign. Keeping a simple note of what you notice, and when, helps a lot. Our free perimenopause symptoms checklist lets you tick things off and take it to your GP. For the full list of what can happen, see our guide to perimenopause symptoms.

How do you know you're in menopause after a hysterectomy?

Usually, menopause means 12 months without a period. That doesn't work if you have no womb. So doctors go by other things.

• If you're 45 or over: NICE, which writes the guidance doctors follow, says menopause can be identified without blood tests in people who've had a hysterectomy. It's based on the type and mix of symptoms you have, such as hot flushes.
• If you're 40 to 45: NICE says a doctor may consider a blood test for a hormone called FSH to help confirm it.
• If you're under 40: NICE says the diagnosis should be based on your symptoms plus raised FSH on two blood samples, taken 4 to 6 weeks apart. One test isn't enough.

Women's Health Concern agrees that if you've had a hysterectomy, blood tests may be used, because your periods are no longer a guide.

If you'd like to know more about the stages, our guide to perimenopause vs menopause explains them in plain words.

What if it happens before 45?

The NHS says early menopause is when it happens before 45, and premature menopause is before 40. Surgery to remove your ovaries is one of the causes it lists.

This matters for your long-term health. The NHS says it's important to replace the missing hormones if menopause starts before 45, because there's a higher chance of problems with your bones and heart.

If both your ovaries were removed, the NHS hysterectomy guide says it's important to carry on with HRT until you reach the usual age of menopause. It gives 51 as the average. NICE says much the same for women under 40.

Our guide to early menopause symptoms goes into this in more detail, including POI (premature ovarian insufficiency).

HRT after a hysterectomy: what to talk about

The NHS says that after a surgical menopause you should be offered HRT (hormone replacement therapy). Whether it's right for you is your choice, made with your GP or specialist. Here are some things worth asking about.

Oestrogen-only HRT. NICE says people who've had a total hysterectomy should be offered oestrogen-only HRT. People who still have a womb are offered combined HRT instead. NICE explains that for people with a womb, oestrogen-only HRT raises the risk of womb (endometrial) cancer.

Breast cancer risk. For people without a past breast cancer, NICE says there's very little or no increase in breast cancer risk with oestrogen-only HRT.

If you had a subtotal hysterectomy. NICE's advice on oestrogen-only HRT is for a total hysterectomy. If your cervix was kept, or you had other surgery too, ask which type suits you.

It won't be an exact match. The NHS says the HRT you're offered is unlikely to exactly match the hormones your ovaries made.

It isn't for everyone. The NHS says HRT isn't recommended for women who've had a hormone-dependent breast cancer or liver disease.

If you'd rather not take HRT, or can't, our guide to menopause without HRT sets out the other options. If you take any medicines, don't stop or change them without talking to your GP or pharmacist first.

Looking after your bones and heart

Lower oestrogen can lead to thinner bones (osteoporosis) and a higher risk of heart disease, says Women's Health Concern. This is true at any menopause. It's even more important to think about if yours came early.

Women's Health Concern suggests some simple everyday steps:

• Eat well. A balanced diet, low in saturated fat and salt, with plenty of calcium and vitamin D.
• Move. Aim for 150 minutes a week, mixing things like walking or swimming with strength exercise, such as weights.
• Stop smoking, if you smoke.
• Keep alcohol down. Under 14 units a week, with at least two alcohol-free days.

Once you're healed from your operation, ask your GP or nurse when it's safe to start building up exercise again.

How you might feel

A hysterectomy can stir up a lot of feelings. The NHS recovery guide says you may feel a sense of loss and sadness afterwards. It also says that for some women, a hysterectomy can trigger depression. If those feelings won't go away, see your GP.

If your menopause came early, it can be a lot to take in on top of everything else. The NHS says you can refer yourself to NHS talking therapies without seeing a GP first. The NHS also points to the Daisy Network, a support group for women with premature menopause.

When to see your GP

Book an appointment if:

• you've had both ovaries removed and haven't been offered or talked about HRT
• you had your surgery before 45 and have menopause symptoms
• your ovaries were kept and you think menopause symptoms are starting
• symptoms are affecting your sleep, work, relationships or mood
• you notice any bleeding from the vagina after menopause

You don't need to be sure. Saying "I think this might be menopause" is enough to start the conversation.

Where relaxation fits in

If hot flushes arrived suddenly after surgery, and they're breaking up your nights or leaving you frazzled during the day, you might like something calming to come back to. Cool and Calm, our hypnosis download for menopause hot flushes, is a gentle relaxation with soft cooling imagery, to help you unwind and drift off. It's a relaxation recording, not a treatment, and it doesn't replace advice from your GP.

Related: early menopause symptoms, perimenopause vs menopause and hot flushes.

This page is general information, not medical advice. If you're worried about any symptom, please talk to your GP or pharmacist.