In the Clinic with Camille
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Do the ovaries work without the uterus?
Although the ovaries and uterus work hand-in-hand (so to speak), for a long time we've thought that ovarian hormone production would continue more or less unchanged if someone needed to have a hysterectomy.
It turns out that removing the uterus does affect ovarian function.
In this episode, I share some of the newer studies looking at how hysterectomy affects ovarian function & hormone production, as well as some outstanding questions to consider.
The key takeaway point?
It's all connected.
The uterus and the ovaries are likely in close communication with each other.
We don't fully understand this relationship yet, but it's logical and fascinating.
As we learn more about physiology, I imagine we'll continue to uncover obvious-in-retrospect ways that different organs, systems, cells, and tissues interact with one another.
In the meantime, I view this as more evidence that bodies are complex and that our herbal, nutrition, diet and other recommendations may be working via multiple pathways.
References about the ovaries + the uterus
Atalay, M. A., Cetinkaya Demir, B., & Ozerkan, K. (2016). Change in the ovarian environment after hysterectomy with bilateral salpingectomy: Is it the technique or surgery itself? European Journal of Obstetrics, Gynecology, and Reproductive Biology, 204, 57–61. https://doi.org/10.1016/j.ejogrb.2016.07.483
Chun, S., & Ji, Y. I. (2020). Effect of Hysterectomy on Ovarian Reserve in the Early Postoperative Period Based on the Type of Surgery. Journal of Menopausal Medicine, 26(3), 159–164. https://doi.org/10.6118/jmm.20010
Iwase, A., Nakamura, T., Nakahara, T., Goto, M., & Kikkawa, F. (2014). Assessment of ovarian reserve using anti-Müllerian hormone levels in benign gynecologic conditions and surgical interventions: A systematic narrative review. Reproductive Biology and Endocrinology: RB&E, 12, 125. https://doi.org/10.1186/1477-7827-12-125
Moorman, P. G., Myers, E. R., Schildkraut, J. M., Iversen, E. S., Wang, F., & Warren, N. (2011). Effect of hysterectomy with ovarian preservation on ovarian function. Obstetrics and Gynecology, 118(6), 1271–1279. https://doi.org/10.1097/AOG.0b013e318236fd12
Singha, A., Saha, S., Bhattacharjee, R., Mondal, S., Choudhuri, S., Biswas, D., Das, S. K., Ghosh, S., Mukhopadhyay, S., & Chowdhury, S. (2016). DETERIORARON OF OVARIAN FUNCTION AFTER TOTAL ABDOMINAL HYSTERECTOMY WITH PRESERVARON OF OVARIES. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 22(12), 1387–1392. https://doi.org/10.4158/EP161215.OR
Trabuco, E. C., Moorman, P. G., Algeciras-Schimnich, A., Weaver, A. L., & Cliby, W. A. (2016). Association of Ovary-Sparing Hysterectomy With Ovarian Reserve. Obstetrics and Gynecology, 127(5), 819–827. https://doi.org/10.1097/AOG.0000000000001398
Yuan, Z., Cao, D., Bi, X., Yu, M., Yang, J., & Shen, K. (2019). The effects of hysterectomy with bilateral salpingectomy on ovarian reserve. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 145(2), 233–238. https://doi.org/10.1002/ijgo.12798
Transcript of The Ovaries Need the Uterus episode
Well, hi there, welcome to In the Clinic with Camille. My name is Camille Freeman. I'm a clinical herbalist and a licensed nutritionist, and I focus on helping other clinicians work with complicated cases and/or building and growing their practices.
So today, I want to share with you something that I have learned about recently relating to the uterus and the ovaries, which if you know me at all, you will know is one of my very favorite things to talk about.
So this isn't directly relevant to your clinical work, but I think that it may help frame the way you think about the body or reinforce the way that you think about the body in a sort of nonlinear way.
So here this has to do with hysterectomy. And just in case you need a short review, hysterectomy is when the uterus is surgically removed and you can have a hysterectomy and leave one or both ovaries intact or you can have a hysterectomy where the ovaries are taken out as well.
And generally speaking, most physicians will try to leave the ovaries in, if at all possible, with the idea that you're not going to plunge someone into a rapid menopause.
We've always thought, OK, well, the ovaries are really under the control of the hypothalamus and the pituitary.
Right. And so that's where they're getting their signals to keep producing follicles and to make estrogens and progesterone and so on and so forth.
So taking out the uterus should be fine because the ovaries can still kind of bop along and do their thing without the uterus.
And it's turning out that the ovaries need the uterus, that there is a relationship between the ovaries and the uterus.
And by fiddling around with one, you are affecting the other.
Now, what I don't want you to take away from what I'm getting ready to say is that people should not have a hysterectomy. That is absolutely not my message.
There are plenty of people who very much need a hysterectomy.
And I don't want you to be discouraged if you yourself have had one or if it is indicated for you in the future because that is not my message here. The message is really just about how interesting the body is. That is the takeaway point of what I'm getting ready to tell you. It's very cool.
So there's a bunch of studies that started coming out, as far as I can tell, really in the early kind of 2010s, looking at, well, what do we notice about the way the ovaries function if we take out the uterus?
And what they found is that when you take out the uterus, the person will enter menopause more quickly than people who have their uterus intact, that the ovaries stop working as well when you remove the uterus.
So just to give you a little refresher here, one of the main ways that we now measure ovarian reserve, which is just how many functional follicles and ovaries are left, are follicles or eggs are left in, the ovaries is antimalaria and hormone. Antimalaria and hormone is essentially a signaling molecule that is made from the granuloma cells in the follicles of the ovary.
And it is a marker of ovarian reserve.
So the more antimalaria hormone or AMH someone has, the farther away they are from menopause and the more robust their ovarian reserve is.
They've got lots of ovary, ovarian reserve, lots of follicles left.
If the AMH levels are high and as they start to go down, that person gets closer to menopause.
Sometimes we'll also look at FSH or follicle-stimulating hormone, which is, as you probably recall, a hormone that is produced in the anterior pituitary gland and that stimulates the follicles, hence the name follicle-stimulating hormone.
So it's going to stimulate the granulosa cells in particular.
And as menopause gets closer and the granulosa cells in the follicle stop working as well, the body will be like, oh, we're not, we're not doing as good of a job here.
So why don't we increase our FSH levels and see if we can encourage those ovaries to do what they're supposed to be doing. So FSA levels tend to go up as people get closer to menopause or as the ovaries stop doing their thing.
So closer to menopause equals lower AMH and higher FSH.
All right, little refresher there.
Let me just review a couple of different things that we've learned from the research.
Quite a number of studies have taken groups of people who are undergoing hysterectomies with the ovaries intact and people who are not. And they've compared them. They've tracked them moving forward in time and said, OK, well, let's look and see if we could tell any differences in terms of the ovarian function in these groups. And there are quite a number of studies, not all of them, but many I would say most of the high-quality studies are finding that AMH levels actually go down and levels go up after a hysterectomy. When you compare those folks to people who didn't have a hysterectomy.
So it seems like, taking out the uterus is causing the ovaries to stop working as well. Very interesting.
Now, a number of people have said, well, you know, maybe the surgery itself is damaging the blood flow and that is affecting the ovaries ability to do what they need to do.
People have also said, well, maybe people who are getting a hysterectomy already have underlying medical conditions that would mean they would go into menopause earlier anyway, even if they kept their uterus, that it's just a sort of confounding variable in this case. So I just wanted to say a couple of words on this.
First of all, Singa and colleagues in 2016 published a very interesting paper where they not only looked at serum AMH and serum FSH levels in people after they got a hysterectomy versus those who didn't. But they also did some fancy ultrasound stuff where they were measuring blood flow to the uterus, to the ovaries, pardon me.
And they actually found that blood flow did not change in the people who had gotten the hysterectomy versus those who did not, but that they still found lower serum AMH levels and higher serum FSH levels, meaning that the people who had a hysterectomy had lower ovarian reserve compared to folks who didn't, even though blood flow was the same.
So it seems like probably blood flow is not the answer here.
There have also been a number of studies looking at people one year, two years, etc, post-surgery.
So it's unlikely that at that point you're still healing from the surgery.
Of course, there are always shifts that are going to happen after surgery, but some of these are laparoscopic surgeries and so forth.
So one year, two years out, we wouldn't expect those numbers to be influenced by healing from the surgery.
So it's unlikely that it's the surgery itself that seems to be the case here.
Now, this argument about, well, what if these folks were getting a hysterectomy because of an underlying condition that's, you know, not replicated?
Here's the thing about that.
Most of the studies have checked AMH and or FSH levels in both the kind of hysterectomy group and the control group before the hysterectomy. Right. So there prospective studies in many times they're looking at these levels before these people go through the surgery and they're not finding any difference immediately before the surgery.
So if it was due to some underlying condition, we would already expect to be seeing the AMH going down and the FSH going up right before the hysterectomy. And that doesn't seem to be the case. So that is probably not the explanation either. So what is it?
Well, again, this is still out for discussion, but probably it is that there there are paracrine an/or endocrine signaling from the uterus that influences the ovaries. We don't think of the uterus as being a hormone or signaling molecule producer.
But of course, it is.
It's certainly we certainly know that it produces paracrine signals, but it seems like that it's probably communicating with the ovaries and that when you take the uterus out, the ovaries don't have the signals that they need to carry on working as well as they were before.
So I just think that's really, really fascinating because we always think of the body as separated into these systems and we're like, oh, well, the ovaries make the hormones and the uterus is just sort of the baby sack, essentially, is how people think of it.
But it turns out that they're interrelated, just like most things in the body are interrelated. And this is one of the most interesting things about being a clinician and learning more about the body is that we start to realize these these absolutely amazing interconnections that we see.
And I think it reinforces this idea that sometimes when we just pull on one or two strings, everything else shifts.
And part of it is just because these things are connected in ways we don't fully understand. So I think that's totally fascinating.
I thought this was interesting to you and if nothing else, that it made you think in a slightly different way about how the uterus and ovaries work. I'll be back next week with a few more tips for you to think about. In the meantime, I hope you have a wonderful week and I will talk to you soon.