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Surgical Menopause

Awareness of menopause and its management options has grown significantly in recent years. However, most information focuses on natural menopause. In contrast, surgical menopause and its effects are less widely understood, and many women receive limited information before and after surgery.

Surgical menopause can bring significant benefits when medically necessary but may also cause substantial short- and long-term effects, particularly if it occurs early.

Women should receive clear, personalised information about the procedure, hormone therapy options, and the importance of lifestyle, nutrition, and exercise in supporting health and wellbeing.

What is surgical menopause?

Surgical menopause happens when both ovaries are removed before they would naturally stop functioning. This causes an abrupt drop in ovarian hormones, particularly estrogen, rather than the gradual hormonal changes seen in natural menopause.

Ovaries may be removed for several reasons, including:

  • Cancer-related reasons – for example, due to ovarian or uterine cancer, where the womb and fallopian tubes are also removed.
  • Genetic risk – such as BRCA1 or BRCA2 gene mutations that increase ovarian and breast cancer risk.
  • Non-cancer causes – including severe endometriosis, persistent ovarian pain, recurrent cysts, severe premenstrual syndrome (when medical treatments have failed), or as part of gender-affirming surgery.
  • Emergency surgery – in rare cases (e.g. twisted ovarian cysts or ectopic pregnancy).

What are the consequences of surgical menopause?

Removing both ovaries has similar outcomes to natural menopause but with key differences:

  • Sudden symptom onset – Menopausal symptoms (hot flushes, night sweats, mood changes) can begin abruptly and may be more severe.
  • Health risks in younger women – Without hormone replacement, women under 45 face higher risks of osteoporosis, cardiovascular disease, stroke, dementia, and early mortality.
  • Reduced testosterone – The ovaries produce about half of a woman’s testosterone. Removal can affect sexual function and libido in some women.

Managing surgical menopause

Women should receive comprehensive information about surgical menopause and its short- and long-term effects — both before and after surgery — and their GP or primary care team should be fully informed.

Management discussions should include:

  • Hormone Replacement Therapy (HRT) – type, dose, timing, and duration.
  • Lifestyle and nutrition advice – to support overall health and recovery.

HRT Recommendations

Women under 45 should usually be offered HRT until at least the average age of natural menopause (~51 years) to reduce long-term health risks.

HRT may be recommended even if menopausal symptoms are mild or absent, unless medically contraindicated (e.g. hormone-dependent cancer).

For women over 45, HRT can still help control symptoms caused by the sudden loss of estrogen.

For women with BRCA1/2 mutations who undergo risk-reducing ovary removal, evidence shows that HRT use does not negate the protective effect of surgery against breast cancer. HRT can generally be used until the average age of menopause, with non-hormonal options considered afterwards if needed.

For surgical menopause, a medium starting dose of oestrogen is often appropriate due to the abrupt hormone loss. The dose can be adjusted based on symptom control, with corresponding changes in progestogen if needed.

Each HRT regimen should generally be trialled for at least 3 months before making changes.

  • If the womb has been removed: estrogen-only HRT can be used.
  • If the womb is intact: oestrogen must be combined with progestogen to protect the womb lining from cancer.
  • If surgery was for severe endometriosis: combined oestrogen and progestogen are recommended to reduce the risk of stimulating residual endometriosis.

Ideally, HRT should start as soon as possible after surgical menopause to avoid severe symptoms. However, timing may depend on individual circumstances or pending medical results.

  • Women already taking oral HRT may need to pause treatment 6 weeks before surgery due to a higher risk of blood clots.
  • Transdermal HRT (patches, gels, sprays) is safer in this context and can be continued or restarted soon after surgery.

Women already using vaginal estrogen or prasterone pessaries can often continue up to surgery. Afterward, their healthcare team will advise when to restart.

For women who were not using these treatments before surgery, local oestrogen can be helpful if vaginal dryness, pain, or urinary symptoms develop.

After hysterectomy, most women can resume sexual activity after 6–12 weeks, following medical guidance. Those with pre-existing sexual difficulties may benefit from psychosexual counselling or women’s health physiotherapy.

Testosterone replacement may be considered after surgical menopause for women who continue to experience distressing low libido despite adequate estrogen therapy. It is not routinely required and should be discussed individually.

Psychological Wellbeing

Some women experience emotional and psychological challenges after surgical menopause. These may relate to hormonal changes, body image, fertility loss, or self-esteem. Open discussion, emotional support, and referral to counselling or specialist services can help.