By Susan Hutchinson, MD
- Hysterectomy is the removal of the uterus. Additional surgery involves removal of the cervix, fallopian tubes, ovaries, lymph nodes and channels.
- The ovaries produce changing levels of estrogen and progesterone and the uterus and brain react to these changes. About 2 of 3 migraine women have their worst attacks with menses.
- Surgical menopause causes an immediate dramatic drop in hormones. This worsens migraine in 2 of 3 women. Natural menopause eventually improves migraine in 2 of 3.
- Consider taking steps before surgery to reduce risk for problematic headaches.
Introduction—What is a Hysterectomy?
Hysterectomy is the surgical removal of a women’s uterus or womb. A hysterectomy can be “partial” or “total.” A “partial” or subtotal procedure involves removal of the upper part of the uterus—the fundus. The mouth of the uterus or cervix is not removed. This term has also been used to indicate one or more ovaries remain in the body. In a “total” or complete hysterectomy, the uterus and cervix are both removed. When the phrase is properly used, the ovaries again remain intact. The reasons vary for hysterectomies and so does the procedure. A hysterectomy frequently involves removal of both fallopian tubes and ovaries. Technically, this is not a hysterectomy, but a hysterectomy with bilateral salpingo-oopherectomy (BSO). A radical hysterectomy for cancer also involves lymph node and channel removal. Be clear on exactly the “type of hysterectomy” planned. For this reason, a detailed conversation about hysterectomy is necessary with your providers.
The Uterus and Ovary Hormones
The uterus does not produce the female sex hormones, estrogen, and progesterone. The ovaries produce estrogen and progesterone. In women after menarche and before menopause, the estrogen and progesterone levels change throughout the menstrual cycle. This happens as long as the ovaries are present, whether the uterus is present or not. For most women with migraine, the drop in estrogen just before menses is a big trigger for menstrual migraine. While the uterus does not produce estrogen or progesterone, it is influenced by them. Estrogen causes the lining of the uterus to build up every month in preparation for possible pregnancy. Progesterone stabilizes the lining of the uterus. When the egg does not implant, both estrogen and progesterone levels drop to low levels at the end of the menstrual cycle. With an intact uterus bleeding occurs. Removal of the uterus will result in no more menses.
Migraine and Hormone Swings
Menstrual migraine is due to sensitivity of the brain pain centers to normal change in hormone levels, especially estrogen. This menstrual headache is often the worst of the month. The effects of progesterone and its role in migraine are less certain. Researchers continue to work to increase our understanding of both estrogen and progesterone changes in migraine.
If only a hysterectomy has taken place with one or both ovaries left intact, then the ups and downs in estrogen and progesterone will continue. In this setting, one can expect little change in migraine pattern.
When a woman undergoes a hysterectomy with BSO, then the ups and downs in estrogen and progesterone no longer occur. This woman should improve if she had menstrual migraine before hysterectomy with BSO. This would at least seem logical especially for those with a hormonal trigger. BEWARE, however, a dramatic drop in estrogen and progesterone occurs with a hysterectomy with BSO. This drop can wreck havoc on a woman’s migraines.
Studies have looked at the effect of menopause on migraine. How women enter menopause with migraine seems to matter. Migraine women that are “thrown” into menopause with a hysterectomy with BSO frequently are worse. Women who “gently” go into menopause as their ovaries begin producing less and less estrogen and progesterone typically fare better. Statistics show that two of three women will experience improvement in their migraine if they go into menopause naturally. Only one of three women with migraine will experience an improvement in migraine with surgical menopause, meaning that their ovaries are removed.
Talking to your Surgeon about Hysterectomy
Many important medical indications exist for a hysterectomy. These include prolonged and heavy bleeding, cancer of the uterus or ovaries, severe endometriosis, or large fibroids. Therefore, it may not always be possible to avoid a hysterectomy. In this case, there are some steps a woman with migraine can take prior to the hysterectomy to help prevent a major worsening of her migraines. Here are some recommendations:
- Discuss with your doctor if your ovaries are to be left in. In most cases, this is desirable to avoid the sudden drop in estrogen and progesterone. Leaving the ovaries in can also prevent hot flashes, night sweats, insomnia, vaginal dryness, and the increased risk of osteoporosis that are typical of menopause.
- If the ovaries have to come out, see if an estradiol patch (such as Vivelle) can be worn immediately after the surgery to prevent the massive drop in estrogen. This concept is known as “add-back estrogen .” Non-oral forms of estrogen such as the patch can be better at creating steady levels of estrogen (important for migraine prevention) as opposed to oral estrogen therapies.
- If estrogen after surgery is contraindicated, then start an oral preventive well before the surgery to help prevent post-hysterectomy migraines. If you are already on an oral preventive, consider upping the dose. A good choice may be a beta-blocker or an anti-epileptic, Gabapentin, or an SNRI (serotonin norepinephrine reuptake inhibitor) such as Venlafaxine (Effexor) or Duloxetine (Cymbalta). These medications have been shown to decrease vasomotor symptoms, such as hot flashes, as well as possibly prevent migraine.
Migraine and Hysterectomy Summary
A hysterectomy becomes a necessary surgery for many women with migraine. However, it should NEVER be done for the sole purpose of lessening migraine. Take the choice of leaving the ovaries in unless there is cancer or a high risk of ovarian cancer. Preparing ahead of time with migraine management before a hysterectomy can help lessen the negative impact on migraine.
Susan Hutchinson, MD, Director-Orange County Migraine &Headache Center, Irvine, CA.