Dear MKE SEX,
A few days ago I read an article about someone who had an ectopic pregnancy after a hysterectomy. I just don’t understand how that’s even possible. Can you explain this?
Confused About Conception
This is one of those times when I wish there was one quick explanation. People get hysterectomies for a whole bunch of different reasons, and they also get them using different surgical methods and procedures. So the answer to your question depends in part on why and how the hysterectomy is being performed.
Types of hysterectomy
A total hysterectomy removes the uterus and the cervix but leaves the ovaries and fallopian tubes in place. Removing the ovaries (called oophorectomy) will immediately induce menopause regardless of the age or medical history of the patient. Early menopause has been linked to other health problems (osteoporosis, heart disease, type 2 diabetes, and others) so leaving the ovaries intact can be a good option for some people who get a hysterectomy. Even without a uterus, people with ovaries will usually still cycle monthly, experiencing ovulation and some of the symptoms of menstruation (though bleeding with menstruation is quite rare after hysterectomy).
It is also possible to remove most of the uterus and leave the cervix in place. This is often done if there is any other pelvic reconstruction being performed at the same time. The cervix is quite muscular, and so it can be a fairly stable foundation from which to reconstruct and repair the pelvic floor. If the cervix is removed, the top of the vagina is closed during the surgery (this is typically referred to as a vaginal cuff). Surgically closing it off doesn’t necessarily make the vaginal cuff 100% impermeable. Often there may be tiny openings at sites of surgery, for a variety of reasons.
If there’s a cervix (or other little openings in the vaginal cuff), if there is at least one fallopian tube and ovary, and if fertility isn’t being suppressed with hormonal birth control, it’s possible for sperm to make their way through the lower portion of the pelvic cavity to a waiting egg. And that means there is a very slight chance of fertilization of an egg. Without a uterus, a fertilized egg will try to implant on other surfaces—most commonly the inside of the fallopian tube. When any implantation happens outside of the uterus, the result is ectopic pregnancy. The chances of ectopic pregnancy following these types of hysterectomy are exceedingly low, but they do very rarely occur.
Reasons for hysterectomy
Doctors tend to remove more tissue and organs in a hysterectomy if the reason for surgery is cancer, or a family history of cancer. But they don’t always take out everything if cancer isn’t the immediate concern; there are many other reasons why people have hysterectomies.
One of the more common reasons for a hysterectomy is uteropelvic dysfunction. That could include severe menstrual cramps (dysmenorrhea), heavy menstrual periods (menorrhagia), pelvic organ prolapse, pelvic pain, cysts, and fibroids. Let’s look at a hypothetical example of a cisgender woman approaching menopause who is experiencing one of these conditions. She and her doctor may decide to remover her uterus but keep the cervix in place, perhaps because they plan to use it during a pelvic reconstruction. They may decide to leave the ovaries so that this woman’s body keeps producing estrogen (removing her ovaries will plunge her into menopause, unless she starts HRT). Post hysterectomy, this woman will have a cervix and ovaries, but no uterus. The fallopian tubes may or may not be removed in a case like this. You could see how a (rare) ectopic pregnancy might occur here, either in the fallopian tubes or even just in the abdominal cavity.
In my work, I also talk to trans guys who are planning a hysterectomy. For the past few decades, the approach of this surgery for trans men has been to remove the uterus and the cervix as well as the ovaries (oophorectomy) and fallopian tubes (salpingectomy). Most of these tissues/organs are removed with the intent of preventing future atrophy and/or disease. (More research needs to be done around surgery and long-term pelvic health for trans men, but that is another column!) Typically in a case like this where the cervix is removed, the top of the vaginal canal is surgically closed. (Sometimes the vaginal canal itself may be removed/closed if done as part of a separate genital reconstruction procedure.) Regardless, because there are no ovaries remaining after the procedure described here, the chances of ectopic pregnancy are essentially nil.
If you really want to geek out on the topic of post-hysterectomy ectopic pregnancy, check out this article: “Ectopic pregnancy after hysterectomy may not be so uncommon.”
–Big thanks for input from the Tool Shed team on this article!
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