Vet School 101 Spay it forward: Ovariectomy vs. ovariohysterectomy in veterinary medicine

Did you know that sometimes veterinarians spay in different ways? Some of us take out the ovaries and the uterus. Others take the ovaries alone.

The debate among veterinarians on this point has often been heated. European vets can’t for the life of them figure why American vets take it all out. Vice versa’s typically the case, too. Why NOT prevent all those pesky potential uterine issues while you’re at it? Well, why offend the bloody uterus if she don’t really NEED to go? You can always take it out later, right?

This is an issue worth talking about now that the spay-and-neuter-always mantra is being slowly eroded. Whether by veterinary science or by those who would seek idealized individual care for their pets, questions are arising as to the ideal timing of pet sterilization. Here’s a post on this.

Meanwhile, the debate on the uterus: “Don’t throw out the baby with the bath water,” holler the Europeans. “But the baby’s a liability!” argue the Americans.

A recent article by veterinary surgeon Phil Zeltzman in this month's Veterinary Practice News discusses this point in some detail. He’s a Belgian trained doc spracticing in the US so he's in a unique position to observe both sides of the fence. Yet predictably, perhaps, his view seems slanted in favor of removing the ovaries alone.

He argues that if our reigning principle as medically trained personnel is “above all do no harm,” then the possible complications involved in removing a healthy uterus must be considered: a greater risk of excess bleeding, longer time under anesthesia and more significant pain.

Considering that excessive bleeding is the number one surgical complication of the spay procedure, and the anesthetic risk the second likeliest intra-op issue, it would seem the ovariectomy would be the best way, right?

Problem is, some veterinarians argue that leaving the uterus behind confers some significant disadvantages—namely, the risk of uterine infection and uterine cancer. “Above all do no harm” to this camp means removing the potential source of a future problem…as long as you’re in there anyway.

So far, however, there’s no evidence to back the claim of the ovariohysterectomizers. No uterine infections have been the result of hundreds of thousands of simple ovary removals in Europe. That’s because removing the ovaries means no more of the hormones whose fluctuations give rise to uterine infections. And uterine cancer? Occurring at a rate of 0.003 percent, is that really a good reason?

I’m with Dr. Zeltzman. I’m all for sticking with ovary removal alone. But there’s a catch. It’s called the “legal” trap. When the rest of your country does things one way and you do things another, your chances of getting into trouble for your efforts to do things better increase.

I’ve learned this the hard way. When I’ve used different suturing techniques than other vets (usually because my veterinary surgeon boyfriend argues convincingly that a new way might be better), the emergency veterinarians who have had to recheck my patients for a minor complaints have expressed dismay (to the owner!) over my different approach. They’ve suggested to my client that my new technique gave rise to the complication their pet is experiencing.

When that happens, the trust my clients place in me can be eroded. In at least a couple of cases I’ve had to explain 1) why I believe that my techniques did not cause the problem and 2) why my new way might be better. That’s hard to do convincingly after they’ve spent $400 at the ER.

So when I perform ovariectomies (usually on large breed dogs) I explain to my clients the benefits this method confers. I give them a choice. That may mean more explaining but I think it’s worth the effort.

Nonetheless, should their dog acquire a rare form of uterine cancer in the future…will they blame me?

In Europe no one would bat an eye. In the US, another veterinarian might suggest the uterine cancer is the result of my negligence. “You should have removed that sucker like the rest of us do.”

No matter that I’ve saved hundreds of dogs the risks, complications and discomfort of the hysterectomy—I’m more likely to be sued over this one case.

That’s why this topic is worth talking about. YOU are the ultimate arbiters of what happens to your pets when they get spayed and neutered. It may be a routine procedure but you DO have choices. If owners start asking their veterinarians WHY they do things one way versus another (while being careful to respect their healthcare providers’ rationale, of course) then perhaps more veterinarians will come to understand what I believe:

Just as no anesthetic protocol, no suturing technique and no vaccination protocol is one size fits all, sterilizing animals requires individualized approaches based on the needs of our individual pets. Practicing veterinary medicine requires a series of judgment calls when it comes to any given problem. So why should spaying your pet be any different?

December 18th, 2008

Add Comment65 Comments

One of the main arguing points I've heard many rescuers use to promote spaying is that the removal of the uterus will prevent pyometra. Does removal of just the ovaries prevent that as well?

Kristie December 18th, 2008 09:42:48 AM

Kristie: Yep. Pyometra is the infection in the uterus I referred to above. Once the hormones that cause the heat cycle stimulate the uterus the chances of pyometra rise. If the ovaries are no longer producing the hormones, the risk of pyometra is gone.

Dr. Patty Khuly December 18th, 2008 09:52:32 AM

In your other post on this subject, I commented that I had my own suspicions about my dog having had an ovariectomy, rather than an ovariohysterectomy, when she was spayed by a shelter vet. (Although I always poo-pooed it as being too unlikely.) There's just something "different" about this dog, in comparison to others. Male dogs, both sterilized and intact, are inordinately "interested" in her. It's mostly other dog owners who ask what is so unusual about my dog, that she attracts so much attention, and causes male dogs to follow her around, licking, and drooling. (They often think she's intact, or even in estrus and are surprised to learn she was spayed in 2000.)

Dr. Khuly, you suggested it was possible for some uterine (or, I suppose, ovarian) tissue to have been left behind, and that might be the cause. (Although I'm sure you're as skeptical as am I, that that's what's going on.)

Still, it got me thinking about why we remove everything, rather than just sterilizing the animal. Thanks for this post, as well as your continued support of treating pets and their owners individually. One size doesn't fit all.

Marjorie December 18th, 2008 10:05:04 AM

Oops. I meant I suspected a 'tubal ligation', not the complete removal of the ovaries. :-)

Marjorie December 18th, 2008 10:08:20 AM

Dr. Kuhly- what is the cause of a "stump pyo", then? Or are they way more rare than I've been lead to believe?

Megan December 18th, 2008 10:22:52 AM

Stump pyometra is an infection that occurs in the "stump" of the uterus--the part inevitably left behind after an ovariohysterectomy spay. This seems to happen either because some bit of the ovary was left behind by the surgeon, because (as happens rarely) some ovarian tissue is "ectopic" (out of its normal place and legitimately unseen by the surgeon), or because of hormone administration (as was formerly used to treat urinary incontinence in females).

Stump pyometra seems as likely as a complete pyometra in these cases. So whether the uterus is completely removed or not, if a bit of the ovary is left behind, or if female hormones are administered, either version of the same complication can occur. Both are bad. And both are rare (now that we don't use these hormones to treat incontinence), whether ovariectomy or ovariohysterectomy is performed.

Dr. Patty Khuly December 18th, 2008 10:36:10 AM

I read once on a board (forgive me, I don't have the reference) of just removing the uterus and leaving the uterus. Supposedly this leaves the animal with all its hormones intact, removes the risk of pyo (athough from the reference to "stump pyo" above I see this is unlikely.

Just wondering what the reasoning is on this one. Personally, I can see the point of leaving the animal with its hormones intact (we know that removal of estrogen leaves humans with all sorts of problems) but knowing what I do of dog anatomy I can't for the life of me see a benefit to this. Interested to hear Dr. K's interpretation.

Kim December 18th, 2008 11:08:55 AM

Kim: Neither can I. It's an invasive procedure performed simply to remove the risk of pyometra? I guess you could argue that the pregnancy, urinary incontinence (in dogs) and pyometra are taken care of--while mitigating the risk of some of the conditions we now question occur more frequently with early spays--cruciate ligament ruptures in dogs, for one.

Problem is, the mammary tumor issue is still there. So is the constant cycling of the in-heat kitty.

I don't know whether this is worthwhile. Thanks for raising the issue. years from now we might consider it the best approach...who knows?

Dr. Patty Khuly December 18th, 2008 11:28:05 AM

This is a really interesting post. I didn't know ovary-only removal was an option. I'm very interested now that I know.

I've read tons of spay-gone-wrong stories most of which involved hemorrhaging to death. I'd think the risk of that is higher than the risk of uterine cancer if it trully is .003%.

BTW, why do you say that " the spay-and-neuter-always mantra is being slowly eroded"?

Stefani December 18th, 2008 02:51:38 PM

Does that 0.003% figure include benign leiomyoma of the uterus? I've seen a few cases of that, though I've never seen uterine cancer. Of course, we treated them by removing the entire uterus (in one of the cases, the uterus had developed inflammation/infection due to the presence of the growth, which was hanging out of the vulva. Compared to humans, dogs and cats recover extremely well from ovariohysterectomies, so honestly I fail to see the advantage of removing the ovaries only...

brebis noire December 18th, 2008 03:10:34 PM

Stefani: Check out the post in the link for more info but here's the baiscs: Because new research has raised questions as to the right timing of spay and neuter (studies that raise eyebrows on the issue of an increased incidence of osteosarcoma and cruciate ligament degeneration, in particular, in dogs spayed and neutered at the standard six months of age), the idea that every dog must be sapyed and neutered early (as some legislation ims to enforce) is getting a bit of a black eye.

These are only a handful of studies but the idea that some pets might be better off waiting for their surgeries is starting to change some of our recommendations. It may not be too long before tubal ligations and vasectomies become more the standard until pets are old enough to be ideally spayed and neutered.

There's no doubt there's change in the air. Jury's still out, though.

Dr. Patty Khuly December 18th, 2008 03:16:49 PM

brebis noire: I imagine it doesn't given that it's histologically benign, but I'm not sure. I got the figure from Dr. Zelzman's article. I've never seen a leiomyoma, though. To help out I looked up leiomyoma and uterus under dogs in VIN and got no hits. Pretty darn rare, it seems. But it's worth thinking about.

For my part, I absolutely prefer ovariectomies in older, large breed dogs. I think the risk of bleeding is significant in these cases and I prefer taking the "easy" way out whenever I can--I hate big dog OHEs!

Dr. Patty Khuly December 18th, 2008 03:22:53 PM

My Birchard and Sherding (Saunders manual of small animal practice) says that leiomyomas account for the vast majority of uterine tumours, but that they are generally uncommon. Yes, I agree about older, large breed dogs - you get a similar problem on the inside as you do on the outside when you're neutering a big older dog. Blue bags are not fun. It's definitely something to consider, in that case.

brebis noire December 18th, 2008 03:53:42 PM

ok please forgive my ignorance...I am NOT a professional. The pic of the organs...is that JUST the uterus or is that a uterus with pups in it??? Whatever it is, what dog breed did it come from? It's humongous!!!

agadoresmama December 18th, 2008 07:08:39 PM

Interestinly I feel that it is potentially much easier to deal with removing the uterus in some larger breeds than the ovaries. Not that I just remove the uterus, but I feel I have had more problems trying to exteriorize the ovaries and get them tied off. Thus I worry more about bleeding from my ovarian stumps then I ever do from the uterine stump; I feel that is very easy to tie off vessels individually if necessary and control bleeding to the uterus.

Just today I had to spay a 9 yr old lab and it took me three times as long to work with the ovaries as compared to the rest of the uterus. Bearing that in mind I don't think it takes that much longer to remove it all than if just dealing with the ovaries so I guess I would fall into the camp that just says remove the uterus and ovaries. Just one humble opinion in a sea of many.

J.C. December 18th, 2008 07:24:53 PM

I have a question that's not totally related to this post. I had a dog once who had a recessed vulva. I was told by an internist that I should have let my dog go through one heat cycle so it could have corrected itself, but because I spayed her at 4 months she was doomed to a lifetime of recurrent UTI's. When do you reccommend spaying dogs?

Kristie December 18th, 2008 08:36:54 PM

Kristie, my scottie has a recessed vulva (she was spayed at 6 months) & has only had one UTI during her 3.5 years on earth. So while you may need to look out for the symptoms of a UTI, your dog is certainly not doomed to a life of infections. I was also told that she may need surgery to correct her vuvla issues, but obviously have not had to subject her to that.

Jessica December 18th, 2008 11:18:22 PM

Hi Jessica, My dog passed away a couple of years ago but she did suffer from chronic uti's. I spent a pretty sizeable fortune on Baytril for 6-8 weeks at a time. It seemed like she never fully recovered from her UTI's despite good readings on urine cultures after each course. My internist reccommended a vulvaplasty even though she said there was no evidence that it would actually help. I opted not to put her through that because she had also had a total hip replacement and a TPLO. That poor dog had more problems than any animal should have to deal with.

Kristie December 18th, 2008 11:24:47 PM

agadoresmama: Obviously I don't know the story behind the photo you're referring to, but I can tell you that a normal canine uterus isn't that large! That one most likely either A) has pups in it or B) is full of pus from a pyometra. The photo at the very top shows a normal uterus. It's that "V" of red tissue between the surgeon's hands.

Barb December 19th, 2008 12:52:58 AM

Dr. Patty: Thank you for this information! I have always assumed that leaving the uterus would predispose the dog to pyo. This is very interesting, and it's always good to have more options.

Barb December 19th, 2008 12:56:06 AM

JC: I agree that the majority of the time is spent exteriorizing the ovaries and ligating the ovarian vessels, but with big fat dogs I find that I spend an inordinate amount of time ligating vessels in broad ligament-area fat. And though I also agree that most of the pain comes from ovarian exteriorization, consider that your incision will be smaller, too. Moreover (and here's what the textbooks don't always explain), I find that it's easier to exteriorize and visualize the ovaries when your incision is dedicated to them alone. I used to find that I saved no time but now that I do more ovariectomies I'm getting better at them and it's much faster for me than an OHE in a big dog. In smaller dogs and cats? Absolutely no difference, you're right.

Dr. Patty Khuly December 19th, 2008 07:32:38 AM

agadoresmama: Yes, that is one big pus-filled PYO!! (I hope it's a German shepherd but I fear it might be a smaller dog--I've seen some HUGE pyometras in small dogs.)

Dr. Patty Khuly December 19th, 2008 07:49:28 AM

We had a 7 year-old Golden come in recently with a pyo. The uterus weighed nearly 20 pounds! It was huge - at least the size of the one in the above picture, if not bigger! The dog had a hard time, but she made it. And she is much thinner!

Interesting points in this post. I'll have to print it out and discuss it with my boss.

sassy December 19th, 2008 03:03:44 PM

all I have to say is WOW

agadoresmama December 19th, 2008 07:46:07 PM

Dr. K - So when you go for just the ovaries are you still approaching from the midline of the abdomen or are you going at them from the sides? I have a friend who moved to the UK a couple years after vet school and she was telling me that they do it from the sides (think we are crazy for going after things from the ventral abdomen). I guess it is because we have routinely taken the uterus as well.

I would have to see it(ovariectomies) done a few times to appreciate it. I don't think my incisions are that big now going for everything. With the lab that I was referring to from last week I don't think I could have done the procedure in a smaller incision. There was more fat around the ovarian vessels and there was very little give - even with the ovarian ligament broken down -- I was putting my sutures all the way up near the dogs back!

I am not against learning something new - don't know anyone around here that is just taking the ovaries though.

J.C. December 19th, 2008 09:48:21 PM

JC: I've heard that the Europeans go at it from the sides. I just move my incision cranially. Remember, I'm talking just the big dogs, for me, so this means I still have to break or stretch the ovarian ligament deep inside a deep-chested dog. I'm going to ask my freindly neighborhood vet surgeon about the lateral approach, though. I'll get back to you on that.

Dr. Patty Khuly December 20th, 2008 07:06:41 AM

News on the lateral approach to ovariectomy: two different vet surgeons claim it's a legitimate a approach but much harder to stop bleeding if you get some serious gusher action. However, they both agree that it's all about how comfortable a surgeon is with any given approach. I, personally, would hate to have 2 incisions to deal with.

Dr. Patty Khuly December 26th, 2008 08:21:23 AM

But I should hasten to add: The last time any vet surgeon I knew spayed an animal it was their own. I'll warrant that's one procedure any general practitioner can handle with greater aplomb than any boarded vet surgeon!

Dr. Patty Khuly December 26th, 2008 08:23:01 AM

I have read all of these posts with great interest. My vets have just informed me that they are doing keyhole spays as well as the traditional but have left it up to me to decide. They have explained the obvious upsides to this procedure but I am doing my homework before booking her in. My concern is that she is a 22 month old 52kg Leonberger bitch and is in optimum health. However, After she had her second season she became very hormonal and almost depressed for about 8 weeks. I left spaying her until now as another debate amongst breeders of giant dogs is to wait until they are physically developed as neutering stunts their growth but thats a different story...

Anyway, of all of the posts nothing is said of hormones. When humans have their ovaries removed they still experience PMT. Surely this is the case with dogs? I am favouring removal of all at the mo because I do not want to spay her and still experience her hormonal attitude every 6 months. I need convincing either way. As my vet is relatively new to keyhole and ovariectomies she seems to be favouring this because she has been trained in this field. What do you think?

Karvinley January 30th, 2009 05:02:02 PM

I've wondered why uterine ablation has never been mentioned as a possible means of controlling unwanted pregnancies. Would it not be feasible for dogs and cats? Thanks for the education.

Gerri February 4th, 2009 07:55:50 AM

I have a question of my own regarding this article. Are there known long-term complications of ovariohysterectomy (vs. ovariectomy, not keeping the animal's reproductive system intact)? This entry only addressed short-term complications, serious as they may be.

Sonja February 21st, 2009 10:06:42 PM

Dr. Khuly:

May I ask you about timing of this surgery as it relates to the estrus cycle. I have a 5 year old bitch who has successfully free whelped two litters (7 and 9 pups for a total of 16). I have decided to proceed with a lap ovariectomy. I have read and been told in the past to time this mid cycle.

Would you explain the risks of having the ovariectomy close to the time of the next estrus cycle?

Thanks for your help.

Laura

NYC

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Urgent! My 22 month old 52kg Newfoundland dog is scheduled for spay surgery tomorrow morning. I just today read an article from Animal Wellness about Menopausal Mutts. I also found an older article from 1972 on Partial Spay. Both advocate doing a hysterectomy but leaving the ovaries intact. In the Partial Spay article the vet removes the uterine horns, body of the uterus, and the entire cervix but leaves the ovaries intact. This prevents pregnancy and mentstrual flow and presumably, also pyometra. My last Newf developed spay incontinence right after her surgery and was on stibesterol 1mg od and sudafed 120mg bid for the rest of her life. I really don't want to go through this again. I'm thinking of requesting a partial spay tomorrow, but don't know what the vet will say. Is there any newer information on this? Thank you!

Joan Fisher June 1st, 2009 05:14:58 PM

My large breed Doberman was diagnosed with Pyometria. Vet. insisted immediate hysterectomy. Reassured he would take out everything. Months later... A full heat cycle, menstruation. Trouble! My dog was now said to have Ectopic Ovarian Tissue remaining.. She has remained lathargic, with a hanging belly, and from a once extremely fast to rise pup, she has trouble rising.. Where do we go from here? She's only just four! What are potential health risks? Thanks...

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My dog is a mix lab, she is 9 1/2 yrs old. She just had a ovariohysterectomy on July 17/09 due to pyometra, her uterus was 3 times it's normal size and was full of puss. She seems to be recovering well except her poop is black and this worries me to the point that I am freightened. Is this normal or is she bleeding inside. I am so scared, please help me. Thank you kindly.

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ewrtew July 23rd, 2009 01:43:32 AM

Hi,

I'm a final year vet student from Ireland and I don't know if this point has already been raised in one of the above comments, but one danger I would see with an ovariectomy, as opposed to a complete ovariohysterectomy, is the possibilty that a small amount on ovarian tissue could be left behind [as I understand sometimes happens with 'regular' spays]; this would potentially mean that the post-op bitch would still be at risk of pyometra, and even becoming pregnant! Then the whole operation with all of its anaesthetic risk, cost and time involved, would have been a complete waste. I just thought it was an interesting point in the whole debate.

Deevet August 13th, 2009 02:04:27 PM

Another point: Here in Ireland, the norm is to do the full ovariohysterectomy; in fact, the first I even heard of ovariectomies being done on their own was from a French surgeon who lectures in our vet school. Similarly, any vets I tell about the 'ovariectomy only' approach are always surprised - they hadn't heard of it either!

And while most cat spays are approached laterally [doing both ovaries from one flank incision], bitch spays here are always done with a ventral midline incision. Nobody would consider doing 2 lateral incisions! Interesting to hear of all the variations in other parts of the world.

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