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Management of Surgical Menopause in Female Patients with Bladder Cancer Undergoing Radical Cystectomy - Beyond the Abstract

The management of surgical menopause in premenopausal women undergoing radical cystectomy (RC) is an under-recognised area within urological oncology. While the majority of women requiring RC for bladder cancer are postmenopausal, a small group are premenopausal. For these women, routine bilateral oophorectomy results in an abrupt and permanent loss of ovarian function, with consequences that extend far beyond the perioperative period. Despite this, awareness of surgical menopause and its management among urologists remains limited, and there is currently no cystectomy-specific guidance to support counselling or follow-up. Our Nature Reviews Urology review was written to address this gap.

Surgical menopause induces a sudden cessation of ovarian sex steroid hormone production, leading to profound vasomotor, sexual, skeletal, cardiovascular, and cognitive sequelae, with evidence linking premature oophorectomy to a range of long-term risks, including increased all-cause mortality.1

A central message of the review is that ovarian preservation, where oncologically safe, is the most effective way to reduce avoidable morbidity. Contemporary data show that ovarian involvement at the time of RC is uncommon and typically associated with macroscopic, locally advanced disease.2 On this basis, both the European Association of Urology and the American Urological Association now support gynaecological organ preservation in carefully selected patients.3,4 Nevertheless, real-world practice remains variable, and oophorectomy is still performed in premenopausal women who may not require it for oncological control.5-7

Where oophorectomy is unavoidable, timely recognition and proactive management of surgical menopause are essential. Hormone replacement therapy is the cornerstone of symptom control and bone protection and should, in the absence of contraindications, be continued until the average age of natural menopause (around 51–52 years). To minimise peri-operative venous thromboembolism risk, we recommend initiating hormone replacement therapy (HRT) approximately 4–6 weeks after surgery, with transdermal preparations preferred as first-line therapy. Although concerns are sometimes raised about HRT and bladder cancer outcomes, current evidence is limited, and bladder cancer is not considered a contraindication to HRT in existing surgical menopause guidance.

Given the predictable long-term risks associated with surgical menopause, we recommend integrated, multidisciplinary follow-up that addresses vasomotor and genitourinary symptoms, sexual health, bone health, cardiometabolic risk, and psychosocial well-being. Improving awareness and standardising care in this area represents a clear opportunity to reduce preventable morbidity and improve long-term outcomes for premenopausal women undergoing radical cystectomy.

Written by:

  • Elizabeth Day, Department of Urology, Ayr University Hospital, Ayr, UK
  • Niyati Lobo, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
References:

  1. Tuesley, K.M. et al. Hysterectomy with and without oophorectomy and all-cause and cause-specific mortality. Am J Obstet Gynecol. 223,723.e1-723.e16. (2020).
  2. Lobo, N. et al. Gynaecological organ involvement in women undergoing radical cystectomy: a multicentre study. BJU. Int. 133, 474-479 (2024).
  3. Van der Heijden A, Bruins HM, Carrion A et al. European Association of Urology Guidelines on Muscle-Invasive and Metastatic Bladder Cancer, 2025th edn. Arnhem, The Netherlands: EAU Guidelines Office, 2025. ISBN 978-94-92671-29-5
  4. Holzbeierlein J, Bixler BR, Buckley DI et al. Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/SUO guideline (2017; Amended 2020, 2024). J Urol 2024; 212: 3–10
  5. Sussman, R.D. et al. To oophorectomy or not to oophorectomy: practice patterns among urologists treating bladder cancer. Urol. Oncol. 36, 90.e1–90.e7. (2018).
  6. Gupta, N. et al. Practice patterns regarding female reproductive organ-sparing and nerve-sparing radical cystectomy among urologic oncologists in the United States. Clin. Genitourin. Can. 21, e236–41. (2023).
  7. Day E, et al. Contemporary practice patterns in female radical cystectomy: results of a UK and Ireland survey. BJU. Int. https://doi.org/10.1111/bju.70159 (2026).
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