Prophylactic Oophorectomy

Removal of the Ovaries at the time of Hysterectomy maybe essential for instance if there is severe endometriosis involving the ovaries. Often a hysterectomy is performed for pathology of the uterus and then the gynaecologist and patient must decide if the ovaries should be removed as well. As this short paper discusses until recently healthy ovaries were often removed in order to prevent future ovarian cancer. Ovarian cancer is difficult to screen for and is often diagnosed at a late stage. However if the ovaries are removed before the onset of menopause the patient may be subjected to an increased risk of heart disease.

PROPHYLACTIC OOPHORECTOMY AT THE TIME OF HYSTERECTOMY

A M Shaw FCOG (SA)

It has been the general consensus until recently, that if a hysterectomy is performed in a woman over 45, oophorectomy should be considered. The function of the ovaries after this time is erratic and there is a possibility that ovarian cancer or the residual ovarian syndrome could develop. John Studd proposed that all women undergoing a hysterectomy after 40 should be offered the option of bilateral oophorectomy with subsequent hormonal replacement. In the USA 50% of women undergoing hysterectomy at 40 to 44 years also had a bilateral oophorectomy.

In 2009 Parker et al published his analysis of the data of the Nurses Health Study, an observational study that had a follow up of 24 years. 29380 nurses had a hysterectomy; 55.6% had a hysterectomy with bilateral oophorectomy and 44.4% had had a hysterectomy alone. Nurses with a unilateral oophorectomy or with hysterectomy for gynaecological cancers were not included. The groups were similar except the women with the oophorectomy were slightly older, 51.9 vs. 50.3 years. Women with a bilateral oophorectomy had significantly increased hazard ratios (HR) for all cause mortality 1.12, coronary heart disease 1.17 and stroke 1.14. Breast cancer and ovarian cancer were decreased in the oophorectomy group but total cancer mortality and lung cancer were increased. 99 of 13,305 (0.26%) with ovarian conservation developed ovarian cancer in the follow up period. 67 of these were women younger than 45 at the time of hysterectomy. 34 died of the disease. Cardiovascular risk was particularly prominent in the younger age group The HR was 1.41 in women less than 45 but was not significant above 55. When the results were analysed according to age in women who had never used hormonal replacement, the HR for all cause mortality was significant at 1.73 in women less than 50 and not significant in women above 50.

The crucial element seems to be the age at hysterectomy and whether hormonal therapy was used. Oophorectomy at any age does not increase survival. Oophorectomy in a woman younger than 50 increases mortality unless hormone therapy is given. Compliance with chronic medication is poor. The younger the patient is at time of oophorectomy the more likely that we are subjecting her to premature menopause and early death. In view of this data bilateral oophorectomy in a premenopausal woman should only be performed for compelling reasons. In a postmenopausal woman the ovary continues to produce testosterone. Oophorectomy should be individualised. Since oophorectomy does not increase survival, a woman should be entitled to keep her ovaries if she wants to.

References
  1. Studd J. Does retention of ovaries improve long-term survival after hysterectomy? Climacteric 2006;9:164-166
  2. Parker et al. Ovarian Conservation at the Time of Hysterectomy and Long-Term Health outcomes in the Nurses health Study. Obstetrics and Gynecology 2009;113:1027-1037

Contact Details

Dr. Alice Shaw
Pr No.:1606263


dralice@aliceshaw.co.za
Tel: 044 384 0926
Fax: 044 384 0970