Ovaries – If they’re Normal, Leave them Alone

That’s what I’ve been telling my patients for years. And I will continue to say it after reading the results of a recent study comparing long term health outcomes in women whose ovaries were removed at time of hysterectomy for benign disease to those whose ovaries were left in place. The study found that women who had oophorectomy (removal of the ovaries) had an increased risk for death from cardiovascular disease. How high?

With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.

That’s a significant risk, I’d say.

As expected, women whose ovaries were removed had a lower risk of ovarian cancer, probably the most common reason some doctors give for removing normal ovaries at the time of hysterectomy. But this benefit was far outweighed by the cardiovascular risks conferred by removing the ovaries.

A surprising new finding in this study was an increased risk of lung cancer in women whose ovaries were removed. There is not obvious biologic reason for this, so it remains unexplained (and could be a statistical aberration).

The overall study findings were not surprising

Previous studies have found that removal of the ovaries confers increased risk of death from cardiovascular disease, which also occurs more frequently in women who undergo premature menopause. A decision analysis published in 2005 using data available at that time suggested age 65 as the cutoff for leaving the ovaries in place, since after that age, there was no added benefit. This more recent study suggests there should be no upper age limit.

What I found interesting in this study was that removal of the ovaries at the time of hysterectomy for benign disease did not appear to confer protection against future ovarian in women with a family history of ovarian cancer. This stands in direct contrast to well done prospective randomized data showing a clear benefit to prophylactic oophorectomy in this group. The authors suggest that their findings support a benefit from hysterectomy alone in preventing ovarian cancers, perhaps from a disruption of the influx path for potential carcinogens or changes in hormonal or triggering pathways. This would suggest that a randomized trial of hysterectomy without oophorectomy in women at high risk for ovarian cancer might be in order. (Currently, when prophylactic oophorectomies are done, the uterus is frequently kept in place.) It’s an interesting idea, but one that would need to be well-studied before suggesting anything other than current practice for these women.

Is there ever a reason to remove the ovaries?

Absolutely. If a woman has cancer of the ovary, the risk for death far, far outweighs any benefit to leaving the ovaries. (The exception is the young women with very early stage unilateral or borderline ovarian cancer – more limited surgery is generally offered to these women.)

Uterine cancer is also an indication for oophorectomy. Again, exceptions are often made in premenopausal women with early stage uterine cancers, and some of these women are being treated hormonally rather than with surgery. It will be interesting to see if anyone uses these study findings to recommend against removal of the ovaries in older women with very early stage uterine cancer.

I find the more difficult women to counsel are those having a hysterectomy for endometriosis with ovarian involvement, or for pelvic abscess or adhesions trapping a normal ovary and causing severe pain. For these women, the risk of continued pain and stress related to it, as well as the potential risks for additional surgery needs to be weighed against their risks for cardiovascular disease. The stress associated with chronic pain should not be minimized. For some of these women, removal of the ovaries may continue to be appropriate.

What if you’ve had your ovaries out?

It’s important to remember that oophorectomy is not the only modifiable risk factor for heart disease – diet, exercise, and treatment for underlying conditions such as hypertension and elevated cholesterol are just as important (and may be even more so). There is still an awful lot you can do to be sure you maximize your odds of beating heart disease as you age.

Oophorectomy is not the same as a hysterectomy

Hysterectomy is removal of the uterus. Oophorectomy is removal of the ovaries. Other than the risks associated with having surgery itself, hysterectomy alone does not confer an increase risk of mortality, and, unlike oophorectomy, does not increase long term heart disease risks. For many women, hysterectomy remains an important option for treatment of benign conditions such as uterine fibroids.
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