Bilateral oophorectomy at the time of hysterectomy may do more harm than good, increasing the risk of death, cardiovascular disease, osteoporosis, and even lung cancer for a minimal trade-off in preventing ovarian cancer, according to an examination of available data.
An analysis of observational studies suggests that physicians and patients should fully discuss the issue before making a decision about which way to go at the time of hysterectomy.
“Prudence suggests that a detailed informed consent process covering the risks and benefits of oophorectomy and ovarian conservation should be conducted with women faced with this important decision,” Dr. William H. Parker wrote (J. Min. Invas. Gyn. 2010;17:161–6).
Dr. Parker, of the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif., plumbed numerous studies to examine the long-term health implications of premenopausal bilateral oophorectomy.
The surgery is usually recommended at the time of hysterectomy because it eliminates any later risk of ovarian cancer, which kills approximately 15,000 women every year in the United States.
However, Dr. Parker said, less than 1% of women who have a hysterectomy with ovarian conservation go on to develop ovarian cancer.
On the other hand, the Nurses' Health Study (NHS) and a recent Canadian study found that bilateral oophorectomy is associated with a 26% increased risk of lung cancer; the risk is even higher when patients don't take postsurgical estrogen. “Further studies are needed to confirm these unexpected findings,” he wrote.
The NHS also provided information about all-cause mortality in women who had both ovaries removed.
Over a 24-year follow-up period, oophorectomy was associated with a 12% increase in all-cause mortality and significant increases in the risk of death from coronary artery disease (28%), lung cancer (31%), and all cancers (17%). The risk of death was highest for women who had the surgery before they turned 50; they had a 40% increase in the risk of all-cause mortality.
The NHS also found that women who had oophorectomy without estrogen replacement had twice the risk of myocardial infarction compared with age-matched premenopausal women. The surgery was associated with an 85% increase in the risk of stroke in women who didn't use hormones after menopause.
Whether women used estrogens or not, oophorectomy was associated with a 28% increased risk of death from coronary artery disease in all women.
Dr. Parker found several studies that explored the relationship between oophorectomy and osteoporosis and hip fracture.
One study of 340 postmenopausal women who had the surgery (median age, 62 years) found that these women had 54% more osteoporotic fractures than women with intact ovaries. Two other studies, however, found no such association.
The Mayo Clinic Cohort Study of Oophorectomy and Aging, which followed more than 3,400 women for 25 years, found significant relationships between bilateral oophorectomy and Parkinson's disease (80% increased risk in women who had the surgery compared with women with intact ovaries), anxiety (greater than 200% increased risk), depression (54% increased risk), and cognitive impairment or dementia (70% increased risk).
Other studies suggest that bilateral oophorectomy throws women into a sudden, unnatural menopause that negatively affects mood, thought, memory, energy, libido, and sexual response.
Dr. Parker noted that a randomized trial is underway to examine the short-term associations of bilateral oophorectomy with cardiovascular, bone, and sexual health, as well as health-related quality of life.
“Until these and other data are available, removing the ovaries at the time of hysterectomy should be approached with caution,” he said.
In an accompanying editorial, Dr. G. David Adamson of Palo Alto, Calif., agreed with Dr. Parker's assessment.
“Oophorectomy is not necessarily the wrong decision for many women, but assessment of these data leads to the conclusion that more women are undergoing oophorectomy than should be the case,” he noted.
The reason for this remains unclear, Dr. Adamson wrote (J. Min. Invas. Gyn. 2010;17:141–2). “Given that the data do not support widespread oophorectomy at the time of hysterectomy, it is problematic that so many patients have oophorectomy.
“This implies that the data don't support ovarian conservation in most situations, which is not true, or that physicians are not giving patients a balanced rendition of the literature evidence, for whatever reason, or that women are choosing on their own to have oophorectomy, which does not seem likely,” he noted.
Neither Dr. Parker nor Dr. Adamson reported any conflicts of interest.