Among premenopausal California women undergoing nonradical hysterectomies over a 7-year period, more than one-third underwent concurrent oophorectomies for no apparent reason.
“Regardless of what our national guidelines are telling us to do, we’re still not doing a good enough job of educating our patients and providing guideline-driven care,” Dr. Amandeep S. Mahal said in an interview prior to the annual scientific meeting of the Society of Gynecologic Surgeons.
Dr. Amandeep S. Mahal
Emerging evidence suggests that premenopausal oophorectomy is associated with worsened long-term health outcomes, including increased mortality and risk of cardiovascular events, said Dr. Mahal, a second-year fellow in the department of obstetrics and gynecology at Stanford (Calif.) University Hospital. The current recommendation by the American College of Obstetricians and Gynecologists (ACOG) is that “strong consideration should be given to retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer. However, given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women” (Obstet. Gynecol. 2008;111[1]:231-41).
In an effort to determine the rate of potentially unnecessary oophorectomies being performed in premenopausal women for benign indications, the researchers reviewed 259,294 inpatient, nonradical hysterectomies performed in California hospitals between 2005 and 2011. Women younger than age 50 were categorized as premenopausal. The records were obtained from California’s Office of Statewide Health Planning patient discharge database, which includes all non–federal hospital discharges. Each discharge contains a primary diagnosis as well as up to 19 secondary procedure codes and 24 secondary diagnosis codes. Dr. Mahal and his associates considered oophorectomies as appropriate if a supporting ICD-9 code such as “ovarian cyst” or “endometriosis” was linked to it, and inappropriate if no such codes were linked.
Of the 259,294 benign hysterectomies performed during the study period, 37% included concomitant removal of all ovaries, and 53% of the oophorectomies were performed in premenopausal women. Of the oophorectomies in premenopausal women, 37% were deemed to be “inappropriate” based on the documented reason for removal. The researchers observed that the total number of premenopausal hysterectomies with oophorectomy decreased from 10,166 per year in 2004 to 4,672 per year in 2011, but the percentage of oophorectomies deemed to be inappropriate remained stable, in the range of 36%-38%.
“We were very diligent and went through every possible diagnosis we could think of that would give you a reason to remove ovaries,” Dr. Mahal said. “Even being exhaustive in that manner, we could not find a reason why for more than one in three women who underwent oophorectomy prior to natural menopause.”
Logistic regression analysis revealed Hispanic and black race as the only demographic factors associated with an increased odds of inappropriate oophorectomy at the time of hysterectomy (P less than .001). Hospital characteristics and type of insurance did not account for any observed differences.
Even if premenopausal women have no risk factors for ovarian cancer in the future, undergoing an oophorectomy “is a decision they should make with their physician,” Dr. Mahal said. “One of the things we don’t know [about this study] is how many patients had a conversation with their doctor, understood the risks, and decided ‘it’s worth it for me to go ahead and remove the ovaries at the time of the hysterectomy.’ ”
The meeting was jointly sponsored by the American College of Surgeons.
Dr. Mahal reported having no financial disclosures.