CASE: Hysterectomy candidate asks about her ovaries
A 51-year-old premenopausal woman complains of severe menorrhagia that often causes her to miss work. Although she is taking an iron supplement, her hemoglobin level often drops below 10 g/dL. She has already been identified as having fibroids, with a uterine size of 14 weeks. You order ultra-sonography, which reveals an enlarged uterus with multiple fibroids and normal endometrial thickness, but no intracavitary lesions.
After you describe the treatment options, including uterine artery embolization, the patient requests a hysterectomy as a reasonably low-risk means of cure. During informed consent, she asks whether she should have her ovaries removed during the surgery. Further discussion reveals that her father died of a myocardial infarction when he was 64 years old, but there is no family or personal history of ovarian or breast cancer.
How do you advise this patient, based on her history and recent findings from medical research?
Many gynecologists have been trained to recommend bilateral oophorectomy for women older than 45 or 50 years who request a hysterectomy for benign disease. In these women, oophorectomy is recommended to prevent ovarian cancer and avert the potential for other ovarian pathology that might require later surgery.
In the United States, 78% of women 45 to 64 years old and 55% of women overall undergo bilateral oophorectomy at the time of hysterectomy.1 These percentages mean that almost 300,000 women undergo bilateral oophorectomy each year.1
Hysterectomy alone can sometimes lead to early ovarian failure, but this phenomenon is infrequent. A prospective study of premenopausal women found that, after 5 years of follow-up, 20% of women who underwent simple hysterectomy reached menopause, compared with 7% of matched women who did not undergo hysterectomy.2
In this article, I explore the risks and benefits associated with bilateral oophorectomy and present an algorithm to aid in deciding whether the patient should keep her ovaries—and when oophorectomy might be a better option ( FIGURE ).
Among the hazards associated with bilateral oophorectomy are:
- an increased risk of death from coronary artery disease (CAD), lung cancer, all cancers (except ovarian), and all causes3,4
- an increased risk of osteoporosis and hip fracture5
- when performed before the onset of menopause, an increased risk of parkinsonism, cognitive impairment, dementia, anxiety, and depression.6-8
Benefits include a reduced risk of ovarian cancer, particularly among women who have a BRCA gene mutation or strong family history of ovarian or breast cancer.
Although ovarian cancer causes 15,000 deaths each year in the United States, that figure pales when compared with heart disease, which accounts for 350,000 deaths. In addition, hip fracture may cause approximately 66,000 deaths each year, and dementia attributable to bilateral oophorectomy may affect 100,000 to 200,000 women.9 Reoperation for adnexal pathology or pain after hysterectomy is rare, occurring in only 2.8% of women. Therefore, the benefits of oophorectomy are often outweighed by the risks of CAD, hip fracture, and neurologic conditions.
Estrogen and other drugs mitigate the risks associated with oophorectomy—but many women avoid or discontinue these medications
The assumption that medical treatment will ameliorate the risks associated with oophorectomy is unrealistic. Estrogen may mitigate some risks, but many women avoid hormone therapy. This avoidance can be especially problematic in young women.
In the Nurses’ Health Study, a separate analysis focused on women who had never used postmenopausal hormone therapy.4 In this analysis, all women who underwent bilateral oophorectomy had a greater risk of stroke (HR, 1.85; 95% CI, 1.09, 3.16) and lung cancer (HR, 2.09; 95% CI, 1.01, 4.33) than did women who retained their ovaries. Among women who underwent oophorectomy before age 50 and who did not take estrogen, the risk of coronary artery disease (CAD) was higher (HR, 1.98; 95% CI, 1.18, 3.32), as was the risk of death from all causes (HR, 1.40; 95% CI, 1.01, 1.96), compared with women who retained their ovaries.
Despite estrogen’s proven benefit among oophorectomized women, usage rates continue to decline. In the 6 months after publication of Women’s Health Initiative findings on estrogen–progestin therapy, the continuation rate of estrogen therapy decreased from 12.6% to 9.1%, and new starts also declined significantly.47
Among women who had a diagnosis of osteoporosis and who began treatment with estrogen, estrogen plus progestin, a bisphosphonate, or raloxifene, medication continuation rates were less than 25% at 12 months.48 Moreover, only 18% of women started on a statin to reduce the risk of cardiovascular disease were still taking the drug after 1 year.49