Hysterectomy is the second most common surgery performed
in US after cesarean section. According
to CDC data approximately 600,000 hysterectomies are performed each year. A
nationwide study further reported that unilateral or bilateral
oophorectomy was performed in 68 percent of women at the time of abdominal
hysterectomy, 60 percent at laparoscopic hysterectomy, and 26 percent at
vaginal hysterectomy.
Women have an option of undergoing elective
oophorectomy (EO) along with benign hysterectomy to reduce the risk of ovarian
cancer, thereby reducing a chance of second surgery coupled with decreased perceived
anxiety of breast and ovarian cancer
subsequently.But there are negative side effects of this surgical
induced menopause such as death, total cancer mortality, osteoporosis,
cognitive decline, decreased sexual drive and increased cardiac mishap support
conservation of ovarian function.
There is considerable debated going on between EO and
ovarian conservation, with strong statements are put forward in favor of each. Currently
ACOG recommends “strong consideration should be made for 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.”
Arguments in favor of ovarian conservation:
- EO is detrimental for the overall health of women and decreases the life expectancy due to coronary artery disease. In a landmark study by Parker et al using Surveillance, Epidemiology, and End Results (SEER) database, the National center for Health Statistics, the Women’s Health Initiative, and the National Inpatient Sample it was seen that there is no clear cut benefit of EO at any age and women died early due to associate morbidity.
- The neuroprotective benefits of estrogen were seen in multiple studies and was further supported by declining cognitive functions specially in women undergoing EO under 50 yrs.
- EO leads to increase in hip fracture due to decrease in BMD as estrogen levels plummet. This was specifically seen in the light of mass discontinuation of hormone replacement therapy among postmenopausal women when results of Women’s Health Initiation trial published.
- A decrease in sexual desire and function, resulting in quality of life issues and conflict in interpersonal relationship, depression was seen after oophorectomy.
Arguments in favor of EO:
- Ovarian cancer is the fifth leading cause of death among women in US with estimated 22,280 new cases and 14,240 deaths in 2016. A woman’s lifetime risk of ovarian cancer is 1 in 70 or 1.4% with no known effective screening method that could diagnose it at very early stage. Researchers have estimated that 1000 new cases of ovarian cancer could be avoided if EO is performed in women undergoing hysterectomy in women 40 years and older.
- In women at high risk for ovarian cancer (especially with familial history or genetic predisposition, BRCA1 or BRCA2 mutations) risk-reducing oophorectomy (RRO) reduced cancer specific mortality.
- In general population RRO is an ideal treatment for the prevention of ovarian cancer in women who have known risk factors like being white, never having been pregnant, late age of menopause, and a long estimate number of years of ovulation in absence of effective screening strategies.
- EO leads to avoiding the risk of second surgery after hysterectomy due to adnexal disease or masses.
- Effective replacement therapy available to prevent osteoporosis, cardiac and sexual dysfunctions is being put as a valid argument in support of EO, specifically after the beneficial results of hormone therapy from Women’s Health Initiative studies.
- A recent study by Trabuco et al published in the May issue of Obstetrics and Gynecology has concluded that even if ovaries are spared at the time of hysterectomy, it affects the ovarian reserve as evident by declining levels of Antimüllerian hormone. The study also reported that women undergoing hysterectomy became menopausal 1.9 years earlier than referent patient who has not undergone any surgery.
Despite all these arguments studies have recently
documented that of all the hysterectomies performed for benign reason 36%-38% were
deemed unnecessary and histologically normal.
So, the decision for EO should be made according to
each woman’s individual genetic test results and her risk for developing ovarian
malignancy. Age at the time of benign hysterectomy is an important decisive
factor. In 2010, recommendations from the Society of Gynecologic Oncologists
state “Ovarian conservation before menopause may be especially important in
patients with a personal or strong family history of cardiovascular or
neurological disease. Conversely, women at high risk of ovarian cancer should
undergo risk-reducing bilateral salpingo-oophorectomy.”
A women’s risk of cardiovascular disease, dementia,
osteoporosis, and family history must be taken into account before decisions for
EO or ovarian conservation are made in woman considering hysterectomy.
References:
http://journals.lww.com/greenjournal/Fulltext/2016/05000/Association_of_Ovary_Sparing_Hysterectomy_With.3.aspx
Should ovaries be removed at pre-menopause?
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