Are you about to have a hysterectomy performed and are wondering if you should have your ovaries and tubes removed at the same time? Many women are faced with this dilemma and are confused about what to do. This may be due to conflicting ideas on the internet or from friends, or they are afraid of getting ovarian cancer and they believe this will eliminate their risk.

There has been a paradigm shift in the recommendations, and for good reasons. It used to be thought that removing your tubes and ovaries at the time of a hysterectomy eliminated or reduced your risk of developing ovarian cancer. This procedure is called a prophylactic bilateral salpingo-oopherectomy (BSO), and the recommendations for doing so have changed. There are many reasons why this concept has shifted in thought.

1. Ovarian cancer risk is very low for most women. In the general population, the lifetime risk of ovarian cancer is 1.4%. This varies per population. For white women with three or more term pregnancies and 4 or more years of oral contraceptive use, the lifetime risk is even less, at 0.3% (i.e. one in every 1,000 women). (1)

2. The risk of potential complications from doing a prophylactic BSO where the ovaries are normal is around 3%. Thus, the risk is greater than the benefit. For this and other reasons noted below, the ACOG (American Congress of Obstetrics and Gynecology), in their latest recommendations on this subject, do not advocate removal of ovaries prophylactically unless there is pathology of the ovaries or high risk factors. (2)

3. According to the 2009 Nurses’ Health Study (NHS, removing ovaries during a hysterectomy has been associated with  more cases of coronary heart disease (CHD), stroke, and lung cancer compared with women who had hysterectomy with ovarian conservation. (3) A subsequent NHS confirmed these increases, but also added an increase in colon cancer. (4)

4. Studies do not support the goal of a reduction of ovarian cancer by prophylactic oophorectomy. Two studies confirmed that at no age was there a survival advantage in the oophorectomy group and there were some deaths from ovarian cancer from o.9% of women without ovaries. (4,5)

5. In other studies of the Mayo population, women with oophorectomies had higher risks of anxiety, depression, dementia or cognitive impairment, and Parkinsonism. (5) They had more mood changes and hot flashes too. This was not as significant if women took hormone therapy long term.

6. Unfortunately, women tend to not continue to take hormone therapy. Even though it may have been recommended that the women take hormones to treat the above problems, the data indicates that only 17% of women continue with to take estrogen 5 years after the initial treatment. (6) NHS studies concluded that women with a BSO before the age of 50 but who did not use subsequent estrogen therapy had a higher risk of mortality from all causes than those who did use estrogen by almost 40%. (5)

7. The fear of needing further surgery to remove ovaries is not well supported. The chance of needing a BSO after a hysterectomy is low. Only about 6.2% of women with ovarian conservations require this. The same risk in women who didn’t have a hysterectomy was 4.8%; thus not statistically different. (7)

8. Ovarian cancer does not always come from the ovary. Seventy percent of epithelial ovarian cancers are of the serous high-grade and clinically aggressive type. However, the ovary does not contain epithelial cells. (9) There is other evidence to show that what we have called ovarian cancer may be cancers coming from other pelvic organs that have epithelial cells, such as tubes. It may also come from the lining of the abdomen, called the peritoneum, not needing ovaries for its development.

9. Removal of just the tubes does not seem to cause ovarian problems. Some believe that doing a salpingectomy (removal of just the tubes) could compromise collateral circulation to the ovaries and predispose women to early ovarian failure. However, so far the literature does not confirm this fear and ovaries contained just as many follicles after as before removal of tubes. (10)

10. In those women desiring prophylaxis, removal of the tubes may be better than removal of the ovaries. This would result in maintaining ovarian function, but potentially decreasing the risk of the epithelial tumors though to come from the ovaries but which may actually be coming from the tubes. This can be considered prior to a hysterectomy if desired. (11)

In conclusion, women with an average risk of ovarian cancer should not be performed in women undergoing a hysterectomy. Doing so may increase their risks of developing other fatal medical conditions. If they have a high risk of ovarian cancer, such as BRCA positive or a strong family history of breast or ovarian cancer, this could be recommended. It may be better for patients to remove tubes and preserve ovaries for most women.

 

References

1. Hartge P, Whittemore AS, Itnyre J, McGowan L, Cramer D. Rates and risks of ovarian cancer in subgroups of white women in the United States. The Collaborative Ovarian Cancer Group. Obstet Gynecol. 1994;84(5):760–764.

2. Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the Nurses’ Health Study. Obstet Gynecol. 2013; 121(4):709–716.

3. Parker W, Broder M, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027–1037.

4. Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the Nurses’ Health Study. Obstet Gynecol. 2013;121(4):709–716.

5. Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton LJ III. Survival patterns after oophorectomy in premenopausal women: A population-based cohort study. Lancet Oncol. 2006; 7(10):821–828.

6. Sprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use: Results from the national health and nutrition examination survey, 1999–2010. Obstet Gynecol. 2012;120(3):595–603.

7. Casiano ER, Trabuco EC, Bharucha AE, et al. Risk of oophorectomy after hysterectomy. Obstet Gynecol. 2013;121(5):1069–1074.

8. Pavlik EJ, Ueland FR, Miller RW, et al. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstet Gynecol. 2013;122(2 Pt 1):210–217.

9. Kurman RJ, Shih IM. The origin and pathogenesis of epithelial ovarian cancer: A proposed unifying theory. Am J Surg Pathol. 2010;34(3):433–443.

10. Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton LJ III. Survival patterns after oophorectomy in premenopausal women: A population-based cohort study. Lancet Oncol. 2006;7(10):821–828.

11. SGO Clinical Practice Statement: Salpingectomy for Ovarian Cancer Prevention. Society of Gynecologic Oncology. November 2013. https://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention. Accessed February 10, 2014.