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The benefits of ovarian conservation at the time of hysterectomy for benign disease

William H. Parker, M.D.

Dr. William H. Parker is board-certified by the American Board of Obstetrics and Gynecology and he is an elected Fellow of the American College of Obstetricians and Gynecologists. He has managed the unusual by having a successful private practice and a very impressive academic medical career. Dr. Parker is a clinical professor at the UCLA School of Medicine, he is chair of Obstetrics and Gynecology at Saint John’s Health Center, and he is in private practice in Santa Monica, California. Dr. Parker is a frequent lecturer and teacher of advanced surgical techniques both in the United States and abroad. He has experience in advanced laparoscopic surgery and advanced hysteroscopic surgery. He has published extensively on his research in the areas of treatment for fibroids, including laparoscopic myomectomy and abdominal myomectomy for large fibroids, laparoscopic hysterectomy and ovarian cyst surgery.

Gynecologists have long suggested ovarian removal as the best strategy to decrease the rate of ovarian cancer. 1 The general acceptance of this idea caused the percentage of hysterectomies accompanied by ovarian removal of both ovaries to more than double from 25% in 1965 to 55% in 1999. Of the 600,000 hysterectomies still performed yearly in the U.S., approximately 300,000 are accompanied by prophylactic ovarian removal.

Except for women with families with known BRCA 1 or 2 germ-line mutations, ovarian cancer is a relatively uncommon malignancy. At age 50, only about one in 1,500 women will be diagnosed with ovarian cancer, and at age 70, the age of peak incidence, only 1 in 400 will be found to have ovarian cancer. Ovarian cancer is much less common than lung, colon or breast cancer.

Benefits of postmenopausal ovary

The benefits of preserving ovarian function include lower risks of hip fracture and heart disease. And, 490,000 women die of heart disease every year while about 48,000 women die within one year following hip fracture. Premenopausal removal of the ovaries causes immediate loss of all ovarian hormones. Following natural menopause, the ovary continues to produce two hormones, androstenedione and testosterone, in significant amounts until age 80. 2These hormones are then converted to fat, muscle and skin cells in estrone, the main estrogen found in postmenopausal women.

Ovarian removal has been shown to increase the risk of heart attack significantly. 3 Estrogens inhibit bone loss, and androstenedione and testosterone increase bone formation. One study found that after 16 years of follow-up women, who were postmenopausal at the time of ovarian removal, had 54% more hip fractures than women with intact ovaries. 4 And women older than 60 who have a hip fracture had a twofold increase in mortality. 5

Our study design

The ideal way to study this issue would be with a prospective, randomized trial. However, calculations suggest this would require 8,000 women to be randomly assigned to ovarian removal or ovarian conservation, and then followed for 40 years to determine causes of death. Therefore, this type of study is unlikely to ever be performed.

We chose to examine 20 years of published medical data to determine the risks for five conditions that have been linked to the presence or absence of ovaries: ovarian cancer, breast cancer, heart disease, hip fractures and stroke. The data was then entered into a sophisticated computer model to estimate age-specific risks of mortality.

Study results

To look at one analysis of the data in this study: if you took 20,000 women between ages 50-54 who have had a hysterectomy and compared 10,000 women who had their ovaries removed to the 10,000 women who kept their ovaries, by the time the women reach 80 years of age, 858 more women would have died from the group who had their ovaries removed.

While 47 (out of the 10,000) fewer women would have died from ovarian cancer, 838 more women would have died from heart disease and 158 more would have died from complications of hip fracture.

Summary

Because ovarian cancer is a relatively uncommon cause of death and heart disease a relatively common one, our data show that for women without a family history of ovarian cancer, there is more benefit to ovarian preservation if they need a hysterectomy for benign conditions.

Although not included in this study, because they do not lead to mortality, the effects of ovarian removal on sexuality, mood and cognitive function should be considered.

For premenopausal, and for some post-menopausal women, ovarian removal may lead to the sudden onset of hot flushes and mood disturbances. Other problems may include a low sense of well-being, a decline in cognitive functioning, poor sleep quality, depression and a decline in sexual desire and frequency. 6

While estrogen therapy may reduce both risks and symptoms, many women discontinued hormone therapy after the Women’s Health Initiative and fewer women now start hormones at the time of menopause.

Our findings indicate that women clearly benefit from keeping their ovaries when undergoing hysterectomies before age 65. Hopefully, our results will encourage a dialogue between women and their doctors regarding the potential risks that may result from ovarian removal and help women who are considering this decision.

More about this study can be found at: www.ovaryresearch.com

The New York Times published the results of a more current study by Dr. William H. Parker and colleagues, and this information can be found at: www.nytimes.com/2009/04/08/health/research/28ovar.html

 

1 Gibbs E. Suggested prophylaxis for ovarian cancer. Am J Obstet Gynecol 1971;111:756-65.>1 Gibbs E. Suggested prophylaxis for ovarian cancer. Am J Obstet Gynecol 1971;111:756-65.

2 Sluijmer, A, Heineman M, De Jong F, Evers J. Endocrine activity of the postmenopausal ovary: the effect of pituitary down-regulation and oophorectomy. J. Clin Endrocrinl Metab 1995;80.

3 Colditz G, Willett W. Stampger M, Rosner B, speizer F, Hennekens C. Menopause and the risk of coronary heart disease in women. N Engl J. Med. 1987;316:1105-10.

4 Melton J. Khosla S, Malkasian G, achenback S, Oberg A, Riggs L. Fracture risk after bilateral oophorectomy in elderly women. J Bone Miner Res. 2003;18:900-05.

5 Keene G, Parker M, Pryor G. Mortality and morbidity after hip fractures. BMJ. 1993:13:1248-50.

6 Sherwin BB, Hormones, mood and cognitive functioning in postmenopausal women. Obstet Gynecol. 1996 87:20S-26S.

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