COMMENTARY

Hysterectomy and Cardiovascular Disease: Conserve the Ovaries?

JoAnn E. Manson, MD, DrPH

Disclosures

February 22, 2011

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Hello. This is Dr. JoAnn Manson, Professor of Medicine at Harvard Medical School Brigham and Women's Hospital. I'd like to talk with you today about the subject of hysterectomy for benign disease and the relative merit of ovarian conservation vs bilateral oophorectomy. Recent studies have shed light on this very thorny issue of whether to remove the ovaries when hysterectomy is done for benign disease.

A recent paper was published in the European Heart Journal[1] on a study that was done in Sweden. They studied a large population that included more than 184,000 women with hysterectomy. They were followed with register linkage for cardiovascular hospitalizations. This study suggested that women who had a hysterectomy with oophorectomy done at a younger age (before age 50) had a significant increase in both coronary hospitalizations as well as stroke, about a 40% increase. Even women who had a hysterectomy without oophorectomy had about a 15%-20% increase in cardiovascular hospitalizations.

These findings of an increased risk for cardiovascular outcomes in women with bilateral oophorectomy before age 50 are very similar to our findings in the Nurses' Health Study that we published in Obstetrics and Gynecology in 2009.[2] We followed more than 29,000 women in the Nurses' Health Study who had hysterectomy, and women who had hysterectomy with oophorectomy had a significant increase in all-cause mortality as well as coronary heart disease. It was relatively modest in the overall cohort, but among women who had hysterectomy and bilateral oophorectomy before age 50 and who were not treated with estrogen, there was close to a doubling in the risk for heart disease and stroke and about a 40% increase in all-cause mortality.

Overall, these studies do raise concerns, particularly about hysterectomy with bilateral oophorectomy done before the age of 50. Whether hysterectomy alone increases the risk for vascular outcomes, perhaps as a result of some disruption of the blood supply to the ovaries, remains unclear because of the large number of potential confounding factors for hysterectomy, including obesity. With bilateral oophorectomy, there does appear to be strong evidence of an increased risk for cardiovascular events, suggesting that in younger women who have hysterectomy for benign disease, bilateral oophorectomy should be avoided if possible, and when done, serious consideration should be given to estrogen treatment at least until the average age of natural menopause.

It's important to emphasize that these findings are for women at usual risk. We're not talking about women who are at increased risk for breast cancer or ovarian cancer, strong family history, BRCA gene positivity, etc, in whom the benefits of oophorectomy will often outweigh the risk. These findings suggest that for women at usual risk, bilateral oophorectomy at a younger age does appear to be associated with an increased risk for cardiovascular events. Thank you very much. This is JoAnn Manson.

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