COMMENTARY

Should Ovaries Be Removed at the Time of Hysterectomy?

Peter Kovacs, MD, PhD

Disclosures

August 28, 2014

Oophorectomy and Hysterectomy and Cancer Incidence in the Cancer Prevention Study-II Nutrition Cohort

Gaudet MM, Gapstur SM, Sun J, Teras LR, Campbell PT, Patel AV
Obstet Gynecol. 2014;123:1247-1255

Background

In 2013, over 800,000 new cancer cases were predicted for the female population in the United States. About one third of these cancers were fatal.[1]

In the 40- to 59-year age category, cancer is the leading cause of death and is responsible for about 35% of all mortality. Breast cancer and cancers of the genital organs together make up 40% of cancer cases.[1] Therefore, any intervention that lowers the incidence of these cancers or reduces the associated mortality and morbidity could make a huge impact on the lives of many women.

Hysterectomy is the most commonly performed surgery in the United States.[2] Hysterectomy is also the procedure of choice for numerous benign and malignant conditions. Fibroids, bleeding abnormalities, endometrial pathology, adenomyosis, endometriosis, and various cancers or precancerous diseases may require the removal of the uterus as part of treatment.

The ovaries serve an important endocrine function, and their proper activity during the reproductive years is associated with long-term health benefits. The ovaries and fallopian tubes, however, may also undergo malignant transformation, and the hormones secreted by the ovary play a role in the etiology of certain types of cancers.

A woman has a 1 in 70 risk of being diagnosed with ovarian cancer in her lifetime. This type of cancer is typically diagnosed at an advanced stage, when treatments are less effective and therefore associated with high mortality. Effective screening tools are not available. Certain reproductive factors and preventive measures can, however, modify one's risk.[3]

It is an important question to consider whether the ovaries should be removed at the time of hysterectomy. This cohort study assessed the effect of bilateral salpingo-oophorectomy (BSO) performed with hysterectomy on subsequent cancer risk.

The Study

The participants in this study (n = 66,802) were drawn from the population of the Cancer Prevention Study-II Nutrition Cohort. The mean age of the patients was 62.5 years. Data were collected with the help of questionnaires, and medical registers were used to verify self-reports. During the analysis, important confounders (eg, race, education, parity, reproductive history, physical activity, body mass index, participation in screening programs, medical problems, and medication use) were controlled for.

The cohort included 8621 diagnosed cancers. Breast cancer, colorectal cancer, and hematologic cancers were the most common. One fourth of the participants underwent hysterectomy with adnexectomy, and an additional 15% had simple hysterectomy.

Women who had hysterectomy with BSO had an overall 10% lower risk for cancer. Those who had the surgery before 45 years of age had an even higher risk reduction of 21% (relative risk, 0.79; 95% confidence interval [CI], 0.71-0.87). A simple hysterectomy before age 45 years was also associated with a lower risk for cancer (RR, 0.88; 95% CI, 0.80-0.97).

The risk for breast cancer was reduced by 27% among women who had hysterectomy and BSO before 45 years of age, and by 20% among those who had simple hysterectomy before age 45 years.

When breast cancer cases were removed from the analysis, however, neither hysterectomy with BSO nor simple hysterectomy was protective against cancer. The exception was the group of women younger than 45 years, among whom hysterectomy with BSO was associated with a 17% reduction in risk for all cancers other than breast cancer.

The risk for ovarian cancer was significantly reduced by hysterectomy with BSO (relative risk, 0.12; 95% CI, 0.07-0.21). Simple hysterectomy, however, was associated with an increased risk for ovarian cancer.

Viewpoint

Hysterectomy is offered as a definitive treatment for various benign diseases and as part of treatment or staging of malignant diseases. At the time of the surgery, one has to decide whether to retain or remove the tubes and ovaries.

In the case of younger, reproductive-aged women, especially when the patient desires future fertility, the decision is easy: Unless their removal is absolutely indicated, the ovaries are typically retained. The case seems easy for menopausal women as well. In their case, the ovary no longer serves a reproductive function and its activity as an endocrine organ is minimal.

The situation is not as straightforward when premenopausal women in their late reproductive years undergo hysterectomy. In their case, the ovary still maintains its important endocrine function (eg, skeletal health). The risks and benefits of BSO need to be individually assessed in such cases.

Most breast cancers are hormone-sensitive, and the incidence of other cancers of the reproductive organs become more common among menopausal women. For some, there are effective screening tools, whereas for others, early diagnosis is not possible. Ovarian cancer is typically diagnosed at an advanced stage, when treatments are no longer effective and the disease is associated with high mortality. It is known that the removal of tubes and ovaries significantly reduces the risk for ovarian cancer.[4]

Removal of the still-active ovaries should reduce the risk for cancers in which hormones play a role in the etiology. Simple hysterectomy may also offer some benefits in these cases, because part of the ovarian blood supply is coming from the uterus and is compromised when the uterus is removed, resulting in reduced ovarian activity.

This study found that both hysterectomy alone and hysterectomy with BSO are associated with a reduction in cancer risk, especially when performed before 45 years of age. The risk for breast cancer is reduced by both surgical procedures when performed before age 45 years. Hysterectomy with BSO significantly reduces the risk for ovarian cancer.

This information needs to be shared with the patient who is scheduled to undergo hysterectomy. The decision regarding oophorectomy should be based on her risk for cancer, and her age should be balanced against the long-term health benefits of maintained ovarian function. In the case of an average-risk patient, the younger the patient, the less indicated the removal of her ovaries. As women approach and pass 40 years of age, however, the impact on cancer risk reduction should be discussed with them.

Abstract

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