COMMENTARY

Hysterectomy for Benign Conditions: Remove the Ovaries?

Peter Kovacs, MD, PhD

Disclosures

July 05, 2018

Hysterectomy With Elective Bilateral Salpingo-oophorectomy

Annually, more than 600,000 hysterectomies are performed in the United States. In about 50% of these cases, the ovaries are removed electively as well.[1] Those in favor of oophorectomy argue that this can prevent ovarian diseases later in life, such as ovarian cancer, which carries a lifetime risk of 1.3%.[2] Furthermore, it is argued that menopausal ovaries are no longer sufficiently hormonally active for the woman to benefit from its secretory products (mainly estradiol). The menopausal years are characterized by the typical symptoms and consequences of hypoestrogenism.

The perimenopausal/menopausal ovary, however, is not completely inactive, and the abrupt change in hormone secretion after oophorectomy may be associated with important adverse health effects.

A recent review by Adelman and Sharp[3] addresses the risks of elective bilateral salpin

Consequences of BSO

The rate of BSO with hysterectomy increases with age; rates are highest among women 45-54 years of age. The decision to undergo BSO is often influenced by a personal or family history of breast or ovarian cancer.

The review made the following conclusions:

  • All-cause mortality (ovarian/breast cancer versus cardiovascular disease) is higher after BSO compared with ovarian conservation. Estrogen replacement therapy lowers the risk for all-cause mortality. With respect to all-cause mortality, women seem to benefit from ovarian conservation up to the age of 65 years.

  • BSO is associated with lower risk for ovarian cancer. The risk for breast cancer is also reduced when BSO is done before natural menopause. However, the risk for death from any cancer is lower in women whose ovaries are retained.

  • Several studies (but not all) have shown that the risk for cardiovascular disease is higher among those undergoing BSO. The younger the woman at the time of BSO, the higher the risk. Estrogen replacement therapy after BSO is associated with lower risk for cardiovascular disease.

  • Cognitive impairment and dementia are more common among those undergoing BSO, especially if the procedure is done before age 50 years. Estrogen replacement therapy is associated with slower cognitive decline.

  • Hysterectomy may be beneficial for sexual functioning (eg, if performed for large fibroids), but BSO may negatively affect this by causing vaginal dryness and decreased libido.

  • The risk for osteoporosis and related fractures increases after BSO, especially when performed in younger women. Estrogen replacement offers some protection.

Viewpoint

As a result of follicle loss, natural menopause typically is reached around 50 or 51 years of age.[4] This is accompanied by important changes in ovarian hormone secretion; the cyclic estradiol/progesterone secretory capacity is lost, but the ovaries do not go completely quiet. The menopausal ovaries still secrete androgens (testosterone, androstenedione) and contribute about one third of the total daily androgen synthesis.[1,4] Androgens are required for maintaining bone health, sexual functioning, muscle mass, strength, and overall energy.[1]

BSO is associated with reduced risk for ovarian and breast cancer. One case of ovarian cancer is avoided for every 300 BSO procedures performed. BSO also prevents the need for adnexal mass surgery in the future.

However, some risks—including all-cancer mortality, osteoporosis, cognitive impairment, and cardiovascular disease—are associated with surgical menopause. The impact of menopausal hypoestrogenism can be attenuated with hormone replacement therapy, and the risk is higher among pre- and perimenopausal women.

When hysterectomy for benign disease is planned, the pros and cons of BSO need to be discussed with the patient. The decision whether to proceed with BSO has to be individualized, taking into consideration such factors as age, personal or family history of cancer and cardiovascular disease, and acceptance of estrogen replacement therapy. For women who are younger and at low cancer or cardiovascular disease risk, the ovaries should be retained.

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