Practice changer
Advise patients undergoing hysterectomy for benign conditions that there are benefits to conserving their ovaries. The risk of coronary heart disease (CHD) and death is lower in women whose ovaries are conserved, compared with those who have had them removed.1
Strength of recommendation:
B: A large, high-quality observational study.
Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113:1027-1037.
ILLUSTRATIVE CASE
A 44-year-old woman with a family history of early CHD is considering hysterectomy for painful uterine fibroids. She’s thinking about undergoing concurrent bilateral oophorectomy to prevent ovarian cancer and asks for your input. How would you advise her?
Hysterectomy is the most common gynecologic surgery in the United States. In 2003, more than 600,000 hysterectomies were performed; 89% were not associated with malignancies.2
Ovarian conservation is not the norm
Data from the University Health-System Consortium Clinical Database indicate that between 2002 and 2008, about 55% of women who had a hysterectomy that was not cancer-related underwent oophorectomy. Rates of concurrent oophorectomy included:
- 68% of women ages 65 and older
- 77% of women ages 51 to 64
- 48% of women ages 31 to 50
- 3% of women ages 18 to 30.
A recent analysis from the Centers for Disease Control and Prevention found that among women who underwent hysterectomy for any reason between 1994 and 1998, 55% also had their ovaries removed.3
Hormones and CHD: An unanswered question
Over the last several decades, there has been a great deal of interest in the relationship between hormones and CHD, much of it stemming from the controversy about hormone replacement therapy (HRT). The findings of the Women’s Health Initiative implicated combined exogenous hormones (estrogen and progestin) as a risk factor for CHD.4 Endogenous hormone production, however, may protect against CHD; some studies have demonstrated a decreased risk of cardiovascular death with later age of menopause.5,6
Current oophorectomy recommendations are age-specific. The American College of Obstetricians and Gynecologists (ACOG) recommends that strong consideration be given to ovarian conservation in premenopausal women who are not at risk for ovarian cancer. For postmenopausal women, however, ACOG recommends consideration of oophorectomy as prophylaxis.7 These recommendations are based on expert opinion. Previous studies suggest that ovarian conservation may improve survival in specific age groups.8,9 The large, high-quality observational study reviewed here provides further guidance about the role of ovarian conservation across all age groups.
STUDY SUMMARY: Oophorectomy increases risk of CHD and death
This observational study1 was part of the Nurses’ Health Study. It included 29,380 women, of which 16,345 (55.6%) underwent hysterectomy with bilateral oophorectomy and 13,035 (44.4%) had hysterectomy with ovarian conservation. Women with unilateral oophorectomy were excluded, as were those who had a history of CHD or stroke, and women for whom pertinent data, such as age, were missing. A follow-up survey was sent to participants every 2 years for 24 years, with an average return rate of 90%.
Women who had undergone bilateral oophorectomy had an increased risk of CHD and all-cause mortality ( TABLE ). The authors estimated that with a postsurgical life span of approximately 35 years, every 9 oophorectomies would result in 1 additional death. The authors also pointed out there were no age exceptions: Ovarian-sparing surgery was linked to improved survival in every age group.
Oophorectomy did have a protective effect against breast cancer, ovarian cancer (number needed to treat=220), and total cancer incidence, but it was associated with an increased incidence of lung cancer (number needed to harm=190) and total cancer mortality. There was no significant difference in rates of stroke, pulmonary embolus, colorectal cancer, or hip fracture.
TABLE
Oophorectomy (vs ovarian conservation) increases key risks1
| RISK FACTOR | MULTIVARIATE–ADJUSTED HR (95% CI) |
|---|---|
| CHD (fatal and nonfatal) | 1.17 (1.02-1.35) |
| Breast cancer | 0.75 (0.68-0.84) |
| Lung cancer | 1.26 (1.02-1.56) |
| Ovarian cancer | 0.04 (0.01-0.09) |
| Total cancer | 0.90 (0.84-0.96) |
| Total cancer mortality | 1.17 (1.04-1.32) |
| All-cause mortality | 1.12 (1.03-1.21) |
| CHD, coronary heart disease; CI, confidence interval; HR, hazard ratio. | |
WHAT’S NEW: Ovarian conservation: Better for all ages
The evidence is clear: Conserving the ovaries, rather than removing them, during hysterectomy is associated with a lower risk of CHD and both all-cause and cancer-related mortality.
What about the patient’s age? A 2005 analysis suggested that ovarian conservation conferred a survival benefit compared to oophorectomy in women <65 years.8 Similarly, a 2006 cohort study found increased mortality in women <45 years who underwent concurrent oophorectomy.9 But this is the first study to demonstrate that ovarian-sparing surgery is associated with improved survival in women of every age group.