Translating event effects to mortality effects is even more problematic when applied to contemporary medical practice. Women at risk of common cardiovascular problems such as hypertension and coronary artery disease now have the benefit of advances in diagnosis (blood pressure monitoring, biochemical markers, endothelial function tests, and coronary imaging) and treatment (eg, statins, antihypertensives, and coronary artery stents), which can reduce the likelihood of both cardiovascular events and deaths.
Finally, the relative risk for oophorectomy is based not on a randomized trial but on the observational, longitudinal NHS study,2 which may have been subject to selection bias. Were women who went against prevailing wisdom and retained their ovaries at the time of hysterectomy the same ones who had a prevention/wellness view of personal health? Did they follow a regimen of personal fitness and nutrition that reduced their risk of heart disease? In such a scenario, not captured by the statistical controls in the study,4 the dual facts of ovarian conservation and reduced heart disease are true but unrelated.
MENZIN: I agree that the modeling used by Parker and colleagues depends on several reference data sets that have their own potential biases and limitations. For example, the authors recognized that “no published data were found for coronary risk when oophorectomy was performed after menopause,” yet their study purportedly demonstrated that the excess mortality associated with oophorectomy between the ages of 50 and 65 years was primarily a result of coronary disease.
The clinical importance of postmenopausal hormone production has not been fully determined. Furthermore, the duration of effective estrogen production in conserved ovaries also can be hard to predict; almost 33% of women experience menopause within 2 years after hysterectomy with ovarian conservation.10
The Parker study focuses on mortality; however, the likelihood of medical or surgical intervention for benign or equivocal adnexal pathology also should be considered, along with the potential complexity of such treatments.
Women feel uninformed about their options
GUZICK: In my judgment, the fate of the ovaries in a woman undergoing hysterectomy for benign disease should be based on a thorough discussion with the patient that takes into account her individual risk profile and the psychological weight she attaches to the various outcomes. Key factors in the risk profile include age; menopausal status; family history of heart disease and breast and ovarian cancer; and biochemical, genetic, or imaging findings related to cancer, cardiovascular disease, and osteoporosis.
For example, a 45-year-old woman who is lean and normotensive with a favorable lipid profile, and who greatly fears the prospect of ovarian cancer because a friend died of the disease, may choose to have her ovaries removed. Whether this decision is “right” or “wrong” in general is hard to say, but for this patient the decision is acceptable. Her individual risk for cardiovascular disease and osteoporosis can be monitored more carefully and, if necessary, treated effectively early on. She can be given estrogen for vasomotor symptoms.
For postmenopausal women in their early to mid-50s, the situation is murkier, but a blanket recommendation still seems unwarranted. For women in their late 50s and older, although the Parker model shows a “visual” difference between projected survival curves until age 65, it is not clear whether such differences are statistically significant.
MENZIN: A critical point was highlighted in a recent description of interviews with women awaiting hysterectomy. Bhavnani and Clarke11 found that “many women felt inadequately informed about their treatment options and were unaware of important longer-term outcomes of oophorectomy.” Although the work by Parker and colleagues adds another dimension to the counseling of women considering hysterectomy for benign indications, the complexity of that counseling continues to evolve.
Ultimately, the Parker study demonstrates that oophorectomy does not provide a survival benefit over ovarian conservation. This does not mean oophorectomy is always unadvised. Equivalent treatment arms of randomized trials in oncology have demonstrated that quality of life can vary between alternate therapies. Parker and colleagues did not address this critical issue—one I believe to be at the core of every therapeutic decision and informed consent discussion.
In the end, we must individualize the operation to meet the goals and expectations of the patient.
GUZICK: I agree. A one-size-fits-all approach to clinical decision-making is rarely appropriate. The study by Parker et al provides a framework for women to determine which size is best for them.
The authors report no financial relationships relevant to this article.