Oophorectomy or salpingectomy—which makes more sense?

CASE: PATIENT OPTS FOR HYSTERECTOMY, ASKS ABOUT OOPHORECTOMY
Your 46-year-old patient reports increasingly severe dysmenorrhea at her annual visit, and a pelvic examination reveals an enlarged uterus. You order pelvic magnetic resonance imaging, which shows extensive adenomyosis.

After you counsel the patient about her options, she elects to undergo laparoscopic supracervical hysterectomy and asks whether she should have her ovaries removed at the time of surgery. She has no family history of ovarian or breast cancer.

What would you recommend for this woman, based on her situation and current medical research?

A prophylactic procedure should be considered only if 1) there is a reasonable expectation that it will benefit the patient and 2) there is evidence that, without it, the individual will be at high risk for disease.¹ Bilateral oophorectomy at the time of hysterectomy for benign disease often has been recommended for women older than age 45 to prevent the subsequent development of ovarian cancer (FIGURES 1 and 2).

The 2002 Women’s Health Initiative report suggested that exogenous hormone use was associated with a slight increase in the risk of breast cancer.² After its publication, the rate of oophorectomy at the time of hysterectomy declined slightly, likely reflecting women’s desire to preserve their own source of estrogen.³ For women younger than age 50, further slight declines in the rate of oophorectomy were seen from 2002 to 2010. However, in the United States, almost 300,000 women still undergo “prophylactic” bilateral salpingo-oophorectomy every year.⁴

The lifetime risk of ovarian cancer among women with a BRCA 1 mutation is 36% to 46%, and it is 10% to 27% among women with a BRCA 2 mutation. Annual screening for ovarian cancer using transvaginal ultrasound and CA 125 has not been effective even among this group of women and is not recommended.⁵ There is universal agreement that women with these mutations should strongly consider oophorectomy once they have completed childbearing.⁶ Genetic counseling and testing for these genetic mutations now are readily available.

In the general population of US women, the lifetime risk of ovarian cancer is 1.4%. The risk varies between populations, however. For white women with 3 or more term pregnancies and 4 or more years of oral contraceptive use, the lifetime risk is only 3 women in every 1,000 (0.3%).⁷

KNOW THE FULL RANGE OF RISKS ASSOCIATED WITH OOPHORECTOMY
After menopause and throughout a woman’s life, the ovaries continue to produce androgens, which are converted to estrone. Many studies suggest that endogenous estrogen is beneficial to the heart, bones, and brain.

A 2009 study from the Nurses’ Health Study (NHS) database found that, among women who underwent hysterectomy with oophorectomy, there were more cases of coronary heart disease (CHD), stroke, and lung cancer, compared with women who had hysterectomy with ovarian conservation.⁸

A subsequent NHS report focused on long-term mortality and found that, after 28 years of follow-up, women who had a hysterectomy and bilateral oophorectomy had a higher risk of dying from CHD (hazard ratio [HR], 1.23), colorectal cancer (HR, 1.49), lung cancer (HR, 1.29), and all causes (HR, 1.13) than did women who had hysterectomy and ovarian conservation.⁹ During the 28 years, 44 of 13,302 women (0.9%) died of ovarian cancer. At no age was there a survival advantage in the oophorectomy group. A Mayo Clinic study found similar results.¹⁰

Additional studies of the Mayo population found higher risks of anxiety, depression, dementia or cognitive impairment, and Parkinsonism in women who had their ovaries removed.¹¹ Also, about 90% of premenopausal women experience vasomotor symptoms following oophorectomy; many women also experience mood changes, a decline in feelings of well-being, lower sexual desire, sleep disturbances, and headaches.

Overall, the evidence suggests that the removal of healthy ovaries does not meet the requirements for a prophylactic intervention.

EXOGENOUS ESTROGEN IS NOT A PRACTICAL STRATEGY AFTER OOPHORECTOMY
In the NHS studies, women who underwent hysterectomy and bilateral oophorectomy before age 50 but did not use subsequent estrogen therapy had a higher risk of all-cause mortality than women who did use estrogen (HR, 1.41).⁹ An early response to this finding was to advocate oophorectomy followed by the initiation of menopausal hormone therapy and statins to ward off any negative cardiovascular effects. However, data indicate that only 17% of women continue to take estrogen 5 years after the initial prescription, and only 18% of women still take statins 1 year after their first prescription.¹² Even these figures are overstated because they do not include women who never see a doctor, those who see a doctor but don’t get a prescription, and those who never fill their first prescription.