I am writing this website article at 37,000 feet as I return to LA from Miami. Aside from enjoying the wonderful weather (it was 78 degrees) I had the opportunity to give a talk on women’s health to over 200 women who had gathered for a benefit luncheon for the organization “Hearing the Ovarian Cancer Whisper” or H.O.W. It was their 12th annual event in Palm Beach and was held at the beautiful Flagler Museum. The scientists/ physicians who “discovered” CA 125 and created the use of this marker in evaluating and treating ovarian cancer were there and I was honored to share the afternoon with them. So how appropriate was it to peruse the January issue of the journal Menopause and find an article in the Personal Perspective section on the controversial issue of surgical removal of the ovaries (oophorectomy) for prevention of ovarian cancer either during hysterectomy or as a primary procedure. Does oophorectomy prevent thousands of women from dying of ovarian cancer, or does it create other disorders that impact their health and shorten their longevity?
Ovarian cancer is the fifth deadliest cancer in women and will cause an estimated 15,500 deaths this year in the United States. Clearly an option to prevent this malignancy is to perform bilateral oophorectomy. And indeed, it is done together with removal of the fallopian tubes (salpingectomy) in almost half of all hysterectomies performed for benign reasons. But, as in most medical decisions, there is now a debate about the pros and cons…
Here are the pros that were outlined by the author of the article:
Sixty three percent of cases of ovarian cancer are diagnosed in late stages because there are few warnings that the disease is present in its early stages. Moreover, there are currently no recommended screening tests that have been shown to change mortality rates. (And, the current theory is that many ovarian cancers actually start in the Fallopian tubes, and by the time it spreads to the ovaries it is already a metastatic cancer!) A woman’s lifetime risk of ovarian cancer is 1 in 70. So for that 1 in 70 women, removal of the tubes and ovaries would reduce their risk. It has been estimated that 1,000 cases of ovarian cancer could be avoided annually if the tubes and ovaries are removed during the time of hysterectomy in women who are 40 or older.
Those women who are at high risk for ovarian cancer will obviously benefit the most from prophylactic removal of the Fallopian tubes and ovaries. These are women with either BRCA1 or BRAC 2 mutations or those with a very strong family history of ovarian cancer. We also know that for women with the BRCA mutations the surgery reduces their breast cancer risk. The author points out that the surgery is the only thing we have that can prevent ovarian cancer in women with increased risk. Although not great (and please don’t panic at this list), the risk factors include being white, never having been pregnant, late age of menopause, and a long number of years of ovulation.
There are also secondary benefits to removing the ovaries and tubes at time of hysterectomy. For some women this may help alleviate pain and severe PMS. And for many women, the removal of their ovaries can lead to a significant decrease in anxiety and depression related to their perceived cancer risk.
Now, onto the negative:
and the reasons many gynecologists now feel that the ovaries should be conserved during hysterectomy. The database from the National Center for Health Statistic, the Women’s Health Initiative and other studies have shown that there is no clear benefit for elective removal of the ovaries before the age of 65 and indeed it is detrimental to the life expectancy rate for women with average risk for ovarian cancer. Removing the ovaries increases risk of death from coronary artery disease and after the age of 65 also increases risk of death from osteoporotic fracture. If the surgery is done before the age of 55 it increases a woman’s risk of dying of coronary artery disease by the age of 82 by over 15% from a baseline risk of 7.57%. The surgery before age 55 years increases the risk of dying of osteoporotic hip fracture by the age of 82 to 4.96% from the baseline risk of 3.38%.
There is also data which shows that the surgery can be linked to cognitive impairment caused by estrogen deficiency. In a study quoted by the author, women whose estrogen decreased more than 50% six months after surgery, performed worse in all cognitive functioning tests when compared with women whose estrogen decreased by less than half. The impairment was mitigated with immediate and continuous estrogen therapy until at least age 50. And finally there is one more drawback to bilateral oophorectomy; decreased sexual function and diminished sexual desire. Years after menopause the female ovaries produce both testosterone and another hormone called androstenedione. They are both partially converted to estrogens in the fat cells. After surgical menopause the blood levels of estrogen and male hormone decrease. Lack of estrogen can cause vaginal atrophy and discomfort with intercourse, lack of male hormone has been associated with diminished libido and sexual satisfaction.
It’s possible that therapy with estrogen and perhaps testosterone will prevent these negative outcomes. Studies have even shown that women who undergo the surgery between the ages of 45 and 50 and who receive estrogen therapy have a significantly lower number of deaths related to cardiovascular disease. And we know that estrogen therapy can prevent and treat bone loss in perimenopausal and postmenopausal women.
So there you have it, the pros and cons. The decision to remove the tubes and ovaries while doing a hysterectomy should be made on an individual basis in consideration of a woman’s unique risk for ovarian cancer. The Society of Gynecologic Oncologists (and these are the experts that treat ovarian cancer) now state “Ovarian conservation before menopause may be especially important in patients with the personal or strong family history of cardiovascular or neurological disease. Conversely, women at high risk of ovarian cancer should undergo risk reducing bilateral saplings-oophorectomy.”
Bottom line: The removal of the ovaries can have serious consequences to health and longevity, before and perhaps after menopause. The decision to remove them should be based on a high risk for ovarian cancer..