Keeping Ovaries After Hysterectomy Boosts Survival
By Kathleen Doheny
HealthDay Reporter
MONDAY, Aug. 1 (HealthDay News) -- Removing the ovaries along with the uterus during a hysterectomy done for noncancerous conditions is common in women over the age of 45, but a new study suggests it may not be the wisest course for long-term survival.
Keeping the ovaries is clearly best for women up to age 65 who are at average risk of getting ovarian cancer and get a hysterectomy for noncancerous conditions, said study author Dr. William Parker, a staff gynecologist at Santa Monica-UCLA Medical Center in Los Angeles. His finding appears in the August issue of Obstetrics & Gynecology .
In his review of 20 years of published data from various sources, Parker and his team found that preserving the ovaries in this group of women reduces their risk for heart disease and hip fractures.
"Twenty-five times more women die from heart disease every year than from ovarian cancer," Parker said.
For many years, the prevailing medical wisdom has been to remove the ovaries when the uterus is removed if women are past childbearing age to prevent ovarian cancer, Parker said. About half of women have their ovaries removed during hysterectomy.
However, the ovaries keep making small amounts of estrogen for years after natural menopause. Ovarian testosterone and androstenedione, two hormones, have been documented in some women in their 80s. Muscle and fat cells turn testosterone into circulating estrogen, in turn protecting against heart disease and osteoporosis.
Each year in the United States , more than 600,000 hysterectomies are performed. Ninety percent are performed for benign diseases, Parker said, such as uterine fibroids or endometriosis, in which the lining of the uterus begins to grow on the outside of the uterus and on nearby organs.
Parker's team tried to find out the age-specific risks for five conditions linked to the presence or absence of ovaries, including ovarian cancer, breast cancer, heart disease, hip fractures and stroke. They compared four strategies for hypothetical groups of women aged 40 to 80 who had a hysterectomy: ovary conservation with or without estrogen therapy later, and ovary removal with or without estrogen therapy later.
For women at average risk of ovarian cancer, heart disease, osteoporosis, breast cancer and stroke, the probability of survival to age 80 after hysterectomy at ages 50 to 54 ranged from 62 percent for those who kept their ovaries but didn't take estrogen, to 53 percent for those who had their ovaries removed but didn't take estrogen.
Keeping the ovaries without estrogen therapy reduced the percent of women dying by age 80 of heart disease from 15 percent to 7 percent, and those dying of hip fractures from nearly 5 percent to 3 percent.
The reductions in those two diseases, Parker said, far outweigh the increase in ovarian cancer deaths by age 80.
"If you take out the ovaries, the risk of ovarian cancer goes to zero," Parker said, "but you lose the protection against heart disease and the prevention of osteoporosis."
Was he surprised? "Yes. I really did think that taking out the ovaries wasn't beneficial for [overall] mortality," Parker said. "But I didn't suspect that leaving them in would be so clearly beneficial."
Another expert familiar with the new study, Dr. Richard Paulson, a professor of reproductive medicine at the University of Southern California, Los Angeles, praised the work. "It's wonderful," he said. "When I first read it, my first thought was, why has this not been done before?"
"What has been lacking up to this point was a good analysis for the data. You've got the cancer doctors saying, 'You can't leave them behind, the patient is going to get cancer [of the ovaries] and die.' On the other hand, you have the hormone doctors, the endocrinologists who are saying that the postmenopausal ovaries make important hormones, and we should leave them intact. What was needed was for someone to crunch the numbers and come up with relative risks."
Neither Paulson nor Parker think practice will change overnight. But the new study is food for thought, and women aged 45 and above who are facing a hysterectomy for noncancerous conditions should be aware of the new analysis, they said.
Conserving Ovaries at Hysterectomy May Boost Long-Term Survival
Rueters
By Megan Rauscher
NEW YORK (Reuters Health) Aug 03 - The results of a Markov decision analytic model indicate that leaving both ovaries intact in women 65 years old or younger has long-term survival benefits in patients at average risk for ovarian cancer who undergo hysterectomy for benign disease.
"Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease," Dr. William H. Parker from the University of California , Los Angeles , and colleagues note in the August issue of Obstetrics and Gynecology.
The model they developed, however, shows that women who undergo oophorectomy before age 55 have 8.58% excess mortality by age 80. Those who undergo oophorectomy before age 59 have 3.92% excess mortality.
There is "sustained, but decreasing," benefit of ovarian conservation until the age of 75, "when excess mortality for oophorectomy is less than 1%," the authors report. "These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary artery disease," according to the team.
"The important point," Dr. Parker said, "is that gynecologists who have been looking at the issue of oophorectomy have focused on one thing -- ovarian cancer. Women are living longer and the major killer of women is heart disease, taking 25 times more women's lives than ovarian cancer."
"The ovaries produce testosterone and androstenedione for 30 years after menopause," he continued, "and these hormones are converted into estrogen, continuing the protection of the heart and bones. So, I think we need to look at the bigger picture, including the long-term implications of oophorectomy."
"Our study does shows that oophorectomy may be harmful if performed before age 65 and may be of no benefit at any age," Dr. Parker told Reuters Health. "These results, of course, do not apply to women at high risk of ovarian cancer," he emphasized.
Obstet Gynecol 2005;106:219-226.
Removal of Ovaries Increases Heart Disease Risk
The common practice of removing the ovaries during hysterectomy should be discouraged, new research sustains. Oophorectomy, the removal of ovaries, seems to harm rather than help, and may actually shorten the lives of the female patients undergoing it.
Hysterectomy implies the removal of the uterus and sometimes the cervix (total hysterectomy) and is performed particularly when cancer threatens, but also, more recently, for reasons that are not life-threatening - fibroid tumors, excessive menstrual bleeding, although there are more options for these disorders then hysterectomies. 90% of the 615,000 hysterectomies performed each year are for non-cancerous reasons.
As for the removal of ovaries when hysterectomy is performed, federal data from the late 1990s show that 78 percent of women between ages 45 and 64 who underwent a hysterectomy had their ovaries taken out as well , though most were not at particular risk for ovarian cancer. Medical attitude is generally to take them out as a protective measure, even in women who are not at particular risk of ovarian cancer. Reasons in support of this were that childbearing was over and menopause imminent, as well as ovarian cancer particularly deadly. There is no evidence, however, that oophorectomy is beneficial for these women, this current study confirms. The ovaries can be left intact in women who have a normal risk of cancer.
The lead researcher of the study, Dr. William H. Parker, clinical professor at the University of California, Los Angeles School of Medicine, used data from other studies about women's mortality risks and from studies tracking heart attacks and bone-thinning osteoporosis in oophorectomy patients; he created a model of how women with different characteristics would fare with ovary removal at different ages.
The models suggest that, for women whose ovaries were removed before the age of 65, there was an increased risk of death from heart disease.
As many as 18,000 women a year may die prematurely because of ovarian surgery
Dr. William H. Parker
Dr. Parker found that 9% fewer women who had an oophorectomy between ages 50 and 54 reached the age of 80 than women who had a hysterectomy, but kept their ovaries. He also reached the conclusion that the older a woman was when she had her ovaries removed, the smaller was the impact on her chances of reaching 80 and the younger a woman is when she has an oophorectomy, the longer the absence of ovaries will have an impact on her health.
Surprisingly enough, women who kept their ovaries also reduced their chances of developing ovarian cancer by 40 percent, as compared with women who did not have hysterectomies at all.
Dr. Parker is hoping that doctors will now consider both the advantages and disadvantages of this practice and present both to their patients before advising them to have their ovaries removed. The findings were published in yesterday's issue of the journal "Obstetrics & Gynecology".
Study on ovaries sparks debate
Tuesday, August 02, 2005
By PATRICIA NORRIS
pnorris@repub.com
SPRINGFIELD - Local doctors urged the public to use common sense when digesting a new study that found thousands of women may die prematurely after their ovaries are removed.
"I would encourage women to be reluctant to give up any of their organs until someone can prove to them it is in their health's interest," said Dr. Reed Shnider, director of preventive cardiology and wellness at Baystate Medical Center .
It has been customary for surgeons to remove the ovaries of women who have a hysterectomy, particularly if they are over 45, to eliminate the risk of ovarian cancer. Ovarian cancer is uncommon but frequently deadly, because it has vague initial symptoms and often goes undiagnosed until cancer has spread throughout the body.
The study, published in the journal of Obstetrics and Gynecology, suggests patients need to be aware that ovaries provide benefits long after menopause. The ovaries apparently release small amounts of hormones that reduce heart disease and keep bones healthy, allowing women to live longer.
"The article caught my attention," said Dr. Michel Prefontaine, chief of the division of gynecological oncology at Baystate. "I treat mostly cancer so I have a jaundiced view of the subject. What I do see often enough is women who have had hysterectomies at 49 and then at 59 have ovarian cancer. I feel bad that this was a missed opportunity to prevent disease. But I don't see all of the other women who keep their ovaries and do well."
Prefontaine suggests women should know their family histories for breast and ovarian cancer. It may come down to how a patient interprets her own risk, he said.
"I had a woman today who was reading the article and she was saying, 'I don't care about the risk of heart attack. Ovarian cancer is much worse.' You may live longer but the suffering with ovarian cancer is not negligible," he said.
At the very least, the study should hammer home to doctors and patients that ovary removal should not be automatic.
"It's not going to be a one-minute discussion," Prefontaine said.
Shnider said the study also points out that ovaries know what the cardiologists don't - how to provide women with the right dose and mixture of hormones to keep their hearts healthy. Synthetic hormone replacements have been problematic, Shnider said.
"It appears the ovaries have natural wisdom that we don't have. So it is worthwhile to hold on to every organ you can within reason in order to get the benefits," he said.
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