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New Study about the risks and benefits of having your ovaries removed if you need a hysterectomy

By William H. Parker, MD.

The Question
Women often have their healthy ovaries removed when they are having a hysterectomy (hysterectomy means removal of only the uterus) in order to prevent ovarian cancer from developing in the future.  Data from the CDC show that 50% of women who have a hysterectomy between ages 40-44 have their ovaries removed, and 78% of women between ages 45-64 undergoing a hysterectomy have their ovaries removed.  All together, about 300,000 American women have their healthy ovaries removed every year.

If the ovaries are removed before menopause, a sudden decrease in hormones made by the ovary, including estrogen, testosterone and androstenedione, results.  We know that even after a woman enters menopause, her ovaries continue to make considerable amounts of testosterone and androstenedione, which are then changed into estrogen by other cells in the body.  

Some studies show that women who keep their ovaries have a lower risk of heart disease.  While ovarian cancer accounts for 14,700 deaths per year in the U.S., heart disease causes 326,900 deaths, and stroke causes 86,900 deaths each year.  If a woman is not at high risk for ovarian cancer, then keeping the ovaries might benefit her overall health and survival. So, what is the best thing for a woman to do when faced with this issue?

The Study
Our study was designed to see whether it was better for women who needed a hysterectomy to keep their ovaries or have them removed during surgery. We used the database from the Nurses’ Health Study (NHS), which included 122,700 registered nurses in 1976 when it began.  Over the past 24 years, 16,345 women had a hysterectomy and removal of their ovaries (oophorectomy), and 13,035 women had a hysterectomy with ovarian conservation (ovaries kept).  We considered what diseases and conditions the women had, or died from, in the years after their surgery.

Results
The results showed that women who had their ovaries removed had a higher risk of death from any cause, and primarily from heart disease and lung cancer.  Removing the ovaries at any age did not improve life-span for this group of women. 

During the 24 years of follow-up, 34 of the 13,305 women (0.26%) who kept their ovaries died from ovarian cancer. While breast cancer and ovarian cancer were less frequent in women who had their ovaries removed, the overall risk of death from all types of cancer was higher among women who had their ovaries removed. 

When we considered just the women who never used estrogen therapy after surgery, we found that women who had removal of their ovaries had a higher risk of stroke and lung cancer, and women who had removal of their ovaries before age 50 had a higher risk of heart disease, stroke and death from any cause.

Interpretation
For the past 35 years, doctors have recommended that women who needed a hysterectomy also consider having their ovaries removed in order to prevent the future development of ovarian cancer.  Since ovarian cancer is difficult to detect and difficult to cure, most women having a hysterectomy chose to have their ovaries removed as well.

Our study questions the routine removal of women’s ovaries by showing that heart disease, stroke and lung cancer are more common in women who have their ovaries removed.  And, since heart disease, stroke, and lung cancer are each much more common than ovarian cancer, many more women who have their ovaries removed will die of these conditions than can be saved from getting ovarian cancer.

As is true with all medical decisions, it is important to discuss these issues with your doctor.  People often make very different decisions based on the same medical information.  If you have a family history of heart disease or stroke, maybe keeping your ovaries makes more sense.  Certainly, women with a strong family history of ovarian cancer, or women who know they have the genetic mutation (BRCA) that greatly increases their risk of ovarian and breast cancer, should strongly consider having their ovaries removed.

The Study

Scientific Abstract
Objective: To report long-term health outcomes and mortality following oophorectomy or ovarian conservation.

Methods:  We conducted a prospective, observational study of 29,380 women participants of the Nurses’ Health Study who had a hysterectomy for benign disease; 16,345 (55.6%) had hysterectomy with bilateral oophorectomy and 13,035 (44.4%) had ovarian conservation.  We evaluated incident events or death due to coronary heart disease, stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolus, and death from all causes. 

Results:  Over 24 years of follow-up, for women with hysterectomy and bilateral oophorectomy, compared with ovarian conservation, the multivariable hazard ratios (HR) were 1.12 (95% CI 1.03, 1.21) for total mortality, 1.17 (95% CI 1.02, 1.35) for fatal plus nonfatal coronary heart disease (CHD), and 1.14 (95% CI 0.98, 1.33) for stroke. Although the risks of breast (HR 0.75 95% CI 0.68, 0.84), ovarian (HR 0.04 95% CI 0.01, 0.09), and total cancers (HR 0.92 95% CI 0.86, 0.98) decreased following oophorectomy, lung cancer incidence (HR =1.26, 95% CI 1.02, 1.56) and total cancer mortality (HR=1.17, 95% CI 1.04, 1.32) increased.  For never-users of estrogen therapy, bilateral oophorectomy before age 50 was associated with an increased risk of all-cause mortality, CHD, and stroke. With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.

Conclusions:  Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer, but an increased risk of all-cause mortality, fatal and non-fatal coronary heart disease and lung cancer.  In no analysis or age-group was oophorectomy associated with increased survival.

Study Authors
William H. Parker, MD - John Wayne Cancer Institute at Saint John’s Health Center, Santa Monica, California  http://www.parkermd.com/

Michael S. Broder, MD, MPH - Partnership for Health Analytic Research, Los Angeles, California http://www.pharllc.com/

Eunice Chang, PhD. - Partnership for Health Analytic Research, Los Angeles, California http://www.pharllc.com/

Diane Feskanich, ScD - Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts http://www.channing.harvard.edu/feskan.htm

Cindy Farquhar, MD - School of Medicine, University of Auckland, Auckland, New Zealand http://www.obsgynae.auckland.ac.nz/staff/cindy_farquhar.htm

Zhimae Liu, PhD. - Cerner Health Insights, Beverly Hills, California

Donna Shoupe, MD - Keck School of Medicine, University of Southern California, Los Angeles, California  http://www.doctorsofusc.com/doctor/bio/view/72113

Jonathan S. Berek, MD, MMS - Stanford University School of Medicine, Stanford, California  http://obgyn.stanford.edu/gynonc/faculty/berek.html

Susan Hankinson, ScD - Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts http://www.hsph.harvard.edu/faculty/susan-hankinson/

JoAnn E. Manson, MD, DrPH - Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts http://www.brighamandwomens.org/preventivemedicine/Faculty/Manson.aspx

 

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