Should the ovaries be removed along with the uterus at the time of hysterectomy?

In pre-menopausal women, there remains a lack of research to guide this decision according to the latest Cochrane review

The updated review, conducted by Dr Leonardo Orozco, MD, at the OBGYN Women’s Hospital and the Central American Cochrane Centre, San José, Costa Rica concluded that the findings were limited by the lack of randomised controlled trials (RCTs) in this area.

The authors went on to say that:

‘Although no evidence is available from RCTs, there is growing evidence from observational studies that surgical menopause may impact negatively on cardiovascular health and all-cause mortality.’

Removal of the ovaries (called oophorectomy or ovariectomy) is a procedure commonly carried out in conjunction with a hysterectomy. The justification for this is often based on a perceived risk of ovarian cancer, ovarian cysts, pelvic inflammatory disease or endometriosis and therefore a possible need for future additional gynaecological surgery. However, as removal of the ovaries results in surgically induced menopause, these risks must be carefully weighed up.

Hysterectomy rates in Australia are decreasing over time and in 2004/2005 the rate was 31.2 per 10,000 women with a concurrent oophorectomy being conducted 36% of the time (11.3 per 10 000 women); the highest incidence rate for hysterectomy was in the 45-54 year age group (Hill et al, 2010).

‘The decision whether or not to perform a prophylactic bilateral oophorectomy in premenopausal women with benign gynaecological conditions requiring a hysterectomy is complex. The possible benefits, prevention of ovarian cancer and future gynaecological surgery, have to be weighed against the potential harm caused by surgically induced menopause,’ explained Dr Orozco.

In the systematic review conducted by the researchers, only one pilot RCT was identified that met inclusion criteria. However, the data from this RCT was not available so the review was unable to draw any evidence-based conclusions.

Dr Orozco and colleagues commented:

‘The evidence provided by observational studies does not support high numbers of prophylactic oophorectomy in premenopausal women without BRCA mutations.’

‘Until more data become available, prophylactic oophorectomy should be approached with great caution. The clinician must consider the individual implications for each woman with regard to her baseline risk for developing breast and ovarian cancer, coronary heart disease, and osteoporotic hip fracture.’

Observational studies, such as the Nurses’ Health Study have provided some evidence for a reduction in ovarian cancer mortality and breast cancer risk in women who have had bilateral oophorectomy. Of note, however, the overall (all-cause) mortality rate was higher in those women who had oophorectomies.

Dr Orozco also emphasised the need for a RCT to resolve this question.

References:

Orozco LJ, Tristan M, Vreugdenhil MMT, Salazar A. Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD005638. DOI: 10.1002/14651858.CD005638.pub3.

The full publication can be accessed here. http://www.update-software.com/pdf/CD005638.pdf

Hill EL, Graham ML, Shelley JM. Hysterectomy trends in Australia—between 2000/01 and 2004/05. Aust N Z J Obstet Gynaecol. 2010 Apr;50(2):153-8. doi: 10.1111/j.1479-828X.2009.01130.x. PubMed PMID: 20522072.