You may be facing a hysterectomy for a benign disease such as endometriosis, fibroids, or heavy bleeding. You are pre-, peri-, or postmenopausal, and you are not having any more children.
You may have had a friend who had ovarian cancer and you know it is a miserable disease: difficult to detect at an early stage, requiring a complex surgery, rounds of chemotherapy, and high rates of recurrence and mortality. Your doctor may present to the you option of just taking your ovaries out while “we are there.” It will add nothing to your recovery, so why not?
Here are the reasons to very carefully consider this decision.
Premenopausal women who lose their ovaries suffer immediate loss of all ovarian hormones. After menopause, ovaries do not produce estradiol, but they do produce the androgens (male hormones) testosterone and androstendione. These androgens are converted in body fat and muscle to estrone, the postmenopausal estrogen. Estrone does have benefits.
Removing the ovaries has been shown to increase the risk of heart disease which is the major cause of death in women. While 16,000 women die of ovarian cancer each year, 500,000 die of heart disease, and 50,000 women die each year within one year of a hip fracture. Studies have shown that removal of ovaries after the age of 50 increases the risk of having a heart attack by 40%. Another study demonstrated that removing ovaries after the age of 50 increased the risk of osteoporotic fractures by 54%. The mortality for hip fractures doubled.
The risk of ovarian cancer in the general population is 1/70, or about 1.4%. This statistic does not apply to women who are BRCA mutation carriers, and those who had a mother or sister with ovarian cancer. Their risk is higher. If you have a hysterectomy and leave the ovaries behind, the risk of needing to go back at a later date and have those ovaries removed is about 5%.
A study was done to postulate the excess risk of death due to removing the ovaries in women age 50-54 who were not at high risk for ovarian cancer, heart disease, osteoporosis, stroke and breast cancer. The study determined that the probability of surviving to age 80 was 62% if the ovaries were retained, vs. 54% if they were not. The difference in mortality far outweighed the risk of dying from ovarian cancer which was 0.5%. The survival advantage was about 4% in women aged 55-59 year of age, but after the age of 64 there was no survival benefit to retaining the ovaries.
The study did not take into account the decrease in the quality of life benefits of loss of hormones that include hot flashes, night sweats, mood changes, decline in cognitive function, poor sleep quality, decrease in well-being, depression, and a decrease in sexual desire and function. Although hormone replacement can alleviate symptoms, studies do no demonstrate that the adherence to medication is low.
We now know that there are serious health risks to early menopause, surgical or natural. In 2008, the American College of Obstetrics and Gynecology, ACOG, recommended that retaining ovaries in premenopausal women undergoing hysterectomy for benign disease be strongly considered, unless there are identified genetic risks. A study published in the Journal Menopause this month, demonstrated a very high incidence of removal of the ovaries despite the recommendations of ACOG. Although hormone replacement after oophorectomy may mitigate some of the adverse outcomes, many women worry about the effects of estrogen and are not adherent long-term. The decision to remove ovaries can be a very personal decision made between a woman and her doctor, based on many factors. Consider your options carefully, as the long term consequences can be very significant.
Menopause, The Journal of the American Menopause Society, Volume 24, Number 8, August 2017. Inappropriate oophorectomy at the time of benign premenopausal hysterectomy, A.S, Mahal, et al.
ObGyn.net: September 30, 2011
Benefits of Ovarian Conservation at the Time of Hysterectomy for Benign Disease, William H. Parker, MD
From the New York Times by Tara Parker-Pope, July 25, 2017
Much of the scientific research on resilience — our ability to bounce back from adversity — has focused on how to build resilience in children. But what about the grown-ups?
While resilience is an essential skill for healthy childhood development, science shows that adults also can take steps to boost resilience in middle age, which is often the time we need it most. Midlife can bring all kinds of stressors, including divorce, the death of a parent, career setbacks and retirement worries, yet many of us don’t build the coping skills we need to meet these challenges.
The good news is that some of the qualities of middle age — a better ability to regulate emotions, perspective gained from life experiences and concern for future generations — may give older people an advantage over the young when it comes to developing resilience, said Adam Grant, a management and psychology professor at the Wharton School of the University of Pennsylvania.
“There is a naturally learnable set of behaviors that contribute to resilience,” said Dr. Grant, who, with Sheryl Sandberg, the chief operating officer of Facebook, wrote the book “Option B: Facing Adversity, Building Resilience and Finding Joy.” “Those are the behaviors that we gravitate to more and more as we age.”
Scientists who study stress and resilience say it’s important to think of resilience as an emotional muscle that can be strengthened at any time. While it’s useful to build up resilience before a big or small crisis hits, there still are active steps you can take during and after a crisis to speed your emotional recovery.
Last year Dr. Dennis Charney, a resilience researcher and dean of the Icahn School of Medicine at Mount Sinai in New York City, was leaving a deli when he was shot by a disgruntled former employee. Dr. Charney spent five days in intensive care and faced a challenging recovery.
“After 25 years of studying resilience, I had to be resilient myself,” said Dr. Charney, co-author of the book “Resilience: The Science of Mastering Life’s Greatest Challenges.” “It’s good to be prepared for it, but it’s not too late once you’ve been traumatized to build the capability to move forward in a resilient way.”
Here are some of the ways you can build your resilience in middle age.
■ Practice Optimism. Optimism is part genetic, part learned. So if you were born into a family of Eeyores, you can still find your inner Tigger.
Optimism doesn’t mean ignoring the reality of a dire situation. After a job loss, for instance, many people may feel defeated and think, “I’ll never recover from this.” An optimist would acknowledge the challenge in a more hopeful way, saying, “This is going to be difficult, but it’s a chance to rethink my life goals and find work that truly makes me happy.”
While it sounds trivial, thinking positive thoughts and surrounding yourself with positive people really does help. Dr. Steven Southwick, a psychiatry professor at Yale Medical School and Dr. Charney’s co-author, notes that optimism, like pessimism, can be infectious. His advice: “Hang out with optimistic people.”
■ Rewrite Your Story. When Dr. Charney was recovering from the shooting, he knew that his life was forever changed, but he reframed the situation, focusing on the opportunity the setback presented. “Once you are a trauma victim it stays with you,” he said. “But I knew I could be a role model. I have thousands of students watching my recovery. This gives me a chance to utilize what I’ve learned.”
Study after study has shown that we can benefit from reframing the personal narrative that shapes our view of the world and ourselves. In expressive writing studies, college students taught to reframe their college struggles as a growth opportunity got better grades and were less likely to drop out. A Harvard study found that people who viewed stress as a way to fuel better performance did better on tests and managed their stress better physiologically than those taught to ignore stress.
“It’s about learning to recognize the explanatory story you tend to use in your life,” Dr. Southwick said. “Observe what you are saying to yourself and question it. It’s not easy. It takes practice.”
■ Don’t Personalize It. We have a tendency to blame ourselves for life’s setbacks and to ruminate about what we should have done differently. In the moment, a difficult situation feels as if it will never end. To bolster your resilience, remind yourself that even if you made a mistake, a number of factors most likely contributed to the problem and shift your focus to the next steps you should take.
“Telling yourself that a situation is not personal, pervasive or permanent can be extremely useful,” Dr. Grant said. “There is almost no failure that is totally personal.”
■ Remember Your Comebacks. When times are tough, we often remind ourselves that other people — like war refugees or a friend with cancer — have it worse. While that may be true, you will get a bigger resilience boost by reminding yourself of the challenges you personally have overcome.
“It’s easier to relate to your former self than someone in another country,” said Dr. Grant. “Look back and say, ‘I’ve gone through something worse in the past. This is not the most horrible thing I have ever faced or will ever face. I know I can deal with it.’”
Sallie Krawcheck, a former Wall Street executive, said that after a very public firing, she reminded herself how fortunate she still was to have a healthy family and a financial cushion. While she has never studied resilience, she believes early challenges — like being bullied in middle school (“It was brutal,” she said) and going through a painful divorce — helped her bounce back in her career as well. “I just believe in comebacks,” said Ms. Krawcheck, who recently founded Ellevest, an online investment platform for women. “I see these setbacks as part of a journey and not a career-ending failure. There was nothing they could do to me on Wall Street that was as bad as seventh grade.”
■ Support Others. Resilience studies show that people are more resilient when they have strong support networks of friends and family to help them cope with a crisis. But you can get an even bigger resilience boost by giving support.
In a 2017 study of psychological resilience among American military veterans, higher levels of gratitude, altruism and a sense of purpose predicted resiliency.
“Any way you can reach out and help other people is a way of moving outside of yourself, and this is an important way to enhance your own strength,” said Dr. Southwick. “Part of resilience is taking responsibility for your life, and for creating a life that you consider meaningful and purposeful. It doesn’t have to be a big mission — it could be your family. As long as what you’re involved in has meaning to you, that can push you through all sorts of adversity.”
■ Take Stress Breaks. Times of manageable stress present an opportunity to build your resilience. “You have to change the way you look at stress,” said Jack Groppel, co-founder of the Johnson & Johnson Human Performance Institute, which recently began offering a course on resilience. “You have to invite stress into your life. A human being needs stress; the body and the mind want stress.”
The key, Dr. Groppel said, is to recognize that you will never eliminate stress from your life. Instead create regular opportunities for the body to recover from stress — just as you would rest your muscles between weight lifting repetitions. Taking a walk break, spending five minutes to meditate or having lunch with a good friend are ways to give your mind and body a break from stress.
“Stress is the stimulus for growth, and recovery is when the growth occurs,” said Dr. Groppel. “That’s how we build the resilience muscle.”