important menopause information
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