To Remove the Ovaries or Not?

Oophorectomy is a fairly routine procedure in women with cancers of the gynecologic tract, performed as part of surgical staging. For women with breast cancer and are premenopausal, oophorectomy can even reduce risk of relapse, especially in those who are hormone receptor positive. For women with BRCA gene mutation carriers, an oophorectomy is the surest way to reduce the risk of ovarian cancer. But for all others, an oophorectomy should be considered an elective procedure and new data suggests it is one that requires a careful balance of risks and benefits.

Two papers have been published that raises potential concerns regarding the risks of an oophorectomy. In one study from the John Wayne Cancer Institute, almost 30,000 women enrolled as part of the Nurse's Health Study, which is observational in nature, looked at long-term outcomes following women who underwent total abdominal hysterectomy (TAH) with oophorectomy (BSO) versus those who underwent TAH with ovarian conservation. They reported that over a 24 year period those who underwent BSO were at a higher risk of death from all causes (HR 1.12, 95%CI 1.03, 1.21), fatal and nonfatal MI (HR 1.17, 95%CI 1.02,1.35), and BSO was also associated with an increased risk of lung cancer (HR 1.26, 95%CI 1.02-1.56). Of more concern was the finding that, in no circumstance, was BSO associated with a survival advantage. The second from Montreal was a case-control study involving 422 women with lung cancer compared to 577 controls. They found that after controlling for other factors such as smoking, early medically induced menopause was associated with an increased risk of lung cancer (OR 1.92, 95%CI 1.22, 3.01).

What explains this increased risk is not clear. Yet the publication of these articles this year raise serious questions about the long-term implications of early surgical menopause. As such, these risks must be taken in to account for any woman undergoing surgery for a non-malignant indication. If hysterectomy is indicated, oophorectomy should not and cannot be considered as a routine part of the procedure and frank discussion is warranted.

For more information:

1. Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, Shoupe D, Berek JS, Hankinson S, Manson JE. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses' health study. Obstet Gynecol. 2009 May;113(5):1027-37.

2. Koushik A, Parent ME, Siemiatycki J.Characteristics of menstruation and pregnancy and the risk of lung cancer in women. Int J Cancer. 2009 May 11. [Epub ahead of print]