FIGURE Conservation vs oophorectomy: A guide to decision-making
* Estrogen replacement is recommended for women younger than 45 years who opt for oophorectomy
Ovarian cancer is a real, but relatively low, risk
In 2008, an estimated 21,650 new cases of ovarian cancer were diagnosed (age at diagnosis: mean, 63 years), and 15,520 women died from the disease.10 Because we lack a reliable screening test to detect early-stage ovarian cancer in the general population, most women are given a diagnosis when disease is advanced and the 5-year survival rate is 15% to 25%.
There is agreement that women who are known to have a BRCA mutation, which increases the risk of ovarian and breast cancer, should strongly consider oophorectomy once childbearing is complete.11 In the general population, however, the outlook is different.
In the United States, the lifetime risk of ovarian cancer is 1.4% overall. Among white women who have had three or more term pregnancies and who have used an oral contraceptive for at least 4 years, the lifetime risk of ovarian cancer drops to 0.3%.12
Need for reoperation is very low
The percentage of women who require reoperation after ovarian conservation—2.8%—may surprise you.13 That figure is lower than once thought because many studies were performed before asymptomatic, benign ovarian cysts were determined to be a fairly common phenomenon in postmenopausal women (prevalence, 6.6%). These cysts do not undergo transformation to cancer and, therefore, do not need to be removed.14
In addition, studies indicate that only 0.1% to 0.75% of women who retain their ovaries at the time of hysterectomy develop ovarian cancer.15,16 Therefore, the rationale of performing oophorectomy to avoid future surgery appears to be unfounded.
CAD risk rises sharply after oophorectomy
A recent systematic review found mixed evidence concerning the risk of CAD following bilateral salpingo-oophorectomy.17 In observational studies, however, earlier age of surgical or natural menopause has been associated with a higher risk of cardiovascular mortality.18-20 Early reports from the Nurses’ Health Study found that the risk of myocardial infarction doubled among women who underwent oophorectomy and never used estrogen, compared with age-matched premenopausal women (relative risk [RR], 2.2; 95% confidence interval [CI], 1.2, 4.2).3 Even after age 50, the risk of a first myocardial infarction is increased among oophorectomized women, compared with women who retain their ovaries (RR, 1.4; 95% CI, 1.0–2.0).21
A study by researchers from the Mayo Clinic, who examined all causes listed on the death certificate, found a significant association between bilateral oophorectomy before the age of 45 years and cardiovascular mortality (hazard ratio [HR], 1.44; 95% CI, 1.01–2.05).22 This risk was significantly increased among women who were not treated with estrogen through at least age 45, compared with estrogen-treated women.
Oophorectomy may impair bone health
After menopause, ovaries continue to produce significant amounts of the androgens testosterone and androstenedione, which are converted to estrone peripherally by skin, muscle, and fat cells.23,24 The levels of these hormones remain consistent and have been documented to age 80.25
Both estrogens and androgens inhibit bone resorption, and androgens also stimulate bone formation.26 Low levels of androgens and estrogens are linked to lower bone density and a higher risk of hip and vertebral fracture in postmenopausal women.27-29
Postmenopausal women who have been oophorectomized may have an even greater risk of osteoporosis. Over 16 years of follow-up, 340 women who had undergone oophorectomy at a median age of 62 years had 54% more osteoporotic fractures than women who had intact ovaries.5 Two other studies found no association between oophorectomy and bone loss or fracture risk, however.30,31
Hip fracture is a well-documented cause of increased morbidity and mortality in older women. One study found that, before hip fracture, 28% of patients were housebound; 1 year after hip fracture, the percentage was 46%.32 Women older than 60 who underwent oophorectomy had a doubled risk of mortality after low-trauma hip fracture, compared with women who had intact ovaries (odds ratio [OR], 2.18; 95% CI, 2.03–2.32).5
Loss of ovaries may affect mental health and sexuality
In a premenopausal woman, oophorectomy causes a sudden loss of estrogen and often triggers hot flashes, mood changes, sleep disturbances, headaches, and a decline in feelings of well-being.33,34 Over time, vaginal dryness, painful intercourse, loss of libido, bladder dysfunction, and depression may occur.35,36
Evidence suggests that, in women, sexual desire, sexual sensation, and orgasmic response are influenced by androgens. After elective oophorectomy, declines in sexual desire have been reported.37-39
Mental health and sexuality may rebound over time, however. One study found less improvement in mental health measures and body image 6 months after hysterectomy among women who were oophorectomized, compared with those who retained their ovaries. After 2 years, improvement levels were similar between groups.40