Oophorectomy or Ovarian Conservation at Hysterectomy for Benign Disease

This blog post is based on the TOG article Oophorectomy or Ovarian Conservation at the Time of Hysterectomy for Benign Disease published in April 2022. This is one of the important and most debated aspects of the care of women undergoing hysterectomy due to benign conditions. This has almost always been a grey area in gynaecology, where clinical evaluation and judgment plays an essential role in the crucial decision to conserve or remove ovaries in women above the age of 40 years. This article provides the latest evidence related to this topic. 

I hope you will find this quick summary helpful not only the exam preparation but also for your clinical practice as well. 

Thanks.

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Introduction

• When a perimenopausal or menopausal woman is undergoing a hysterectomy for benign conditions, one of the concerns is whether to remove or conserve the ovaries. Leaving the ovaries can be associated with the risk of ovarian cancer later in life. However, the removal is also associated with some ill effects. All this will be discussed as follows.

Ovarian cancer has poor prognosis

• Diagnosis of cancer at 70 years — associated with 80% mortality
• Incidence — increases with age 10 in 100 000 in 40s 50 in 100 000 in 50s
• > 50% of women diagnosed at the advanced metastatic disease
• The lifetime risk of ovarian cancer - 1.4% 
• With hereditary ovarian cancer syndromes risk is 25-50% for epithelial ovarian cancer
• BRCA mutation — associated with 90% of hereditary ovarian cancers but overall makeup only 10-15% of all ovarian cancers 
• If this high-risk group is excluded, then the incidence for low-risk women <1%

Non-inherited risk factors

• Obesity & PCO
• Ovarian endometriosis can transform into cancer in 2.5% of cases

Ovarian function in the menopause

• Ovaries continue their endocrine function
• After menopause, women with intact ovaries have higher amounts of androgens
• Androgens undergo aromatise conversion to estrone (in adipose tissues)
• Estrone then converted to estradiol peripherally in adipose tissue
• Hyperestrogenic state associated with obesity, metabolic disorders and complications

Clinical impact of oophorectomy in perimenopausal women

All-cause mortality 

• >10% increase in all-cause mortality & composite morbidity (b/w 50-54 yrs) after Bilateral Oophorectomy for benign disease

Cardiovascular disease

• Bilateral Oophorectomy in <45 yrs — increased overall mortality by 1.5x
• HRT provides protection

Bones

• Bilateral Oophorectomy in menopause associated with higher risk of fractures 
• HRT offers 20% protection

Cognitive function

• With oophorectomy in premenopausal women, decline starts at that point and progresses
• Increased risk of Parkinsonism 

Sexual function 

• After Oophorectomy — premenopausal women have significant decrease in sexual pleasure
• This is due to low estrogen and testosterone
• Androgens (released by ovaries) are involved in sexual desire, arousal and orgasm
• Bilateral Oophorectomy — causes 50% reduction in circulating testosterone levels
• Associated with psychological morbidity, relationship issues, low self-esteem and depression, hypoactive sexual desire disorder

Vasomotor symptoms

• Bilateral Oophorectomy — more abrupt and severe onset of surgical menopause

Reduction of risk by tubal procedures

• Salpingectomy without oophorectomy reduces the lifetime risk of ovarian cancer
• Two types of ovarian cancers

Type 1

• Low-grade indolent 
• Includes - low-grade serous, low-grade endometriosis, clear cell, mucinous, transitional (Brenner)
• Genetically stable & tend to present in the ovary

Type 2

• Aggressive epithelial tumours
• Includes - high-grade serous carcinoma, undifferentiated carcinoma and carcinosarcoma
• Distant fallopian tube - appears to be the origin of serous ovarian cancers (esp in BRCA mutations)
• Endometriosis is also associated with clear cell carcinoma 

Effect of bilateral salpingectomy on ovarian reserve

• No difference in ovarian reserve at 3 months 
• Complete salpingectomy is preferable 

Alternative risk reduction measures for ovarian cancer

Reduce lifetime ovulations

• With hormonal contraception - ovarian cancer risk is reduced by 20% for every 5 yrs of use risk is halved if taken for 15 yrs
• Pregnancy & Breastfeeding (>12 Months) — associated with significant risk reduction

Surgical intervention other than oophorectomy

• Hysterectomy with ovarian conservation — reduced risk by 34%
• Tubal ligation — reduced risk by 34%
• Tubal ligation + long-term users of hormonal contraception — reduced risk by 72%
• RCOG recommends bilateral salpingectomy with ovarian conservation as it has a cumulative effect on risk reduction

Risk of repeat surgery if ovaries conserved

• Risk of repeat surgery later in life due to ovarian pathology 
• Must take an individualised approach
• 74% women undergoing hysterectomy have ovarian conservation
• RCOG / NICE recommendations — BSO to be done in case of severe endometriosis (associated with better pain relief & decreased chance of future surgery)
• In mild endometriosis (with normal ovaries) — reasonable to conserve ovaries 

Ovarian Remnant Syndrome

• Post-oophorectomy ovarian stump can lead to postoperative chronic pain
• Caused by surgical factors - inadequate surgical margins, adhesions, or bleeding
• Mostly seen in women with multiple surgeries
• Managed by excising the remaining tissue or with hormonal suppression 

Current Recommendations

Indications for BSO	Considerations for Ovarian Preservation
Suspected or confirmed gynae malignancy	Premenopausal without a genetic predisposition to cancer
Risk-reducing surgery BRCA1, BRCA2, Lynch Syndrome, Peutz-Jeghers Syndrome, Strong family history of ovarian cancer, only after completion of childbearing and >35 years	No significant family history of ovarian cancer
Other Indications Chronic Pelvic Pain Pelvic Inflammatory Disease Severe Endometriosis	No adnexal pathology
	Postmenopausal with no additional risk factors

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