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8/1/2019

Ovarian Conservation at the Time of Hysterectomy

With hysterectomy representing a common opportunity for removal of the ovaries, a general approach to conservation or removal should focus on risk stratification. Placing aside known pathology of the ovary at the time of hysterectomy, the removal of otherwise normal appearing ovaries is a balance of acute surgical risks and long-term health implications with ovarian removal versus retention. An individualized discussion with patients regarding the risks and benefits of ovarian removal versus conservation should occur with patients prior to hysterectomy.

The baseline lifetime risk for ovarian cancer is 1.4% in the general population. Elective bilateral oophorectomy will significantly reduce, though not entirely eliminate, ovarian cancer risk. Oophorectomy will also reduce the risk of breast cancer when performed in premenopausal women. Patients with known hereditary genetic abnormalities such as BRCA 1/2 or Lynch syndrome should consider ovarian removal as dictated by current guidelines, taking care to include further dissection of the ovarian vessels or consult additional expertise with a gynecologic oncologist. Women with a strong family history of gynecologic, colon, and/or breast cancers should be screened to see if they qualify for genetic testing. If an obstetrician–gynecologist does not have the necessary knowledge or expertise to counsel a patient appropriately, referral to a genetic counselor should be considered. Protective effects to reduce ovarian cancer risk include oral contraceptive use, breastfeeding, and previous tubal ligation or salpingectomy. It is unclear if removal of a single ovary changes overall ovarian cancer risk and is not routinely performed for this indication. When ovaries are retained, re-operation in the future for ovarian malignancy is rare, and ovarian operation for any indication in the future appears to be less than 10%.

Elective ovarian removal at hysterectomy also involves short and long-term risks. An ovarian remnant will occur following 3-4% of cases. Unlike salpingectomy alone, ovarian removal does generally confer a small added operative complication risk. Additional surgical time in the operating room with oophorectomy is largely dependent on existing pathology and highly variable. In women less than age 50, elective ovarian removal is associated with increased rates of all-cause mortality. This mortality risk appears to be largely mitigated with estrogen therapy through the average age of menopause. Bilateral salpingo-oophorectomy that causes surgical menopause reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality. In the Nurses' Health Study, all-cause mortality and cancer mortality increased in women who received a bilateral salpingo-oophorectomy. The risk of ovarian cancer after hysterectomy with ovarian conservation is 0.1–0.75%. Death from ovarian cancer after tubo–ovarian conservation in the Nurses’ Health Study was 0.03%. While risks and benefits must be weighed for each individual case, current trends lean towards ovarian conservation in the setting of otherwise normal appearing ovaries at the time of hysterectomy through age 65.

Further Reading:

Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol. 2013 Apr;121(4):709-16. doi: 10.1097/AOG.0b013e3182864350.

 

Mytton J, Evison F, Chilton PJ, Lilford RJ. Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage. BMJ. 2017 Feb 6;356:j372. doi: 10.1136/bmj.j372.

 

ACOG Committee Opinion No. 774 Summary: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. Obstet Gynecol. 2019 Apr;133(4):842-843. doi: 10.1097/AOG.0000000000003165. PMID: 30913193.

Initial Approval: July 2019; Reaffirmed March 2021. Revised September 2022.

 

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