When other treatment options fail, women with fibroids may choose to have a hysterectomy—a procedure that surgically removes their uterus. With fibroids, the issue lies within the uterus. However, statistics show that half of the hysterectomies performed in the US for benign reasons1, like fibroids, include the removal of the ovaries. This procedure is known as an elective bilateral oophorectomy (EO).
A 2014 nationwide survey2 found similar results. One third of obstetrician-gynecologists opt for an EO during hysterectomy among premenopausal women—even when the ovaries are still healthy and normally functioning.
According to these findings, removing the ovaries may seem to be a common practice, but is this procedure within every patient’s best interest?
Choosing to remove healthy ovaries is often done to reduce the risk of ovarian cancer later on. Ovarian cancer is the fifth leading cause of death among women in the US and the fourth leading cause of death in women ages 40-59.1 However, removing the ovaries at the time of a hysterectomy should be looked at on a case-by-case basis, as individual factors need to be taken into consideration.
“It really depends on what the patient wants as well as other factors,” says Dr. Mark Perloe MD, an infertility specialist and Medical Director at Georgia Reproductive Specialists in Atlanta. “For example, age has to be considered. We have to be concerned about the potential for disturbing or interfering with normal ovarian function.”
Endogenous estrogen, or the estrogen produced in the body, is linked to having several protective benefits that are lost when the ovaries are removed. For example, women ages 40-44 years of age who undergo an EO have double the risk of heart attack in comparison to women with intact ovaries. A Mayo Clinic Study found that women who had both ovaries removed before the age of 45 had a 67% higher mortality risk.3
Estrogen deficiency following EO is associated with cognitive decline especially within women younger than age 50. Estrogen also plays a role in maintaining bone mineral density and sexual function—both of which have been seen to decrease after surgical menopause.1
When a hysterectomy is used to treat benign conditions like fibroids, ovary removal isn’t necessary unless an additional issue is found with the ovaries.4 Given this fact, in which cases would EO be medically sound? “In many cases now, people are far more conservative,” Dr. Perloe explained. “But if the ovaries are damaged, for example with significant cysts, then it might be appropriate to remove them. It also depends on what the patient’s risks are,” especially when considering ovarian cancer.
The American Congress of Obstetricians and Gynecologists use the onset of menopause as a deciding factor when considering EO during a hysterectomy. As stated in a Practice Bulletin5, “a strong consideration should be made for retaining normal ovaries in premenopausal women who are not at an increased risk of ovarian cancer.”
Effective ovarian cancer screening is a challenge. Statistics show that 63% of cases are diagnosed late due to lack of symptoms, resulting in a 44% 5-year survival rate at all stages.1 Because of this, ovarian removal may be recommended for women who are at a high risk for ovarian cancer—especially those who have a family history or carry genetic mutations. Removing the ovaries as a preventative measure in these cases does not only reduce the risk of ovarian cancer but can reduce the risk of breast cancer6 and associated gynecologic cancers as well.1
For other women who aren’t genetically predisposed, some may argue that removing the ovaries for preventative measures is wise since the disease is so common within the fourth and fifth decade of life. Additionally, several risk factors outside of family history also need to be considered. Being Caucasian, never having been pregnant, late age of menopause, and a long number of years of ovulation are all considered risk factors for ovarian cancer.1
An alternative to removing the ovaries to decrease ovarian cancer risk is the removal of the fallopian tubes—a procedure referred to as a bilateral salpingectomy. “Patients and physicians are showing a growing acceptance of routinely removing the fallopian tubes but preserving the ovaries during hysterectomy,” writes the American Congress of Obstetricians and Gynecologists. “Removing the fallopian tubes during a hysterectomy may lower the risk of developing the most common type of ovarian cancer—[ovarian serious carcinoma]. Increasing evidence points toward the fallopian tubes as the origin of this type of cancer.”7
If one decides to remove the ovaries, hormone replacement therapy needs to be considered since menopausal symptoms are a concern. “Side effects such as painful intercourse or decreased sexuality should not really be a problem—if the ovaries are left intact.” Dr. Perloe clarifies. “But if the ovaries are removed, estrogen replacement may help maintain adequate vaginal function and also help with sleep disturbances, osteoporosis, hot flashes and memory disorders.”
Estrogen-alone therapy is recommended for women who have had their uterus removed8, but it should be noted that hormone therapy, as with any medication, is not risk-free. Some studies show estrogen-alone therapy may be linked to an increased risk of blood clots9 during the first two years of administration.10
If deciding to take hormone therapy, it’s important to consider more than just the general risks involved. “Factors like a family history of stroke, clotting factors, and lipid levels all need to be considered.” Dr. Perloe explains. “Instead of treating everyone exactly the same, we need to look at individual risks for being on estrogen. I think too much of medicine tries to take a one-size-fits-all approach when what we need is to be seen as individuals with our own risk profiles to any medical treatment.”
The choice to have a hysterectomy, or by extension a bilateral oophorectomy or salpingectomy, should be discussed in depth with your doctor. “It’s something the patient and the physician should be deciding together,” encourages Dr. Perloe. “It’s important that patients have a physician they can trust who is going to provide them with all the options, then together they can weigh the pluses and minuses.”
ABOUT THE AUTHOR Alicia Armeli has a Master of Science in Nutrition and Whole Foods Dietetics (MSN/DPD) and is a Registered Dietitian Nutritionist, a Certified Dietitian, and a Holistic Life Coach. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.
ABOUT THE DOCTOR Mark Perloe is an infertility specialist and Medical Director at Georgia Reproductive Specialists. Dr. Perloe has extensive experience treating conditions related to infertility including menstrual disorders, uterine fibroids, endocrine and other reproductive health problems. He presently serves on the advisory board of the journal of Fertility and Sterility.
- Erekson, E. A., Martin, D. K., & Ratner, E. S. (2013). Oophorectomy: the debate between ovarian conservation and elective oophorectomy. Menopause, 20(1): 110-114. doi: 10.1097/gme.0b013e31825a27ab
- Harmanli, O., Shinnick, B. S., Jones, K., & St. Marie, P. (2014). Obstetrician-gynecologists’ opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey. Menopause, 21(4): 355-360. doi: 10.1097/GME.0b013e31829fc376.
- Parker, W. H. (2014). Ovarian conservation versus bilateral oophorectomy at the time of hysterectomy for benign disease. Menopause, 21(2): 192-194. doi: 10.1097/gme.0b013e31829be0a0
- University of Maryland Medical Center. (2012). Uterine fibroids and hysterectomy. Retrieved July 1, 2015, from http://umm.edu/health/medical/reports/articles/uterine-fibroids-and-hysterectomy
- The American Congress of Obstetricians and Gynecologists. (2008). ACOG Practice Bulletin No. 89. Elective and risk-reducing salpingo-oophorectomy. Obstetrics & Gynecology, 111(1): 231-41.
- Wise, J. (2015). Ovary removal is linked to lower breast cancer mortality in BRCA1 carriers. British Medical Journal, 350: h2182. doi:10.1136/bmj.h2182
- The American Congress of Obstetricians and Gynecologists. (2013). Growing acceptance of removing fallopian tubes but keeping ovaries to lower ovarian cancer risk. Retrieved July 1, 2015, from http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Growing-Acceptance-of-Removing-Fallopian-Tubes
- Cleveland Clinic. (2013). Hormone Therapy. Retrieved July 1, 2015, from http://my.clevelandclinic.org/health/diseases_conditions/hic-what-is-perimenopause-menopause-postmenopause/hic-hormone-therapy
- Eisenberger, A., & Westhoff, C. (2014). Hormone replacement therapy and venous thromboembolism. The Journal of Steroid Biochemistry and Molecular Biology, 142: 76-82. doi:10.1016/j.jsbmb.2013.08.016
- Curb, J. D., Prentice, R. L., Bray, P. F., Langer, R. D., Van Horn, L., Barnabei, V. M., Bloch, M. J., Cyr, G. G., Gass, M., Lepine, L., Rodabough, R. J., Sidney, S. Uwaifo, G. I., & Rosendaal, F. R. (2006). Venous thrombosis and conjugated equine estrogen in women without a uterus. The Journal of the American Medical Association, 166(7): 772-780. doi:10.1001/archinte.166.7.772