This is a complicated topic but here are some things to consider. Among women with a family history of ovarian cancer, after childbearing these women can be offered prophylactic oophorectomy. Among premenopausal women undergoing hysterectomy without a family history there is little indication for oophorectomy. Among postmenopausal women without a family history overall there support to remove the ovaries yet there are some population studies that document deteriorated outcomes among postmenopausal women who undergo oophorectomy - even long after menopause. In one mathematical study there was statistical benefit to keeping the ovaries up to age 65. There would be certainly precedence to remove the ovaries in a menopausal women at the time of hysterectomy but this practice is not without significant criticism. I would recommend you review the ACOG document on this subject. There are also some excellent chapters written on this topic (including one my me) that will flesh this question out a bit more for you.
Here are the National Guideline Clearinghouse recommendations:
The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.
The following conclusion is based on good and consistent scientific evidence (Level A):
- In women ages 50 to 79 years who have had a hysterectomy, use of estrogen therapy has shown no increased risk of breast cancer or heart disease with up to 7.2 years of use.
The following recommendation is based on limited or inconsistent scientific evidence (Level B):
- Bilateral salpingo-oophorectomy should be offered to women with BRCA1 and BRCA2 mutations after completion of childbearing.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Women with family histories suggestive of BRCA1 and BRCA2 mutations should be referred for genetic counseling and evaluation for BRCA testing.
- For women with an increased risk of ovarian cancer, risk-reducing salpingo-oophorectomy should include careful inspection of the peritoneal cavity, pelvic washings, removal of the fallopian tubes, and ligation of the ovarian vessels at the pelvic brim.
- Strong consideration should be made for retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer.
- Given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women.
- Women with endometriosis, pelvic inflammatory disease, and chronic pelvic pain are at higher risk of reoperation; consequently, the risk of subsequent ovarian surgery if the ovaries are retained should be weighed against the benefit of ovarian retention in these patients.
I hope this helps.
James L. Whiteside, MD
What i recently found in an article of NAMS (north american menopause society) is the following: 1.4% lifetime risk of ova cancer. at age 50 risk is 1:1500 at age 70 risk is 1:400. The probability of surviving up to 80 was 62% if BSO is not performed and if perfromed decreased to 54% and that this survivaval advantage far outweights the risk of mortality from ova. cancer. however , BSO after 64 years shows no survival advantages in survival rate. article is called:
elective oophorectomy for bening gynecological disorders from NAMS vol. 14 page 580.
Hope more people join this important topic or have newer insights since this was publised in 2007
There has been more recent scholarship on this topic since 2007. Overall I am not sure there is much difference, however, in the estimates you cite and where the current recommendations stand. You will recall that in my lecture on posterior vaginal wall surgery I mentioned there are three kinds of medical care - evidence based care (e.g. giving beta blockers to a post MI patient), supply sensitive care (e.g. depending on where you live the last 100 days of your life can be profoundly more expensive for the same outcome (death)), and preference sensitive care (e.g. lumpectomy vs mastectomy - no difference in treatment outcome for breast CA and the care choice lies in the patient valuation of these therapies). Most of Medicare/aid spending in the U.S. is for supply sensitive care. More physicians renders more care but not necessarily better health outcomes. For the question of oophorectomy short of compelling evidence (as in the case of the 66 year old woman undergoing hysterectomy) her preference should dictate the therapy choice. Note that one study documents that merely observing the ovaries at the time of hysterectomy will reduce the woman's ovarian cancer risk. This makes some sense because if the overall risk of ovarian cancer in a woman without family history is somewhere between 1-2% and this number creeps up with age, looking at the ovaries at the time of hysterectomy in essence 'resets' the risk estimate back down. There are more complicated epidemiological reasons for that phenomenon but lets keep it simple.
Talk to your patients about the evidence and give them the option to keep or remove her ovaries where appropriate and preferred. Note there is at least one study that documents that among the more common reasons for performing a hysterectomy via the abdomen (either laparoscopically or open) is the physicians intention to remove the ovaries. This makes little sense. Removal of the ovaries is a consideration in surgical approach but the ovaries can be removed via a vaginal approach and a good candidate for such should not be converted to an abdominal approach merely to remove the ovaries.