Removal of ovaries at time of hysterectomy- RANZCOG

Question 1

Benefits of ovarian conservation

Answer 1

The postmenopausal ovaries are physiologically active and continue to produce oestradiol (at low levels)
and testosterone.

Question 2

Disadvantages of ovarian conservation

Answer 2

No reduction in risk of breast and ovarian ca

Question 3

Summary of evidence from trials listed in RANZCOG guideline:

Answer 3

• Modelling study in 2005 concluded that “women younger than 65 years of age clearly benefit from ovarian conservation, and at no age is there a clear benefit from prophylactic oophorectomy”
• Women aged <55 may have higher all cause mortality and mortality related to CVD

Question 4

Risks of BSO

Answer 4

1. Increased mortality due to Coronary Heart Disease (CHD)6
2. Increased morbidity and mortality due to osteoporosis related fracture
3. Increased risk of cognitive dysfunction, including dementia
4. Increased risk of depressive and anxiety symptoms
5. In premenopausal women:  More severe and prolonged vasomotor symptoms than those seen following natural
   menopause.  Reduction in libido and sexual dysfunction.

With the exception of osteoporosis related fracture, it is unclear whether the incidence and severity of
the above conditions are ameliorated by oestrogen replacement therapy

Risk may be increased in women aged under 65

Question 5

Factors that may affect decision making for BSO

Answer 5

The factors that will influence the decision making are likely to be:
 The woman’s risk (real or perceived) of ovarian cancer.
 Indications for hysterectomy and the planned surgical
approach.
 Personal risk factors for CHD, osteoporosis and depression.
 Absolute and relative personal contraindications to
oestrogen therapy.

Question 6

Principles of ovarian conservation in TAH without known ovarian ca

Answer 6

• Oophorectomy without consent may consitute assault
• It is for the patient to make the decision based upon informed discussion which has been documented
• The benign disease may be better treated by including oophorectomy eg. endomteriosis, PID, unexpected pathology found at surgery
• Oophrectomy may be indicated where there are unwanted ovarian endocrine effects eg. PMS, hirsutism, mastalgia

The advantages of oophorectomy relate to: - the prevention of ovarian cancer; lifetime risk 1 in 70 of dieases; 1 in 100 of death, 60% of women presenting at a surgically incurable stage - the increase in these risks if there is a positive family history
- the avoidance of further surgery for subsequently developing ovarian pathology

The disadvantages of oophorectomy relate to: - the longer the use of HRT, the greater the increased risk of breast cancer and cardiovascular disease - the loss of libido, which may be difficult or impossible to treat