Oophorectomy during Hysterectomy

Funtcions of ovary Cardiovascular

increase in HDL

decrease in LDL
Stimulates NO , prostacyclin release from

endothelium - vasodilatation antioxidant effect decreasing atheroma

Bone
prevents osteoporosis
Inhibits

osteoclastic activity Inhibits release of IL-1 by monocytes Increases absorption of calcium from gut Increases 1,25 -dihydroxy Vit D activity Stimulates calcitonin secretion from C cells of thyroid

CNS

promotes neuronal growth and neurotransmission

estrogen inhibition of GABAergic inhibitory influence -development and transient maintenance dendritic spines - improvement in memory

 improves cerebral perfusion by vasodilatation effect,

cognition. Increases opoid activity in brain Prevents the generation of the -amyloid peptide

Others
Urogenital-

maintain the epithelium of vagina, urinary bladder, urethra Skincollagen content, elasticity

Effects of oophorectomy

cardiovascular disease
osteoporosis, hip fractures dementia, short-term memory impairment

decline in sexual function

decreased positive psychological well-being hot flushes

urogenital atrophy

Benefits of the Postmenopausal Ovary

Reproductive Age pg/mL Estradiol Testosterone Progesterone 150 400 12,00020,000 Natural Menopause 1015 290 <100 Surgical Menopause 10 110 <100

Elective and risk-reducing salpingooophorectomy

Elective salpingo-oophorectomy (ESO) refers to removal of the ovaries at the time of another indicated procedure.
Risk-reducing salpingo-oophorectomy(RRSO) refers to the removal of normal ovaries and is performed as a standalone surgical procedure.

Cardiovascular disease
Cardiovascular disease primary cause of mortality among women 4,54, 613 deaths per year 48,000 die within 1 year after hip fracture 14, 857 deaths due to ovarian cancer
(US statistics)

Nurses Health Study

Prospective study of 121,700 women

HAZARD RATIO Coronary artery disease Stroke <45y 1.3 45-55 1.8 >55y 0.99 OVER ALL 1.15

1.2

1.2 1.07

1.17 0.6

1.17 0.8

Hip fracture 0.7

Oophorectomy was associated with an increased risk of coronary heart disease. This increase was statistically significant for all women ,<45 years. Risks of stroke, hip fracture, colorectal cancer, and pulmonary embolism did not differ significantly between groups.

Women's Health Initiative Observational Study BSO may not have an adverse effect on cardiovascular health, hip fracture, mortality compared with hysterectomy and ovarian conservation.

Limitations of WHI study incorrect self-report of BSO status.In the NHS, self-report of BSO was nearly perfect compared with adjudication of the surgical record. unable to determine whether women who reported prior hysterectomy and BSO underwent these surgeries concomitantly or at different times.

 survivor bias because WHI participants began

follow-up many years after they underwent hysterectomy. Follow-up time was also longer in the NHS compared with WHI study (24 vs 8 years)

Cochrane data base-BSO Between 40-55 doubles the baseline risk-BSO after 50 increases risk of first MI by 40% compared to controls

Ovarian conservation at the time of hysterectomy Parker WH et al 2009 women clearly benefit from keeping their ovaries when undergoing hysterectomies before age 65

Osteoporosis
5632 person-years of follow-up 16 years
194 women experienced fractures (72% from

moderate trauma). moderate trauma fractures of the hip, spine, or distal forearm; standardized incidence ratio [SIR], 1.54; 95% CI, 1.29-1.82.

 Oophorectomy before age 45 years is a well-

established risk factor for osteoporosis . Even in women who undergo BSO after natural menopause, the risk for osteoporotic fractures may be increased compared with the risk in women who have intact ovaries
Melton LJ et al. Fracture risk after bilateral oophorectomy in elderly women 2003;18:900-905.

Mental health and sexual function

666 women with bilateral oophorectomy

and 673 referent women were studied. followed for 24 years depressive and anxiety symptoms were assessed using a structured questionnaire via a direct or proxy telephone interview performed from 2001 through 2006.
Mayo clinic cohort Study of Oophorectomy and Aging

BSO

hazard ratio

95% CI

depressive symptoms

1.54

1.04-2.26

anxiety symptoms

2.29

1.33-3.95

In addition, treatment with estrogen to age 50 years in women who underwent bilateral oophorectomy at younger ages did not modify the risk.

Cognitive impairment or dementia, Parkinsonism

women who underwent bilateral oophorectomy had an increased risk of cognitive impairment or dementia, parkinsonism.

Mayo clinic cohort Study of Oophorectomy and Aging

Is it necessary to perform oopherectomy at the time of hysterectomy in women with endometriosis without a great degree of ovarian involvement?

ACOG Management of endometriosis guideline recommends that in patients with normal ovaries, a hysterectomy with ovarian conservation and removal of the endometriotic lesions should be considered

BSO for prophylaxis for future possibility of pelvic pain,residual ovary syndrome, or ovarian cyst formation?

2561 women having hysterectomy without BSO for any indication was followed for 20 years, subsequent oophorectomy performed just in 2.8%. Sonographic screening of asymptomatic postmenopausal women showed unilocular cysts in 3.3%-none developed ovarian ca

Deckel et al. The residual ovary syndrome: a 20-year experience

 A 2005 analysis suggested that ovarian conservation

WHATS NEW: OVARIAN CONSERVATION: BETTER FOR ALL AGES

conferred a survival benefit compared to oophorectomy in women <65 years. In 2006 <45 years ovarian-sparing surgery is associated with improved survival in women of every age group. Elective and risk reducing salpingo-ophorectomy. ACOG Practice BulletinNo 89.

Hysterectomy itself reduces risk of ovarian cancer opportunity to examine the ovaries at the time of hysterectomy protection of ovaries from transtubal migration of potential vaginal carcinogens.

 Oophorectomy is associated with menopausal symptoms

for which HRT is indicted . HRT is not without risk. long term compliance of HRT 20-40% patients still can develop peritoneal carcinoma (12%)

 No studies have examined the operative morbidity of

adding oophorectomy at the time of abdominal hysterectomy. theoretical risk of ligation or obstruction of the ureter at the time of ligation of the ovarian vessels

SUMMARY

 Between 50-54 and who are at average risk for CHD ,

osteoporosis, stroke63% likelihood of surviving to age 80. 53% after BSO(without ERT) Difference in survival(8.58%) primarily because fewer women dying of CHD(16% vs 8%) and hip fracture far outweigh the 0.47% mortality rate from ovarian cancer after hyst for benign disease. Surgery 55-59 survival advantage is 4% Surgery >64- no survival advantage

ACOG RECOMMENDATIOS (2008)

BSO should be offered to women with BRCA1 and

BRCA2 mutations after completion of childbearing. 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.

ACOG RECOMMENDATIOS.
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.

GDG (NICE) RECOMMENDATIONS-2007

Removal of healthy ovaries at the time of

hysterectomy should not be undertaken. [D(GPP)] Removal of ovaries should only be undertaken with the express wish and consent of the woman. [D(GPP)] Women with a significant family history of breast or ovarian cancer should be referred forgenetic counselling prior to a decision about oophorectomy . [D(GPP)]

GDG RECOMM.
In women under 45 considering hysterectomy for AUB

with premenstrual syndrome a trial of pharmaceutical ovarian suppression for at least 3 months should be used as a guide to the need for oophorectomy. If removal of ovaries is being considered, the impact of this on the womans wellbeing and, for example, the possible need for hormone replacement therapy (HRT) should be discussed. Women considering bilateral oophorectomy should be informed about the impact of this treatment on the risk of ovarian and breast cancer.