A voice for women's health

Hysterectomy

HANG ON TO YOUR OVARIES
A recently published paper in the May 2009 issue of the Journal of Obstetrics and Gynaecology has revealed that removal of the ovaries when performing a hysterectomy does not lead to an increased rate of survival for women. (1) For several decades women have been advised to have their ovaries removed when having their uterus removed to protect them from the risk of getting ovarian cancer. In fact so widespread was the practice known as a bilateral oophorectomy that many women had them removed when undergoing a hysterectomy without their knowledge or consent.

In a dramatic development that has disturbing similarities to the publication of data in 2002 from the Women’s Health Initiative (WHI) study that revealed that women using Hormone Replacement Therapy (HRT) were significantly increasing their risk of developing breast cancer, heart disease, strokes and blood clots, this latest study found that while removal of the ovaries is associated with a decreased risk of breast and ovarian cancer, it increased the risk of heart disease and lung cancer and all-cause mortality. The paper concluded: “In no analysis or age group was oophorectomy associated with increased survival.”

Dr William Parker, the lead author of the paper, is quoted as saying: “This finding is contrary to 35 years of teaching in gynaecology.”

“In the 1970s, it was decided that taking out the ovaries to prevent ovarian cancer would be the new strategy. This study shows that you’re more likely to die if you have your ovaries taken out, unless you’re among a group of women with a family history that places you at high risk for ovarian cancer or breast cancer,” he said. (2)

Of course this announcement begs the question of who decided it was a good idea to remove the ovaries during a hysterectomy and the decision to adopt the practice of performing a bilateral oophorectomy was based on what evidence?

The new research involved a pros-pective, observational study of 29,380 women participants in the famous Harvard Nurses’ Health Study who had a hysterectomy for benign disease. (1) The researchers evaluated incident events or death due to coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolism and death from all causes in 16,345 women who had a hysterectomy with both ovaries removed, and 13,035 women who had a hysterectomy but kept their ovaries.

After 24 years of follow-up, women in the first group had 895 cases of breast cancer – a 25% lower risk than those who kept their ovaries – and 96% less risk of ovarian cancer (just 5 cases). But they were 12% more likely to die during the follow-up period. Their risk of heart disease was 17% higher than the risk faced by women who kept their ovaries. They also had a 17% greater risk of dying of cancer, and in a completely unexpected finding, they were at greater risk of lung cancer. The paper stated: “The association of oophorectomy with lung cancer was unexpected and warrants further study.”

The risks of heart disease and death appeared to be even greater for women who had their uterus and ovaries removed before the age of 50 and did not take oestrogen replacement therapy, adding to the debate over oestrogen and the role it plays in heart disease in women. It is believed that women who keep their ovaries live longer because even though the ovaries make less oestrogen after menopause, they produce two other important hormones – androstenedione and testosterone – which are converted into oestrogen by fat and muscle.

Dr Isaac Schiff, a professor at the Harvard School of Medicine, said the study did not mean that women undergoing hysterectomies should never have their ovaries removed. “A woman with a strong family history of ovarian cancer or breast cancer should still be given the option of having her ovaries removed. The individual patient should be given the information, and decide what’s the best for her,” he said. Dr Schiff was not involved in the study. (2)

The paper concludes by stating that as removing the ovaries has not been shown to improve survival rates for women by reducing ovarian cancer, there is no longer any reason to continue with the current practice. “Given that approximately 300,000 US women per year undergo elective oophorectomy, these findings have important public health implications.”

One of the issues resulting from the publication of this study is ensuring that gynaecologists change their practice and perhaps inform former patients that removing their ovaries has now been shown not to be such a good idea.

It is almost seven years since the publication of research that revealed that the use of HRT during menopause for the vast majority of women carried more risks than benefits. Many gynaecologists were extremely reluctant to accept the findings and within a few years there was evidence of a considerable backlash as some doctors attempted to discredit the research and resurrect the menopause industry.

There is also the issue of why this study was not treated to the same sort of media fanfare that resulted from the publication of the HRT studies. In both cases the research revealed that current practice was increasing the risks to women of heart disease and some cancers. Women who are considering a hysterectomy must be given this information and encouraged to make their own decision. Those who have already had a hysterectomy are also entitled to this information.

References:
(1) William Parker et al. “Ovarian Conservation at the Time of Hysterectomy and Long-Term Health Outcomes in the Nurses’ Health Study.” Journal of Obstetrics and Gynecology. Vol.113 No.5 May 2009.
(2) “Women Who Keep Ovaries Live Longer” The New York Times. 28 April 2009.

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