Ovary removal at benign hysterectomy linked to higher mortality, cancer, CVD risk in some

Key takeaways:

• The risks of removing ovaries during a benign hysterectomy may outweigh the benefits in certain women at low risk for ovarian cancer.
• The findings support guidelines to preserve ovaries in premenopausal women.

Certain women who had their ovaries removed during a hysterectomy for benign conditions faced higher risks for all-cause mortality, CVD and cancer, a recent study showed.

Researchers said the findings support current guidelines that recommend a conservative approach for ovary removal.

According to Mathilde Gottschau, MD, PhD, a staff member at the Danish Cancer Society Research Centere, and colleagues, more evidence was needed to substantiate current recommendations about removing ovaries during hysterectomy for benign conditions.

“Bilateral salpingo-oophorectomy (BSO) at benign hysterectomy decreases the risk for ovarian cancer, and women at high risk for this type of cancer will have a substantial survival benefit from BSO,” they wrote in Annals of Internal Medicine. “In premenopausal women, BSO leads to an abrupt decline in endogenous sex hormone production, whereas after menopause it mainly affects androgens.”

Therefore, current guidelines for women without an increased risk are typically more conservative, especially for premenopausal women. However, “these guidelines are based on evidence from a limited number of studies, most of which used self-reported information,” the researchers wrote.

So, Gottschau and colleagues conducted a nationwide cohort study to compare long-term outcomes in women who did and did not have BSO during hysterectomy for benign conditions.

The researchers evaluated data from a population-based cohort of 142,985 women 974 with BSO and 120,011 without — who had a hysterectomy for a benign condition.

Gottschau and colleagues found that women who had a BSO had higher 10-year mortality across all age groups. However, the differences were only statistically significant for those aged 45 to 54 years (risk difference [RD] = 0.79 percentage points; 95% CI, 0.27-1.3). At 20 years, the mortality was inconsistent with that at 10 years in women aged at least 65 years.

“A clear beneficial effect of BSO was seen only in 20-year mortality among women having surgery during late postmenopausal ages,” the researchers wrote.

When it came to risk for CVD hospitalization, women with BSO who were aged younger than 45 years when they had surgery faced a higher 10-year cumulative risk (RD = 1.19; 95% CI, 0.09-2.43) than those who did not have BSO.

Finally, women who had BSO also saw a higher 10-year cumulative risk for cancer at ages:

• 45 to 54 years (RD = 0.73; 95% CI, 0.05-1.38);
• 55 to 64 years (RD = 1.92; 95% CI, 0.69-3.25); and
• 65 years and older (RD = 2.54; 95% CI, 0.91-4.25).

“This population-based register study confirms that the adverse health risks outweigh the potential health benefits of BSO at benign hysterectomy in premenopausal women and thereby supports current guidelines for women without a high lifetime risk for ovarian cancer,” Gottschau and colleagues concluded. “The lack of a clear survival benefit and the cancer excess in postmenopausal women suggest the need for a cautious approach when deciding whether to perform BSO at hysterectomy in these women.”

In a related editorial, Elizabeth Casiano Evans, MD, an associate professor at the University of Texas Health Center at San Antonio, and Deslyn T.G. Hobson, MD, an assistant professor in obstetrics and gynecology at Wayne State University School of Medicine in Michigan, wrote that “the question of BSO at the time of benign hysterectomy is complicated, and there are many confounding factors.”

“The more recent practice of opportunistic salpingectomy can offer reduced ovarian cancer rates without compromising ovarian function,” they wrote. “Data showing that use of hormone replacement will mitigate risk rely on patients’ adherence to medication. Ultimately, the decision for BSO is best left to shared decision making between patient and physician.”

References:

• Evans EC, et al. Ann Intern Med. 2023;doi:10.7326/M23-0756.
• Gottschau M, et al. Ann Intern Med. 2023;doi:10.7326/M22-1628.