Not removing ovaries during benign hysterectomy: Benefits may outweigh risks

For pre- and postmenopausal women undergoing hysterectomy for benign indications, the benefit of removing the ovaries may not outweigh the risk. Recent results of a nationwide Danish cohort study found that although all women, despite their age, were less likely to develop ovarian cancer with ovary removal during benign hysterectomy in comparison with women who did not have their ovaries removed, ovary removal increased the risk in other health conditions.1 The risks of ovary removal were evident across age groups, although in different ways based on the menopausal status at the time of surgery. In comparison with women who did not have their ovaries removed, ovary removal was linked to a higher likelihood of hospitalization for cardiovascular disease in premenopausal women (<45 years old), to an increased risk for all types of cancer combined other than ovarian cancer 10 years after surgery in women at menopause (45–54 years old) and after menopause (≥55 years old), and to more deaths 10 and 20 years after surgery in women 45–54 years old but fewer deaths 20 years after surgery in women older than 65 years. “Our results support current recommendations for not removing the ovaries in premenopausal women who do not have a high risk for ovarian cancer,” says Mathilde Gottschau, MD, PhD, of the Danish Cancer Society Research Center in Copenhagen and lead author of the study. “Our results also suggest caution in removing ovaries in postmenopausal women.” Whether or not to remove ovaries during benign hysterectomy in women at low risk for ovarian cancer is widely debated because of the importance of preventing ovarian cancer as well as the importance of preventing unnecessary comorbidities from ovary removal. Dr Gottschau and her colleagues used comprehensive Danish registries to emulate a target trial to assess overall hospitalizations for cardiovascular disease, overall cancer incidence, and all-cause mortality among women who underwent benign hysterectomy with bilateral salpingo-oophorectomy (BSO) (n = 22,974) or without BSO (n = 120,011) between January 1977 and December 2018. Their findings support prior evidence showing more hospitalizations for cardiovascular disease in premenopausal women who underwent BSO versus women who did not undergo BSO and add new information about the adverse effects (AEs) on cancer risk and mortality for menopausal and postmenopausal older women. In an accompanying editorial, Elizabeth Casiano Evans, MD, and Deslyn T. G. Hobson, MD, underscore that the question of BSO during benign hysterectomy remains complicated and is best answered through shared decision-making between patient and physician.2 They point out that there are other approaches that may help to mitigate the AEs of BSO while reducing ovarian cancer risk, such as salpingectomy, as the fallopian tube is where most ovarian cancers originate.