Bilateral oophorectomy: Solving the risk/benefit equation - Choosing candidates, monitoring outcomes

Key Points

Bilateral oophorectomy at the time of hysterectomy for benign disease has been commonly recommended to women over the age of 40 or 45 years to prevent the development of ovarian cancer. In the United States, at least 300,000 women annually have bilateral oophorectomy at the time of hysterectomy: approximately 54% of all hysterectomy procedures.¹ Concomitant bilateral oophorectomy is most often performed in women 50 to 54 years of age. In this group, 78% of hysterectomies include bilateral oophorectomy.¹

However, prophylactic surgery should be performed only if there is evidence that it clearly benefits the patient.² Recent evidence suggests that there may be long-term health benefits and longer survival for women who choose ovarian conservation at the time of hysterectomy for benign disease. In addition, oophorectomy improves quality of life and provides a survival benefit for other women.³

Ovarian cancer prevention in women at increased risk

For women with BRCA1 and BRCA2 mutations, annual screening for ovarian cancer using transvaginal ultrasound and the CA125 blood test has not proven effective for detecting disease early enough to influence survival, and is not recommended.¹⁰ The only intervention shown to be effective in reducing the incidence of ovarian cancer in women carrying the BRCA1 or BRCA2 gene mutation is bilateral salpingo-oophorectomy.¹¹ As a result, authorities agree that women who have known genetic mutations that increase the risk of ovarian and breast cancers should strongly consider oophorectomy after completion of childbearing.¹²

About 2% of women have a family history consistent with an increased risk of ovarian or breast cancer. Recent studies suggest that a large number of low-penetrance genetic variants account for instances of women who have a strong family history but do not have BRCA1 or BRCA2 mutations.¹³ Genetic counseling from a trained healthcare provider can help these women make informed decisions about the advisability of oophorectomy. Removal of the fallopian tubes and ovaries in women with the BRCA1 or BRCA2 gene mutation reduces the risk of ovarian cancer by 80%.¹⁴ Further, a large retrospective study noted a decreased risk of breast cancer during follow-up after unilateral oophorectomy alone or bilateral oophorectomy performed with or without hysterectomy, particularly when these procedures were done before age 45 years (ratio of observed to expected cases ranging from 0.65 to 0.89).¹⁵ Both fallopian tubes also should be removed at surgery because recent evidence has shown that most BRCA-related ovarian cancers are actually of tubal origin, beginning in the epithelial cells of the fimbria of the fallopian tube.¹⁶ This finding also explains why ultrasound is not effective for cancer screening.

Additionally, some women without a family or personal history that increases their risk of ovarian cancer may wish to have their ovaries removed because of concerns about the possibility of developing ovarian cancer. If one of these women wishes to proceed with oophorectomy after a full discussion of her specific risk for ovarian and breast cancers and the risks and benefits of the surgery, I would certainly respect her wishes.