Should the ovaries be preserved at surgery for benign indications beyond the menopause?

Liselotte Mettler, Department of Obstetrics & Gynaecology, University Hospitals Schleswig-Holstein, Campus, Michaelisstr. 16, 24105 Kiel

Ovarian conservation up to the age of 65 benefits long-term survival for women at an average risk of ovarian cancer when undergoing hysterectomy for benign disease. The role of prophylactic oophorectomy at the time of hysterectomy has long been a controversial issue. It is thought that the role of the ovary is for reproduction and hormone production and when each of these functions ceases the ovary serves no purpose other than generating mischief. It is also known that ovaries produce other essential cytokines important for the continuation of life; conversely, even unsuspicious-looking ovaries may develop ovarian cancer. Therefore, only an individual decision can be taken that is tailored to the patient’s family history, personal history, previous surgery, present status and wishes.

A calculated increase in mortality associated with oophorectomy in the absence of oestrogen therapy derives almost entirely from an enhancement of coronary heart disease; however, the validity of the findings can easily be questioned. Nevertheless, even if no coronary heart disease increase is seen with oophorectomy, there remains no demonstrable advantage to the procedure in terms of longevity. In the already complex discussion regarding oophorectomy in perimenopausal women, the issue of potential effect upon mortality must be brought up, because it has been shown that patients without oophorectomy live longer. It is our responsibility as physicians and patient advocates to continuously challenge new findings with a critical eye, a reasoned perspective and whenever possible a smattering of imagination.

Regarding the decision whether to take out the ovaries or not in females beyond the reproductive age, it seems certain that beyond the age of 65 the ovaries should be taken out in cases of hysterectomy as malignant transformations seem to be further increased from that age onwards. Before the age of 65 years, the decision whether to leave the ovaries in situ remains a decision between the doctor and his/her patient.

Reference

L. Mettler, A. Garzon, H. Kühling-von Kaisenberg and CS von Kaisenberg. Ovarian Surgery and Follicular Reserve. Expert Review of Endocrinology and Metabolism 2006, vol. 1 no. 6, pp. 743-752.