Is elective oophorectomy (ovary removal) recommended at the time of hysterectomy (uterus removal) in women under 65 years of age?

From the Guidelines

Elective oophorectomy at the time of hysterectomy is generally not recommended for women under age 65 who are not at high risk for ovarian cancer. The ovaries continue to produce hormones even after menopause, including testosterone and small amounts of estrogen, which provide cardiovascular, cognitive, bone, and sexual health benefits 1. Removing healthy ovaries before age 65 has been associated with increased risk of mortality, cardiovascular disease, cognitive decline, osteoporosis, and sexual dysfunction. The decision should be individualized based on the patient's age, menopausal status, and risk factors. Women with BRCA1/2 mutations or strong family history of ovarian cancer may benefit from prophylactic oophorectomy, with the recommended timing of risk-reducing bilateral salpingo-oophorectomy (RRBSO) varying depending on the risk, typically between 35 and 40 years of age for women with a BRCA1 pathogenic or likely pathogenic variant, and between 40 and 45 years of age for women with a BRCA2 pathogenic or likely pathogenic variant 1. For average-risk women, ovarian conservation is typically the better option until at least age 65. If oophorectomy is performed in premenopausal women, hormone replacement therapy should be considered until the natural age of menopause (approximately age 51) to mitigate the risks of surgical menopause, unless contraindicated.

Some key points to consider include:

• The risk of ovarian cancer varies depending on the type of genetic mutation, with BRCA1 and BRCA2 mutations carrying a higher risk 1.
• The benefits of RRBSO in reducing the risk of ovarian cancer must be weighed against the potential risks of premature menopause, including osteoporosis, cardiovascular disease, and cognitive changes 1.
• The decision to undergo RRBSO should be made in consultation with a gynecologic oncologist, taking into account individual risk factors and preferences 1.
• Hysterectomy should not be routinely recommended at the time of RRBSO unless other indications for this procedure exist, such as a pathogenic variant in the MLH1, MSH2, or MSH6 genes, or other risk factors for endometrial cancer 1.

Overall, the decision to perform elective oophorectomy at the time of hysterectomy should be based on a careful consideration of the individual patient's risk factors, preferences, and medical history, with the goal of minimizing morbidity, mortality, and improving quality of life.

From the Research

Elective Oophorectomy at the Time of Hysterectomy

• The decision to perform elective oophorectomy at the time of hysterectomy in women under 65 years of age is complex and depends on various factors, including the patient's individual circumstances and ovarian cancer risk 2, 3, 4, 5.
• Studies have shown that elective oophorectomy is associated with short- and long-term health consequences, such as decreased cognition and sexual function, increased risk of osteoporosis and cardiac mortality, and adverse effects on quality of life 2, 3.
• However, elective oophorectomy may also have benefits, including reduced risk of ovarian cancer, repeat surgical operation due to adnexal masses, and anxiety related to perceived risk of ovarian and breast cancer 2, 3.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that the decision to perform elective oophorectomy at the time of hysterectomy should be individualized and based on the patient's risk factors, medical history, and personal preferences 5.
• Age is a significant factor in the decision to perform elective oophorectomy, with older women being more likely to undergo the procedure 4.
• For women with an average risk of ovarian cancer, ovarian conservation until at least age 65 seems to benefit long-term survival 2.
• In women with a hereditary ovarian cancer risk, such as those with BRCA mutations, risk-reducing oophorectomy is recommended between age 35 and 40 and between age 40 and 45 years for women carriers of BRCA1 and BRCA2 mutations, respectively 6.

Considerations for Elective Oophorectomy

• The potential benefits and risks of elective oophorectomy should be carefully considered and discussed with the patient before making a decision 2, 3, 5.
• A careful history and risk assessment must be performed to determine if a patient is a candidate for a risk-reducing oophorectomy 5.
• The surgeon should consider the implications of ovarian removal on the health of their patient, including the potential effects on quality of life, cognition, and sexual function 2, 3.
• Hormonal replacement therapy (HRT) may be considered for women who undergo elective oophorectomy, particularly those with a hereditary ovarian cancer risk, to alleviate menopausal symptoms and improve quality of life 6.