Berek on health risks of removing ovaries

Jonathan Berek

For the last three decades, physicians have routinely recommended that women undergoing a hysterectomy for benign conditions also have their ovaries removed. This practice has been changing and will likely continue to change with results of a large study published in the May issue of Obstetrics & Gynecology. The research involved more than 29,000 women in the Nurses' Health Study who had a hysterectomy for benign disease; just over half also had their ovaries removed. In tracking the women for 24 years, the researchers found that ovary removal was associated with an increased risk of death from coronary heart disease and lung cancer. Although it also led to a decreased risk of breast and ovarian cancer, ovary removal failed to provide an overall survival benefit.

Jonathan Berek, MD, professor and chair of obstetrics and gynecology, was a co-author of the paper. He recently spoke with staff writer Michelle L. Brandt about the significance of these findings.

1. What's the main reason gynecologists have recommended that women who get a hysterectomy also have their ovaries removed?

Berek: It's been the standard of care that surgeons incidentally remove the ovaries when performing a hysterectomy for benign conditions in women age 40 and older to prevent ovarian cancer. There's been a gradual change over the past few years, though. Several researchers, including our own group, have published small studies suggesting that removal of the ovaries and fallopian tubes in women at average risk of ovarian cancer might be deleterious because of an increased risk of cardiovascular disease.

2. Did any aspect of the study results surprise you?

Berek: We found that among those women who had their ovaries removed, there was a 30 percent increase in deaths caused by lung cancer. We didn't expect that, and we don't know why, although there are some data that suggest that estrogens might protect against the development of lung cancer. This is an important finding and something that needs to be further studied.

3. Do the findings challenge the belief that removing the ovaries is best for long-time survival?

Berek: What was found is that incidental removal of ovaries did not reduce mortality overall and, furthermore, led to an increased risk of death from cardiovascular disease and coronary artery disease, particularly in premenopausal women. This means that in women who don't have a strong family history of ovarian cancer and breast cancer, ovaries can be preserved when they undergo a hysterectomy for benign disease.

When in the past a 40- or 50-year-old woman underwent a hysterectomy for bleeding or symptomatic fibroids and asked her doctor, "Should I have my ovaries removed?" the doctor probably would have routinely indicated that she should in order to prevent ovarian cancer. However, these data should make physicians rethink that dogmatic approach, especially when counseling patients with a significant risk of cardiovascular disease.

4. Are there women who should still consider having their ovaries removed when getting a hysterectomy?

Berek: Ovaries should be removed prophylactically in women who are at high risk for developing ovarian cancer, and those with a strong family history of breast and ovarian cancer, especially those who have BRCA1 and BRCA2 mutations. Women with other risk factors that predispose them to ovarian cancer, such as having no children and never having taken birth control pills, might also consider incidental removal.

5. You specialize in ovarian cancer. Does it make you nervous that doctors may be moving away from something that was designed to prevent the disease?

Berek: Ovarian cancer is horrible, and we need to discover ways to prevent and detect the disease. Women should be reminded that the use of the oral contraceptive pill significantly reduces the risk of ovarian cancer—for those who have taken the pill for five years or longer, their risk of ovarian cancer is cut in half. Our study shows that the few lives we do save by ovary removal in women at average risk for the disease are offset by a substantial increase in deaths from other causes, especially coronary heart disease. Therefore, the decision to preserve or remove ovaries should be individualized and these issues should be thoroughly discussed with the patient.