How often will ovarian
preservation result in
reoperation?
Gilbert Sayegh MD
Cornelia DeRiese MD
BACKGROUND



Approximately 78% of women between the ages of 45-64
years have prophylactic oophorectomy when
hysterectomy is perfomed for benign disease. [15]
According to the CDC, thera are approximaltely 600,000
hysterectomies performed yearly in the U.S., 51% of
them include bilateral oophorectomy.
Literature quotes 7.6% re-op rates to have ovaries
removed at a later date. [13]




Most of these repeat surgical procedures are performed due to
pelvic pain or pelvic mass.
Many re-op occur within 5 years of the hysterectomy. [13]
Women with endometriosis, pelvic inflammatory disease, and
chronic pelvic pain are at higher risk of reoperation if ovaries are
retained. [13]
The American College of Obstetricians and
Gynecologists has advised that the decision to perform a
prophylactic oophorectomy during hysterectomy should
be individualized, based upon factors such as loss of
ovarian function and the risk of future ovarian surgery if
the organs are retained. [13]
CLINICAL CONSIDERATIONS

Prior to performing elective
oophorectomy the following factors
should be considered:
Age
 Genetic risk of ovarian cancer
 Atherosclerosis
 Osteoporosis
 Heart disease

ADVANTAGES OF PROPHYLACTIC
OOPHORECTOMY

Reduction in risk of developing
ovarian cancer

Incidence 1.7%
Reduction in risk of developing breast
cancer [7]
 Relief of bothersome symptoms
causing chronic pelvic pain.

DISADVANTAGES OF
PROPHYLACTIC OOPHORECTOMY
Surgical menopause








Loss of natural ovarian hormones
 When compliance with estrogen therapy is assumed to be perfect,
oophorectomy yields longer life expectancy than retaining the ovaries. [7]
Increase in risk of cardiovascular disease [1,2,7]
 Oophorectomy after age of 50 increases risk of developping an MI by 40%
[15]
Increase in risk of osteoporosis
 Oophorectomy after age 40 increases risk of hip fx by 50% [11]
Increase in risk of neurologic impairments:
 Cognitive impairment affecting short term memory and general dementia.
[11]
 Parkinson’s [11]
 Adverse occular changes
 Decline in psychological well being [5]
Irritability, mood swings
Hot flushes
Adverse skin and body composition changes
Decline in sexual function
 Vaginal dryness
OBJECTIVE
There are no West Texas studies evaluating
the re-op rate for ovarian disease after
hysterectomy.
 Our objective is to collect and interpret data
from our institution in order to be able to
more appropriately counsel patients who
have to undergo a hysterectomy for benign
indications about the pros and cons of
elective oophorectomy. This will include the
risks and benefits, morbidity and mortality of
reoperation and we also want to look at
excess expenses.

DESIGN

Retrospective chart review of patients
who undergone a hysterectomy with
or without oophorectomy, and
oophorectomy by itself.
MATERIALS AND
METHODS




Chart review of subjects who underwent
hysterectomies at UMC from 1993 to present.
Using dictated operative reports, we will collect
data on reason for the procedure and type of
hysterectomy and whether ovaries were left behind
or removed.
We will also collect data on subjects who returned
at a later date for a separate procedure to remove
ovaries.
Subjects who underwent oophorectomies will be
evaluated to see if they had previous
hysterectomies.
WHAT RESULTS ARE WE
LOOKING TO FIND?


Reoperation rate within our patient
population.
 Between 1993 and present, there were
3251 hysterectomies performed at
UMC.
 During the same time there were 1586
oophorectomies performed.
The data will be stratified by:
 Age groups
 Indications for the hysterectomy
 Mode of surgery.
RESULTS CONT’D

As additional information for the cost
analysis, we will look to see if there
were any complications including:
•
•
•
•
Wound infections
Bleeding
Damage to major organs
Any other reason that prolonged hospital
stay.
Conclusion




Hysterectomy is the second most frequently performed major
surgical procedure for women of reproductive age in the United
States.
During 2000–2004 the overall hysterectomy rate for the U.S
was 5.4. per 1,000 women. Highest among women between
ages 40-44 years old.
 38% of women between the ages of 18-44 years old have
concurrent oophorectomy with their hysterectomy
 78% of women between the ages of 44-64 years old have
concurrent oophorectomy with their hysterectomy
The overall hysterectomy rate for women living in the South was
6.5 per 1,000
The three conditions that make up 90% of all hysterectomies
were uterine leiomyoma ("fibroid tumors"), endometriosis, and
uterine prolapse.
CONCLUSION CONT’D

Looking at cost

Average cost for hysterectomy with or
without BSO is in the range of $24003700 depending on the type of surgery
being performed.
• This is only the cost of the surgery
Oophorectomy alone is ---------- Hospital stay is $2000 per day
 Anesthesia is $2000 per case
 Pathology is $600-1000 per specimen

CONCLUSION CONT’D


Dr Parker et al designed a model to study the major risks and benefits related to the
decision to have prophylactic bilateral oophorectomy at the time of hysterectomy for
benign disease in women who have average risk of ovarian cancer.
 Results:
• Women younger than 65 y.o. clearly benefit from ovarian conservation and
at no age is there clear benefit from oophorectomy.
• He concluded that women younger than 65 had increase risk
• Dying from heart disease
• Women choosing ovarian conservation at ages 50-54, there is
8.5% survival advantage measured at age 80 compared with
the oophorectomy group.
• Increase mortality from hip fractures.
• Pt who were followed to a median of 15 years who were
postmenopausal at the time of oophorectomy had 54% more
osteoporotic fractures than women with intact ovaries.
• His argument is that postmenopausal ovaries continue to secrete
small amounts of estrogen for years. Ovaries have also shown to
secrete significant amount of testosterone and androstenedione
which is converted to estradiol and estrone in muscle and fat.
Another study that looked at 121700 women determined that oophorectomy between
age 40-44 years old doubled the risk of MI compared to women with intact ovaries.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Shoupe D, Parker WH et al. Elective oophorectomy for benign gyn. Disorder. Menopause. 2007;may-jun; 14
Parker WH, Shoupe D et al. elective oophorectomy in gyn patients. Curr Opin Obstet Gynecol. 2007
aug;19(4)
Bhavnani V, Clarke A. Women awaiting hysterectomy: a qualitative study of issues involved in decision about
oopherectomy. BJOG. 2003 Feb;110(2): 168-74
Fry A, Busby-Earle C et al. Prophylactic oophorectomy versus screening. Psychooncology. 2001 May-Jun;
10(03): 231-41
Fong YF, Lim FK et al. Prophylactic oophorectomy: a continuing controversy. Obstet Gynecol Surv. 1998
Aug; 53(8): 493-9
Das N, Kay VJ, et al. Current knowledge of risks and benefits of prophylactic oopherectomy. Eur J Obstet
Gynecol Reprod Biol. 2003; 109(1): 76-79
Speroff T, Dawson NV et al. A risk benefit analysis of elective bilateral oophorectomy. Am J Obstet Gynecol.
1991 Jan; 164
Garcia CR, Cutler WB. Preservation of the ovary: a reevaluation. Fertil Steril. 1984 Oct; 42(4)
Suchaartwatnachai C, Jetsawangsri T et al. Prophylactic oophorectomy of benign uterine disease in
premenopausal women: 11 years review. J Med Assoc Thai. 1994 Oct; 77(10)
Farquhar CM, Harvey SA et al. a prospective study of 3 years of outcomes after hysterectomy with and
without oopherectomy. Am J Obstet Gynecol. 2006;194
Moscucci O, Clarke A. prophylactic oophorectomy: a historical perspective. J Epidemiol Community Health.
2007 Mar; 61(3): 182-4
Rocca WA, Bower JH, et al. increased risk of cognitive impairment or dementia in women who underwent
oopherectomy before menopause. Neurology. 2007; 69(11): 1074-83
ACOG Practice Bulletin. Elective and risk reducing salpingo-oophorectomy. Clinical management guidelines
for OBGYN. Number 89, Jan 2008
Walter AR, Brandon RG et al. Survival patterns after oophorectomy in premenopausal women: a populationbased cohort study. The lancet oncology. 2006;7(10)
Parker WH, Broder MS, et al. Ovarian Conservation at the time of hysterectomy for benign disease. Clinical
Obstet & Gynecol. 2007.50(2)