Q: I am a 51-year-old woman and I think I’m almost menopausal. I’m going in for a hysterectomy because I have large fibroids that are causing a lot of pain and bleeding. My doctor recommends getting my ovaries removed at the same time “to prevent future ovarian cancer,” but I’m opposed to having any organs removed unnecessarily. Should I get my ovaries removed? What’s your advice?
A: This is considered to be a $64,000 question in my profession. Before I attempt to answer it, let me make sure you understand that the chance of developing ovarian cancer in your lifetime is “only” 1 in 70. If you’ve reached the age of 40 without being afflicted by this disease, your chance drops to 1 in 100. Yet, most women and their doctors are concerned about ovarian cancer, since its onset is insidious and current modes of universal screening are, quite frankly, not adequate.Your risk increases if you have a family history of ovarian cancer, if several of your relatives have had breast or colon cancer, or if you’ve used fertility drugs for half a year or more (and they didn't work). Since incessant ovulation is felt to be partially responsible for an increased risk of ovarian cancer, never using birth control pills and/or never having a full-term pregnancy can also work against you. (Ovarian cancer risk decreases 40 percent if you have used the pill for two years and 80 percent if you have taken it for 10 years or more). Other risk factors include obesity and a diet very high in animal and milk fat.Having two or more children, on the other hand, can be advantageous and the benefit is even greater if you breastfed them, since breastfeeding suppresses ovulation.
Unless a patient in her 30s or 40s has a high risk family history or positive genetic testing (BRCA gene mutations have been associated with an up to 40 percent lifetime risk of ovarian cancer) and/or ovarian pathology, I do not suggest that she have her ovaries removed during hysterectomy. Removal of the ovaries in these decades can put her into “hormonal shock” that may be difficult to overcome, even with hormone therapy.
In the past, women who are close to or at menopause (average age of 51), have been advised to get their ovaries removed if they were undergoing hysterectomy. Studies of ovarian cancer prevention suggest that more than 1,000 cases of ovarian cancer could be prevented annually in the United States if women over 40 who have hysterectomies also have their ovaries removed.However, a recent study that compared women up to the age of 65 who kept their ovaries with those who had them removed (bilateral oophorectomy), showed that those who underwent the removal before the age of 55 had increased mortality rates of 8.6 percent by the age of 80. The supposition is that even though you stop having your period after menopause, your ovaries continue to produce a small amount of hormones, including male hormones that can be converted back into estrogen-like compounds. These hormones can affect libido, bone density, and to some extent coronary heart disease.It’s important to note, though, that 8.6 percent is not a large number, and it probably applies to a subset of women. If you have any family history of ovarian cancer, I would certainly suggest that your ovaries be removed. Moreover, we know that for women at risk for breast cancer or who have had breast cancer, bilateral oophorectomy will decrease the future incidence or recurrence of this form of malignancy. A final comforting thought: hysterectomy without the removal of the ovaries decreases future risk of developing ovarian cancer by as much as 50 percent. We’re not sure why (a similar but lower decrease also occurs with tubal ligation). Perhaps a change in the blood supply to the ovaries affects malignant transformation of cells. Or it’s possible that after these procedures the uterus and/or tubes no longer act as conduits between the external world (i.e. the vagina) and internal world of the ovaries, so that potentially carcinogenic contaminants can’t reach the ovaries.
Dr. Reichman’s Bottom Line: Discuss all of these factors with your doctor and then weigh the F-factors (fear). Are you more concerned about the potential loss of the small amount of hormones your ovaries are producing or your fear of getting ovarian cancer in the future? Does your history put you at a low or high risk for having these fears come true? Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.