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Over 600,000 hysterectomies are performed every year. Almost half of those
women also will have their ovaries removed, not because the ovaries are
diseased, but as a protective measure against developing ovarian cancer in the
future. However, a recent study in the journal Obstetrics & Gynecology
reports that women undergoing hysterectomy (unrelated to ovarian disease)
receive health benefits from keeping their ovaries intact. Cleveland Clinic
Physician Linda Bradley, M.D., answers some questions about when ovary removal
is necessary, and when ovary conservation is a better option.
For background, what is a hysterectomy?
A hysterectomy is the removal of the uterus, sometimes also including
removal of the ovaries. A hysterectomy may be done for one of several reasons.
Some of the most common are: uterine fibroids, endometriosis, uterine prolapse
or cancer.
What effects does hysterectomy and ovary removal have on a woman?
If you haven't reached menopause yet, a hysterectomy stops your menstrual
cycle and you also won't be able to get pregnant. If your ovaries are removed
before you reach menopause, the sudden loss of your main source of female
hormones will bring on menopause. This "surgical menopause" can cause
more severe symptoms than a natural menopause. The sudden onset of hot flashes,
night sweats, poor concentration, vaginal dryness and lowered libido will shift
women into menopause.
Also, when the ovaries are removed, estrogen also is removed. Normally,
estrogen keeps the blood vessels open. Without it, vascular tone in the heart
changes and heart disease can be a consequence of this change. It can cause a
premature aging of the cardiovascular system.
When and why should the ovaries be removed as part of a hysterectomy?
We advocate ovarian conservation. Each patient’s medical and family
history is unique. We look at every health-related aspect of a person and try to
reach the most conservative decision. With a high-risk ovarian cancer patient,
there is often a family history of ovarian cancer or other cancers that increase
her risk. When there is a strong genetic component, we talk with the patient
about the risks and effects of removing her ovaries versus the risks and effects
of leaving them in. When there is benign disease, we rarely remove the ovaries.
In the benign cases, we advocate removing the ovaries less than 5 percent of the
time.
Until recently, how common was ovary removal?
In the past, when a woman reached age 45, physicians recommended
automatically that the ovaries be removed in the event of any abnormality. Ovary
removal was thought to eliminate the risk of future ovarian cancer. However,
very few women ended up needing future surgery to remove the ovaries because
ovarian cancer is relatively rare. Only one in 70 women develop it. In
comparison, a woman’s risk of breast cancer is one in 8, but we don’t
prematurely remove breast tissue.
Have there been recent improvements in diagnosing ovarian cancer?
We’re getting smarter with technology and catching the early symptoms of
ovarian cancer.
We now regularly and more comprehensively evaluate the symptoms of
nausea, bloating, abdominal distention, urinary frequency, and lower pelvic and
abdominal pain. All of these symptoms may mimic ovarian cancer and would justify
transvaginal ultrasound imaging if they are present and do not improve.
Transvaginal ultrasound, which is a method of imaging the reproductive
tract from the inside using ultrasound, and the CA 125 blood test, which
measures the amount of a tumor marker in the blood, are just two of the tools
that can be used if there is concern that someone has symptoms of ovarian
cancer. In the near future, we’ll have better blood tests and tumor markers to
pick up ovarian cancer, and these tests could be done on an annual basis for
women.
What alternatives to a hysterectomy are available for women?
In the case of fibroids, we might do a myomectemy, which is removal of just
the fibroids and not the uterus. Another option is uterine fibroid embolization,
which has been available for 10 years, but a lot of women don’t know about it.
Fibroid embolization is a minimally invasive alternative to hysterectomy. It
involves injecting a small particle into the artery that feeds the tumor to
block its blood supply. This, in turn, decreases the size of the
fibroids and resolves the symptoms.
If the problem is very heavy menstruation, there are several new medications
and a new IUD available. If a patient is not planning on having children, then
endometrial ablation can be performed. The treatment chosen all depends on the
scope of the problem, desire for reproduction, and age of the patient.
What’s most important to know for women who are considering hysterectomy
with ovary removal?
Take time to speak with a physician and ask for the rational for removing
the ovaries. Determine if the answer meets with your approval. Rarely in
menstruating women should the ovaries be removed unless there are strong risk
factors.
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