Benign hysterectomy with ovarian removal is not associated with clear survival benefit

1. In this population-based cohort study, compared to women without bilateral salpingo-oophorectomy (BSO), women with BSO had a higher overall risk of developing cancer.

2. Notably, women in the BSO group had a higher 10-year mortality than those without BSO.

Evidence Rating Level: 1 (Excellent)

Study Rundown: BSO during benign hysterectomy has been shown to decrease the risk of ovarian cancer. Thus, women at high risk for this type of cancer will have a substantial survival benefit from undergoing BSO. However, there is a gap in knowledge as to understanding the true health consequences of ovarian removal. For example, in premenopausal women, BSO leads to an abrupt decline in endogenous sex hormone production. Conversely, after menopause, it affects androgen levels. Overall, this study found that the adverse health risks outweigh the potential health benefits of BSO at benign hysterectomy in premenopausal women and therefore suggests a cautious approach when deciding whether to perform BSO at hysterectomy in this population. This study was limited by using age as a proxy for menopausal status. Nevertheless, these study’s findings are significant, as they demonstrate that compared with women without BSO, women who received BSO had no significant survival benefit for the premenopausal group.

Click to read the study in AIM 

Relevant Reading: Summary for Patients: Long-Term Health Consequences After Ovarian Removal at Benign Hysterectomy 

In-Depth [population-based cohort study]: This population-based cohort study utilized women in Denmark aged 20 years or older. Patients who had benign hysterectomies between January 1977 and December 2018 at age 20 years or older and were living in Denmark were eligible for the study. Patients who had salpingo-oophorectomy or oophorectomy (uni- or bilateral) before hysterectomy, a family history of cancer before or at hysterectomy, unilateral salpingo-oophorectomy or oophorectomy at hysterectomy, a diagnosis of benign ovarian tumors at hysterectomy, or less than one year of potential follow-up were excluded from the study. The primary outcome was overall cancer (except for nonmelanoma skin cancer), cardiovascular disease, and all-cause mortality. Outcomes in the primary analysis were assessed via Kaplan-Meier estimates and Aalen-Johansen estimates. Based on the primary analysis, women with BSO who were younger than 45 years at surgery had a higher 10-year cumulative risk for hospitalization for CVD (risk difference [RD], 1.19%; 95% Confidence Interval [CI], 0.09 to 2.43%) compared to women without BSO. Women with BSO also had a higher 10-year cumulative risk for cancer for ages 45 to 54 years (RD, 0.73%; 95%CI, 0.05 to 1.38%), 55 to 64 years (RD, 1.92%; 95%CI, 0.69 to 3.25%), and 65 years or older (RD, 2.54%; 95%CI, 0.91 to 4.25%). Compared to women without BSO, women with BSO also had higher 10-year mortality in all age groups, though only ages 45 to 54 years were statistically significant (RD, 0.79%; 95%CI, 0.27 to 1.30%). In summary, this study demonstrates that conserving ovaries in premenopausal women without high risk for ovarian cancer is preferred given the lack of significant survival or health benefit in BSO. 

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