“REMOVE THE OVARIES AT HYSTERECTOMY? HERE’S THE LOWDOWN ON RISKS AND BENEFITS” WILLIAM H. PARKER, MD (FEBRUARY 2010)
Little has changed in Dr. Parker’s view of ovarian conservation since publication of an earlier article in 2005,1 and little has changed in my thoughts on the matter since I wrote a letter in response to that earlier article.2
In this latest article on the subject, Dr. Parker does say that “estrogen and other drugs mitigate the risks associated with oophorectomy,” but he goes on to qualify that statement by adding that “many women avoid or discontinue these medications.”
I was pleased that Dr. Parker acknowledged the availability of estrogen supplementation, bisphosphonates, and lipid-lowering drugs, but I was disappointed that the discontinuation rates for these medications were used as an argument for ovarian conservation.
Balancing the relatively small risk of ovarian cancer against the larger risk of coronary artery disease (CAD) and osteoporosis is not really a fair comparison because atherosclerosis and osteoporosis 1) have a major genetic component, 2) begin long before the decision regarding ovarian conservation is made, and 3) are subject to multiple interpretations.
I propose that patients undergoing pelvic surgery for benign disease be counseled fully about the hazards of repeat surgery, ovarian and fallopian tube carcinoma, and the need for continuation of statin and bisphosphonate drugs to maximize protection.
Does Dr. Parker really believe that ovarian conservation 2 years after menopause confers any real benefit on bones or the cholesterol level when the ovaries are inactive?
Until we have a better method of predicting the likelihood of ovarian and tubal carcinoma—and detecting and treating these cancers—we should exercise every opportunity to appropriately lower that risk.
Robert C. Wallach, MD
Professor, Division of Gynecologic Oncology
Women’s Cancer Program
NYU Cancer Institute
NYU Langone Medical Center
New York City
References
1. Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol. 2005;106(2):219-226.
2. Wallach RC. Ovarian conservation at the time of hysterectomy for benign disease [letter]. Obstet Gynecol. 2005;106(5, Part 1):1106-1107.
Dr. Parker responds: One-issue counseling no longer suffices
Because he is an oncologist, I understand Dr. Wallach’s concerns about ovarian conservation, but I am sorry to disagree with a few of the points he makes. First, contrary to Dr. Wallach’s assertion, a number of groups (as explained in the article) have shown that the ovaries are not at all inactive after menopause.
Ovarian cancer is a terrible disease. However, as I noted in my article, it affects less than 1% of women, excluding known BRCA carriers or others with a strong family history of ovarian or breast cancer. Many women undergo prophylactic oophorectomy at the time of hysterectomy long before osteoporosis or CAD have appreciably developed (66% of those having hysterectomy between the ages of 45 and 49 years, for example), and our data show a significantly increased risk of CAD, the major cause of death for women, after their ovaries are removed. This seems to suggest that reducing the rate of oophorectomy would be a good place to start for primary prevention of CAD.1,2
As I also noted in the article, the continuation rates of estrogen (especially following the Women’s Health Initiative studies), bisphosphonates, and statins are extremely low. In one of the studies I cited, women were counseled extensively about the importance of taking the medication, to no avail. Similar studies in other specialties show comparable results.
We both agree that current information should be used to better counsel women about both risks and benefits of ovarian conservation; a one-issue conversation about ovarian cancer prevention no longer suffices. I also look forward to the time when gynecologists can both achieve early diagnosis and offer effective treatment for women with ovarian cancer.