Oophorectomy

Definition

Unilateral oophorectomy (also called an ovariectomy) is the surgical removal of an ovary. If one ovary is removed, a woman may continue to menstruate and have children. If both ovaries are removed, a procedure called a bilateral oophorectomy, menstruation stops and a woman loses the ability to have children.

Purpose

Oophorectomy is performed to:

• remove cancerous ovaries
• remove the source of estrogen that stimulates some cancers
• remove a large ovarian cyst
• excise an abscess
• treat endometriosis

In an oophorectomy, one or a portion of one ovary may be removed or both ovaries may be removed. When an oophorectomy is done to treat ovarian cancer or other spreading cancers, both ovaries are removed (called a bilateral oophorectomy). Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomies (surgical removal of the uterus), often to reduce the risk of ovarian cancer.

Oophorectomies are sometimes performed on premenopausal women who have estrogen-sensitive breast cancer in an effort to remove the main source of estrogen from their bodies. This procedure has become less common than it was in the 1990s. Today, chemotherapy drugs are available that alter the production of estrogen and tamoxifen blocks any of the effects any remaining estrogen may have on cancer cells.

Until the 1980s, women over age 40 having hysterectomies routinely had healthy ovaries and fallopian tubes removed at the same time. This operation is called a bilateral salpingo-oophorectomy . Many physicians reasoned that a woman over 40 was approaching menopause and soon her ovaries would stop secreting estrogen and releasing eggs. Removing the ovaries would eliminate the risk of ovarian cancer and only accelerate menopause by a few years.

In the 1990s, the thinking about routine oophorectomy began to change. The risk of ovarian cancer in women who have no family history of the disease is less than 1%. Meanwhile, removing the ovaries increases the risk of cardiovascular disease and accelerates osteoporosis unless a woman takes prescribed hormone replacements.

Under certain circumstances, oophorectomy may still be the treatment of choice to prevent breast and ovarian cancer in certain high-risk women. A study done at the University of Pennsylvania and released in 2000 showed that healthy women who carried the BRCA1 or BRCA2 genetic mutations that pre-disposed them to breast cancer had their risk of breast cancer drop from 80% to 19% when their ovaries were removed before age 40. Women between the ages of 40 and 50 showed less risk reduction, and there was no significant reduction of breast cancer risk in women over age 50. A 2002 study showed that five years after being identified as carrying BRCA1 or BRCA2 genetic mutations, 94% of women who had received a bilateral salpingo-oophorectomy were cancer-free, compared to 79% of women who had not received surgery.

The value of ovary removal in preventing both breast and ovarian cancer has been documented. However, there are disagreements within the medical community about when and at what age this treatment should be offered. Preventative oophorectomy, also called prophylactic oophorectomy, is not always covered by insurance. One study conducted in 2000 at the University of California at San Francisco found that only 20% of insurers paid for preventive bilateral oophorectomy (PBO). Another 25% had a policy against paying for the operation, and the remaining 55% said that they would decide about payment on an individual basis.

Demographics

Overall, ovarian cancer accounts for only 4% of all cancers in women. But the lifetime risk for developing ovarian cancer in women who have mutations in BRCA1 is significantly increased over the general population and may cause an ovarian cancer risk of 30% by age 60. For women at increased risk, oophorectomy may be considered after the age of 35 if childbearing is complete.

Other factors that increase a woman's risk of developing ovarian cancer include age (most ovarian cancers occur after menopause), the number of menstrual periods a woman has had (affected by age of onset, pregnancy, breastfeeding, and oral contraceptive use), history of breast cancer, diet, and family history. The incidence of ovarian cancer is highest among Native American (17.5 cases per 100,000 population), white (15.8 per 100,000), Vietnamese (13.8 per 100,000), white Hispanic (12.1 per 100,000), and Hawaiian (11.8 per 100,000) women; it is lowest among Korean (7.0 per 100,000) and Chinese (9.3 per 100,000) women. African American women have an ovarian cancer incidence of 10.2 per 100,000 population.

Description

Oophorectomy is done under general or regional anesthesia. It is often performed through the same type of incision, either vertical or horizontal, as an abdominal hysterectomy . Horizontal incisions leave a less noticeable scar, but vertical incisions give the surgeon a better view of the abdominal cavity. After the incision is made, the abdominal muscles are stretched apart, not cut, so that the surgeon can see the ovaries. Then the ovaries, and often the fallopian tubes, are removed.

Oophorectomy can sometimes be done with a laparoscopic procedure. With this surgery, a tube containing a tiny lens and light source is inserted through a small incision in the navel. A camera can be attached that allows the surgeon to see the abdominal cavity on a video monitor. When the ovaries are detached, they are removed though a small incision at the top of the vagina. The ovaries can also be cut into smaller sections and removed.

The advantages of abdominal incision are that the ovaries can be removed even if a woman has many adhesions from previous surgery. The surgeon gets a good view of the abdominal cavity and can check the surrounding tissue for disease. A vertical abdominal incision is mandatory if cancer is suspected. The disadvantages are that bleeding is more likely to be a complication of this type of operation. The operation is more painful than a laparoscopic operation and the recovery period is longer. A woman can expect to be in the hospital two to five days and will need three to six weeks to return to normal activities.

Diagnosis/Preparation

Before surgery, the doctor will order blood and urine tests, and any additional tests such as ultrasound or x rays to help the surgeon visualize the woman's condition. The woman may also meet with the anesthesiologist to evaluate any special conditions that might affect the administration of anesthesia. A colon preparation may be done, if extensive surgery is anticipated.

On the evening before the operation, the woman should eat a light dinner, then take nothing by mouth, including water or other liquids, after midnight.

Aftercare

After surgery a woman will feel discomfort. The degree of discomfort varies and is generally greatest with abdominal incisions, because the abdominal muscles must be stretched out of the way so that the surgeon can reach the ovaries. In order to minimize the risk of postoperative infection, antibiotics will be given.

When both ovaries are removed, women who do not have cancer are started on hormone replacement therapy to ease the symptoms of menopause that occur because estrogen produced by the ovaries is no longer present. If even part of one ovary remains, it will produce enough estrogen that a woman will continue to menstruate, unless her uterus was removed in a hysterectomy. To help offset the higher risks of heart and bone disease after loss of the ovaries, women should get plenty of exercise , maintain a low-fat diet, and ensure intake of calcium is adequate.

Return to normal activities takes anywhere from two to six weeks, depending on the type of surgery. When women have cancer, chemotherapy or radiation are often given in addition to surgery. Some women have emotional trauma following an oophorectomy, and can benefit from counseling and support groups.

Risks

Oophorectomy is a relatively safe operation, although, like all major surgery, it does carry some risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, accidental damage to other organs, and post-surgery infection.

Complications after an oophorectomy include changes in sex drive, hot flashes, and other symptoms of menopause if both ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for cardiovascular disease and osteoporosis. Women with a history of psychological and emotional problems before an oophorectomy are more likely to experience psychological difficulties after the operation.

Complications may arise if the surgeon finds that cancer has spread to other places in the abdomen. If the cancer cannot be removed by surgery, it must be treated with chemotherapy and radiation.

Normal results

If the surgery is successful, the ovaries will be removed without complication, and the underlying problem resolved. In the case of cancer, all the cancer will be removed. A woman will become infertile following a bilateral oophorectomy.

Morbidity and mortality rates

Studies have shown that the complication rate following oophorectomy is essentially the same as that following hysterectomy. The rate of complications associated with hysterectomy differs by the procedure performed. Abdominal hysterectomy is associated with a higher rate of complications (9.3%), while the overall complication rate for vaginal hysterectomy is 5.3%, and 3.6% for laparoscopic vaginal hysterectomy. The risk of death is about one in every 1,000 women having a hysterectomy. The rates of some of the more commonly reported complications are:

• excessive bleeding (hemorrhaging): 1.8–3.4%
• fever or infection: 0.8–4.0%
• accidental injury to another organ or structure: 1.5–1.8%

Because of the cessation of hormone production that occurs with a bilateral oophorectomy, women who lose both ovaries also prematurely lose the protection these hormones provide against heart disease and osteoporosis. Women who have undergone bilateral oophorectomy are seven times more likely to develop coronary heart disease and much more likely to develop bone problems at an early age than are premenopausal women whose ovaries are intact.

Alternatives

Depending on the specific condition that warrants an oophorectomy, it may be possible to modify the surgery so at least a portion of one ovary remains, allowing the woman to avoid early menopause. In the case of prophylactic oophorectomy, drugs such as tamoxifen may be administered to block the effects that estrogen may have on cancer cells.

Resources

periodicals

Kauff, N. D., J. M. Satagopan, M. E. Robson, et al. "Risk-Reducing Salpingo-oophorectomy in Women With a BRC1 or BRC2 Mutation." New England Journal of Medicine 346 (May 23, 2002): 1609–15.

organizations

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS-2345. http://www.cancer.org .

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org .

Cancer Information Service, National Cancer Institute. Building 31, Room 10A19, 9000 Rockville Pike, Bethesda, MD 20892. (800) 4-CANCER. http://www.nci.nih.gov/cancerinfo/index.html .

other

"Ovarian Cancer: Detailed Guide." American Cancer Society. October 20, 2000 [cited March 14, 2003]. http://www.cancer.org/downloads/CRI/CRC_-_OVARIAN_CANCER.pdf .

"Prophylactic Oophorectomy." American College of Obstetricians and Gynecologists. September 7, 1999 [cited March 14, 2003]. http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZONIHKUJC&sub_cat=9 .

"Removing Ovaries Lowers Risk for Women at High Risk of Breast, Ovarian Cancer." ACS News Today November 8, 2000. [cited May 13, 2003]. http://www.cancer.org .

Surveillance, Epidemiology, and End Results. "Racial/Ethnic Patterns of Cancer in the United States: Ovary." National Cancer Institute. 1996 [cited March 14, 2003]. http://seer.cancer.gov/publications/ethnicity/ovary.pdf .

Tish Davidson, A.M.
Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Oophorectomies are usually performed in a hospital operating room by a gynecologist, a medical doctor who has completed specialized training in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics.

QUESTIONS TO ASK THE DOCTOR

• Why is a oophorectomy being recommended?
• How will the procedure be performed?
• Will I have a remaining ovary (or portion of ovary)?
• What alternatives to oophorectomy are available to me?