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OVARIEN & GESUNDHEIT
Ovarien sind wichtig für die Gesundheit
Ovarian Conservation at the Time of Hysterectomy for Benign Disease
William Parker, MD, Michael Broder , MD MPH, Zhimei Liu PhD, Donna Shoupe, MD, Cindy Farquhar , MD, Jonathan Berek , MD
Obstetrics and Gynecology 2005; 106:219-26 Erhalt der Ovarien vor 65 begünstigt längeres Leben; Frauen mit Ovarektomie vor dem 55. Lebensjahr haben eine 8,38% höhere Sterblichkeit um die 80 - vor dem 59. Lebensjahr eine 3,92% höhere Sterblichkeit.
Es gibt einen weiteren Nutzen, allerdings abnehmend bis zum ALter von 75 Jahren, wo die Sterblichkeit wegen Ovarektomie weniger als 1% beträgt. Diese Resultate blieben unverändert auf Grund von zahlreichen genauen, sorgfältigen Analysen vor allem bezüglich des Risikos von Herz-Kreislauferkrankungen. Schlussfolgerung: Der Erhalt der Ovarien vor dem 65. Lebensjahr begünstigt langes Leben und wirkt sich positiv auf ältere Frauen aus.
Results : Ovarian conservation benefits long-term survival for women before age 65; women with oophorectomy before age 55 have 8.38% excess mortality by age 80 and before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease.
Conclusion : Ovarian conservation before age 65 benefits long-term survival and may have some benefit for older women.
http://www.ovaryresearch.com/study.htm
Practice changer
Ovary-sparing hysterectomy:
Is it right for your patient?
It may be, if her surgery is not cancer-related.
FAST TRACK
Tell patients undergoing hysterectomy for benign reasons that women are nearly 30 times more likely to die of cardiovascular disease than ovarian cancer.
480_JFP0909 480 8/17/09 11:35:40 AM
Sarah-Anne Schumann, MD
Department of Family Medicine,
The University of Chicago
P U R L s E D I T O R
John Hickner, MD, MSc
Department of Family Medicine,
Cleveland Clinic
PURLs methodology
This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and fi ndings leading to the selection of this study as a PURL can be accessed at
www.jfponline.com/purls.
478_JFP0909 478 8/18/09 12:12:23 PM
www.jfponline.comVOL 58, NO 9 / SEPTEMBER 2009 479
PURLs® Priority Updates from the Research
Literature from the Family Physicians
Inquiries Network
478 VOL 58, NO 9 / SEPTEMBER 2009 THE JOURNAL OF FAMILY PRACTICE
ILLUSTRATIVE CASE
A 44-year-old woman with a family history of early CHD is considering hysterectomy for painful uterine fi broids. She’s thinking about undergoing concurrent bilateral oophorectomy to prevent ovarian cancer and asks for your input. How would you advise her? Hysterectomy is the most common gynecologic surgery in the United States. In 2003, more han 600,000 hysterectomies were performed; 89% were not associated with malignancies.2
❚ Ovarian conservation is not the norm
Data from the University Health-
System Consortium Clinical Database
indicate that between 2002 and
2008, about 55% of women who had
a hysterectomy that was not cancerrelated
underwent oophorectomy. Rates
of concurrent oophorectomy included:
• 68% of women ages 65 and older
• 77% of women ages 51 to 64
• 48% of women ages 31 to 50
• 3% of women ages 18 to 30.
A recent analysis from the Centers for Disease Control and Prevention found that among women who underwent hysterectomy for any reason between 1994 and 1998, 55% also had their ovaries removed.3
❚ Hormones and CHD:
An unanswered question
Over the last several decades, there has been a great deal of interest in the relationship between hormones and CHD, much
of it stemming from the controversy about hormone replacement therapy (HRT).
The fi ndings of the Women’s Health Initiative implicated combined exogenous hormones (estrogen and progestin) as a
risk factor for CHD.4 Endogenous hormone production, however, may protect against CHD; some studies have demon- Advise patients undergoing hysterectomy for benign conditions that there are benefi ts to conserving their ovaries. The risk of coronary
heart disease (CHD) and death is lower in women whose ovaries are conserved, compared with those who have had them removed.1
Strength of recommendation:
B: A large, high-quality observational study.
Parker WH, Broder MS, Chang E, et al. Ovarian
conservation at the time of hysterectomy and
long-term health outcomes in the Nurses’ Health
Study. Obstet Gynecol. 2009;113:1027-1037.
Practice changer
Ovary-sparing hysterectomy:
Is it right for your patient?
It may be, if her surgery is not cancer-related.
Umang Sharma, MD, and
Sarah-Anne Schumann, MD
Department of Family Medicine,
The University of Chicago
P U R L s E D I T O R
John Hickner, MD, MSc
Department of Family Medicine,
Cleveland Clinic
PURLs methodology
This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and fi ndings leading to the selection of this study as a PURL can be accessed at
www.jfponline.com/purls.
478_JFP0909 478 8/18/09 12:12:23 PM
www.jfponline.com VOL 58, NO 9 / SEPTEMBER 2009 479
strated a decreased risk of cardiovascular
death with later age of menopause.5,6
Current oophorectomy recommendations are age-specifi c. The American College of Obstetricians and Gynecologists
(ACOG) recommends that strong consideration be given to ovarian conservation in premenopausal women who are not
at risk for ovarian cancer. For postmenopausal women, however, ACOG recommends consideration of oophorectomy as prophylaxis.7 These recommendations are based on expert opinion. Previous studies suggest that ovarian conservation
may improve survival in specifi c age groups.8,9 The large, high-quality observational study reviewed here provides
further guidance about the role of ovarian
conservation across all age groups.
STUDY SUMMARY
❚ Oophorectomy increases
risk of CHD and death
This observational study1 was part of the Nurses’ Health Study. It included 29,380 women, of which 16,345 (55.6%) underwent
hysterectomy with bilateral oophorectomy and 13,035 (44.4%) had hysterectomy with ovarian conservation.
Women with unilateral oophorectomy were excluded, as were those who had a history of CHD or stroke, and women for
whom pertinent data, such as age, were missing. A follow-up survey was sent to participants every 2 years for 24 years,
with an average return rate of 90%. Women who had undergone bilateral oophorectomy had an increased risk of CHD and all-cause mortality (TABLE). The authors estimated that with a postsurgical life span of approximately 35 years, every 9 oophorectomies would result in 1 additional death. The authors also pointed out there were no age exceptions: Ovariansparing
surgery was linked to improved survival in every age group.
Oophorectomy did have a protective effect against breast cancer, ovarian cancer (number needed to treat=220), and total cancer incidence, but it was associated with an increased incidence of lung cancer (number needed to harm=190) and total cancer mortality. There was no signifi cant difference in rates of stroke, pulmonary embolus, colorectal cancer, or hip fracture.
WHAT’S NEW
❚ Ovarian conservation:
Better for all ages
The evidence is clear: Conserving the ovaries, rather than removing them, during hysterectomy is associated with a lower
risk of CHD and both all-cause and cancer-related mortality.
What about the patient’s age? A 2005 analysis suggested that ovarian conservation conferred a survival benefi t compared to oophorectomy in women <65 years.8 Similarly, a 2006 cohort study found increased mortality in women <45 years who underwent concurrent oophorectomy. 9 But this is the fi rst study to demonstrate that ovarian-sparing surgery is associated with improved survival in women of every age group.
CAVEATS
❚ Study sample and HRT
use could affect outcome
The average age of patients in the treatment (oophorectomy) arm was higher than that of patients in the control group;
the women in the treatment group were older at the time of hysterectomy (46.8 vs 43.3 years), as well. This should not bias
the results, which were adjusted by age
Oophorectomy (vs ovarian conservation)
increases key risks1
RISK FACTOR MULTIVARIATE-ADJUSTED HR (95% CI)
CHD (fatal and nonfatal) 1.17 (1.02-1.35)
Breast cancer 0.75 (0.68-0.84)
Lung cancer 1.26 (1.02-1.56)
Ovarian cancer 0.04 (0.01-0.09)
Total cancer 0.90 (0.84-0.96)
Total cancer mortality 1.17 (1.04-1.32)
All-cause mortality 1.12 (1.03-1.21)
CHD, coronary heart disease; CI, confi dence interval; HR, hazard ratio.
TABLE
Do you advise
women undergoing
hysterectomy
for benign
conditions to:
❑ Undergo concurrent
oophorectomy
❑ Opt for ovarian
conservation
❑ Opt for one or the
other, depending on
whether they are preor
postmenopausal
❑ Follow the
recommendation of
their gynecologist
❑ Other
Go to www.jfponline.com
and take our Instant Poll
PURLs®
INSTANT POLL
479_JFP0909 479 8/17/09 11:35:36 AM
PURLs®
480 VOL 58, NO 9 / SEPTEMBER 2009 THE JOURNAL OF FAMILY PRACTICE
and many other variables.
Nonrepresentative sample. This group of nurses is not representative of the general population in several important aspects, including socioeconomic status, educational level, and race (94% Caucasian).
This may limit the generalizability of the fi ndings. Study design. The observational designand the fact that the patients themselves
decided whether or not to undergo oophorectomy also raise the possibility of unmeasured confounding factors.
Cancer risk. Women with known BRCA mutations were not studied separately,
but the results were adjusted for family history of breast or ovarian cancer. The authors stated that a subgroup analysis of women with a family history of ovarian cancer had similar outcomes, although the data were not included HRT use. As might be expected, patients in the oophorectomy arm of the study were more likely to use HRT. Since the completion of the study in 2000,
practice recommendations have shifted against combined HRT use. Unopposed estrogen, which is not thought to increase
the incidence of cardiovascular disease, remains a treatment option for women who have undergone hysterectomy
and oophorectomy. But the overall effect of unopposed estrogen on survival is still uncertain.4 It is unclear how the recent decline in the use of exogenous hormones would affect these results.
BARRIERS TO IMPLEMENTATION
❚ FP-GYN communication
can be diffi cult
This study provides important information for primary care physicians to discuss with female patients and their gynecologists.
However, some doctors may not have relationships with the gynecologists in their community, or have limited (or
no) infl uence or input into which specialists their patients see. In addition, some gynecologists may hesitate to perform
hysterectomy without oophorectomy in some cases for technical reasons.10 Concern about prevention of ovarian
cancer must be balanced with increased risk of mortality and CHD events. It may be helpful to tell patients who are about
to undergo hysterectomy for a benign condition that women are nearly 30 times more likely to die of cardiovascular disease
(CHD or stroke) than ovarian cancer
(413,800/year vs 14,700/year).11 ■
Acknowledgement
The PURLs Surveillance System is supported in part by
Grant Number UL1RR024999 from the National Center
for Research Resources, a Clinical Translational Science
Award to the University of Chicago. The content
is solely the responsibility of the authors and does not
necessarily represent the offi cial views of the National
Center for Research Resources or the National Institutes
of Health.
The authors wish to acknowledge Sofi a Medvedev,
PhD, of the University HealthSystem Consortium in Oak
Brook, Ill, for analysis of the National Ambulatory Medical
Care Survey data and the UHC Clinical Database.
References
1. Parker WH, Broder MS, Chang E, et al. Ovarian
conservation at the time of hysterectomy and longterm
health outcomes in the Nurses’ Health Study.
Obstet Gynecol. 2009;113:1027-1037.
2. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy
rates in the United States, 2003. Obstet Gynecol.
2007;110:1091.
3. Agency for Healthcare Research and Quality.
Healthcare Cost and Utilization Project (HCUP),
1988-2001: a federal-state industry partnership in
health data. July 2003. Available at http://www.
cdc.gov/mmwr/preview/mmwrhtml/ss5105al.htm.
Accessed June 8, 2009.
4. Anderson GL, Limacher M, Assaf AF, et al. Effect
of conjugated equine estrogen in postmenopausal
women with hysterectomy: the Women’s Health
Initiative randomized controlled trial. JAMA. 2004;
291:1701.
5. Ossewaarde ME, Bots ML, Verbeek AL, et al. Age
at menopause, cause-specifi c mortality and total
life expectancy. Epidemiology. 2005;16:556-562.
6. Atsma F, Bartelink M, Grobbee D, et al. Postmenopausal
status and early menopause as independent
risk factors for cardiovascular disease: a
meta-analysis. Menopause. 2006;13:265-279.
7. American College of Obstetricians and Gynecologists.
Elective and risk-reducing salpingo-oophorectomy.
ACOG Practice Bulletin No 89. Washington,
DC: ACOG; 2008.
8. Parker WH, Broder MS, Liu Z, et al. Ovarian conservation
at the time of hysterectomy for benign
disease. Obstet Gynecol. 2005;106:219-226.
9. Rocca W, Grossardt B, de Andrade M, et al. Survival
patterns after oophorectomy in premenopausal
women: a population-based cohort study. Lancet
Oncol. 2006;7:821-828.
10. Priver D. Oophorectomy in young women may not
be so harmful. OBG Management. 2009;21(8):11.
11. Kung H, Hoyert D, Xu J, et al. Deaths: fi nal data for
2005. Natl Vital Stat Rep. 2008;56:1-120.
FAST TRACK
Tell patients undergoing hysterectomy for benign reasons that women are nearly 30 times more likely to die of cardiovascular disease than ovarian cancer.
480_JFP0909 480 8/17/09 11:35:40 AM
http://www.jfponline.com/pdf%2F5809%2F5809JFP_PURL.pdf
Wie wichtig Gebärmutter und Ovarien sind, ist bereits im Internetlexikon Wikipedia nachzulesen. Ebenso wie folgenschwer sich eine Kastration auf den weiblichen Körper auswirkt!
Übersetzt folgt demnächst!
A hysterectomy is the surgical removal of the uterus, usually done by a gynecologist. Hysterectomy may be total (removing the body and cervix of the uterus) or partial (also called supra-cervical). In many cases, surgical removal of the ovaries (oophorectomy) is performed concurrent with a hysterectomy. The surgery is then called "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO). However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system. According to the National Center For Health Statistics there were 617,000 hysterectomies performed in 2004 with the surgical removal of the ovaries (oophorectomy) performed in 73% of women undergoing hysterectomy. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60 [1]. Removal of the female gonads, the ovaries is female castration, the biological equivalent to the removal of the testes in male castration. There are 22 million women alive in the United States whose female organs have been surgically removed.
Women who have total abdominal hysterectomy with bilateral salpingo-oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). The term "surgical menopause" is misleading, conflating a natural process of aging with the side effects of a medical procedure. A menopausal woman has intact functional female organs, a woman who has been hysterectomized and castrated does not. The uterus is a hormone responsive sex organ that supports the bladder and bowel. When only the uterus is removed women are at three times greater risk of cardiovasular disease--removal of the uterus often interferes with blood flow to the ovaries, so women who undergo hysterectomy reach menopause an average of 3.7 years sooner than the average age of natural menopause. When the ovaries are removed a woman is at a seven times great risk of cardiovascular disease. [2][3][4] [5]The hormones produced by the ovaries cannot be truly replaced. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, and released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.
In women under the age of 50 who have undergone castration, hormone supplements (usually estrogen) are often prescribed as part of hormone replacement therapy (HRT) to offset the negative effects of sudden hormonal loss (most notably an increased risk for early-onset osteoporosis) as well as menopausal problems like hot flashes that are usually more severe than those experienced by women undergoing natural menopause. Cardiovascular problems are also associated with early surgical menopause, but the exact causation is unknown. Hormone replacement treatment is somewhat controversial due to the known carcinogenic and coagulative properties of estrogen; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality of life issues as a consequence of early surgical menopause. The ovarian hormones of estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions.