Prophylactic ophorectomy: primum non nocere

Abstract

In this invited lecture, I will provide an update on the prophylactic oophorectomy debate. Medical practices should follow the principle of “primun non nocere” (first do no harm), and bilateral oophorectomy performed electively at the time of hysterectomy for a benign indication is now under scrutiny and critical reappraisal because the long-term risks may outweigh the benefits in the majority of women. The ovaries are both reproductive and endocrine organs. They secrete hormones both before menopause (primarily estrogen, progesterone, and testosterone) and after (primarily testosterone, androstenedione, and dehydroepiandrosterone). Ovarian hormones have important reproductive actions; however, they also have important endocrine actions via receptors spread throughout most tissues and organs of the body (Rocca and Ulrich, 2012). Removal of the ovaries reduces the risk of ovarian (by 80–90%) and breast cancer (by 50–60%); however, it increases the risk of all-cause mortality (28%), lung cancer (45%), coronary heart disease (33%), stroke (62%), cognitive impairment (60%), parkinsonism (80%), psychiatric symptoms (50–130%), osteoporosis and bone fractures (50%), and impaired sexual function (40–110%). The magnitude of the risk may vary depending on the study referenced, the age at the time of oophorectomy, and the use of postoperative estrogen therapy. The scientific debate about the risks and benefits of prophylactic bilateral oophorectomy continues, and many women continue to undergo prophylactic oophorectomy in 2015 (Llaneza and Perez-Lopez, 2013; Harmanli et al., 2013; Harmanli, 2014). I suggest that the evidence is sufficient to change this practice. At the time of a hysterectomy for a benign condition, if the ovaries are normal and the woman is not carrying a high risk genetic mutation, the ovaries should be conserved. This conservative practice is particularly important in younger women (Rocca and Ulrich, 2012; Harmanli, 2014).