Abstract
Oophorectomy, the surgical removal of one or both ovaries, is a common gynecological procedure performed for a variety of indications, ranging from benign conditions such as ovarian cysts and endometriosis to malignancy prevention and treatment. While often necessary and life-saving, oophorectomy, particularly when performed bilaterally and before natural menopause, can have significant and far-reaching consequences for women’s health. This research report provides a comprehensive review of oophorectomy, encompassing its different surgical approaches (laparoscopic, robotic, open), specific indications, and the complex interplay of long-term health outcomes, including but not limited to cardiovascular disease, cognitive decline (with a focus on Alzheimer’s disease risk), bone health, and sexual function. Furthermore, we examine the current guidelines and recommendations for hormone therapy (HT) and other management strategies aimed at mitigating the adverse effects of estrogen deficiency following oophorectomy. This report will highlight the complexities of this issue and offer suggestions to guide surgical decision-making, improve postoperative management, and foster personalized care for women undergoing oophorectomy.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
1. Introduction
Oophorectomy, derived from the Greek words oophoron (ovary) and ektome (excision), is a surgical procedure involving the removal of one (unilateral oophorectomy) or both (bilateral oophorectomy) ovaries. Historically, oophorectomy has been employed for a wide spectrum of gynecological conditions, reflecting the crucial role of the ovaries in female reproductive health, hormone production, and overall well-being. The incidence of oophorectomy varies considerably based on factors such as age, geographic location, and access to healthcare, but remains a commonly performed surgery, particularly in women undergoing hysterectomy for benign indications. Given the profound physiological consequences of ovarian hormone deprivation, understanding the indications, techniques, and long-term health effects of oophorectomy is paramount for clinicians and patients alike.
The indications for oophorectomy are diverse and can be broadly classified into benign and malignant conditions. Benign indications include ovarian cysts (both functional and neoplastic), endometriosis (particularly when affecting the ovaries), pelvic inflammatory disease (PID) leading to tubo-ovarian abscesses, and symptomatic relief from chronic pelvic pain when other conservative treatments have failed. Oophorectomy may also be performed prophylactically in women at high risk of developing ovarian cancer due to genetic predispositions such as mutations in the BRCA1 and BRCA2 genes. In the context of malignant disease, oophorectomy is a critical component of the surgical management of ovarian cancer, fallopian tube cancer, and certain types of endometrial cancer.
While oophorectomy can effectively address the underlying gynecological condition, the resultant loss of ovarian hormone production, especially in premenopausal women, can trigger a cascade of physiological changes. Estrogen, the primary hormone produced by the ovaries, plays a vital role in numerous bodily functions, including regulating the menstrual cycle, maintaining bone density, promoting cardiovascular health, and influencing cognitive function. The abrupt cessation of estrogen production following bilateral oophorectomy can lead to premature menopause, accompanied by symptoms such as hot flashes, vaginal dryness, sleep disturbances, mood changes, and decreased libido. Furthermore, long-term estrogen deficiency has been linked to an increased risk of osteoporosis, cardiovascular disease, and cognitive decline, including an elevated risk of Alzheimer’s disease. These adverse effects underscore the importance of carefully weighing the benefits and risks of oophorectomy, particularly in younger women, and exploring alternative treatments whenever feasible.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
2. Surgical Techniques and Approaches
The surgical approach to oophorectomy has evolved significantly over the past several decades, with minimally invasive techniques becoming increasingly prevalent. The choice of surgical technique depends on various factors, including the indication for surgery, the size and complexity of the ovarian pathology, the patient’s overall health, and the surgeon’s experience.
2.1. Laparoscopic Oophorectomy
Laparoscopic oophorectomy is a minimally invasive procedure performed through small incisions in the abdomen. A laparoscope, a thin, telescope-like instrument with a camera, is inserted through one incision to visualize the pelvic organs. Surgical instruments are inserted through other incisions to detach the ovary from its surrounding ligaments and blood vessels. The ovary is then removed through one of the incisions, often after being placed in a retrieval bag. Laparoscopic oophorectomy offers several advantages over open surgery, including smaller incisions, reduced postoperative pain, shorter hospital stays, and faster recovery times. However, laparoscopic surgery may not be suitable for all patients, particularly those with large ovarian masses, extensive adhesions, or a history of multiple abdominal surgeries.
2.2. Robotic-Assisted Laparoscopic Oophorectomy
Robotic-assisted laparoscopic oophorectomy is a variation of laparoscopic surgery that utilizes a robotic surgical system. The surgeon controls the robotic arms from a console, providing enhanced precision, dexterity, and visualization compared to conventional laparoscopy. The robotic system allows for more complex surgical maneuvers and may be particularly beneficial in cases involving significant adhesions or difficult-to-reach anatomical locations. While robotic surgery offers potential advantages, it is often more expensive than conventional laparoscopy and requires specialized training for surgeons.
2.3. Open Oophorectomy
Open oophorectomy involves a larger abdominal incision to access the pelvic organs. This approach is typically reserved for cases where laparoscopic or robotic surgery is not feasible or appropriate, such as in the presence of large ovarian tumors, suspected malignancy with need for extensive staging, or significant adhesions that obscure the surgical field. Open surgery is associated with greater postoperative pain, longer hospital stays, and a higher risk of complications compared to minimally invasive techniques.
2.4. Salpingo-oophorectomy vs. Oophorectomy
Salpingo-oophorectomy involves the removal of both the ovary and the fallopian tube. This procedure has become increasingly common in recent years, particularly for prophylactic removal in women at high risk of ovarian cancer. Emerging evidence suggests that many high-grade serous ovarian cancers, the most common and deadly type of ovarian cancer, originate in the fallopian tube. Therefore, removing the fallopian tubes along with the ovaries may provide additional protection against ovarian cancer development. In some cases, salpingectomy (removal of the fallopian tubes) alone may be considered as an alternative to salpingo-oophorectomy, particularly in premenopausal women who are not at significantly elevated risk of ovarian cancer. This approach preserves ovarian function while potentially reducing the risk of future ovarian cancer.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
3. Indications for Oophorectomy: A Detailed Examination
The clinical indications for oophorectomy are varied and often depend on a complex interplay of factors, including the patient’s age, reproductive status, medical history, and the specific characteristics of the underlying gynecological condition.
3.1. Benign Ovarian Cysts
Ovarian cysts are fluid-filled sacs that can develop on or within the ovaries. Most ovarian cysts are benign and resolve spontaneously. However, some cysts can cause symptoms such as pelvic pain, bloating, or irregular bleeding. Oophorectomy may be considered for persistent or symptomatic benign ovarian cysts, particularly if they are large, complex, or suspected of being neoplastic. However, in most cases, observation or cystectomy (surgical removal of the cyst while preserving the ovary) is preferred, especially in premenopausal women.
3.2. Endometriosis
Endometriosis is a condition in which tissue similar to the lining of the uterus (endometrium) grows outside of the uterus, often affecting the ovaries, fallopian tubes, and other pelvic organs. Endometriosis can cause chronic pelvic pain, dysmenorrhea (painful periods), and infertility. Oophorectomy may be considered as a treatment option for severe endometriosis, particularly when the ovaries are significantly affected and other medical or surgical treatments have failed. However, oophorectomy for endometriosis is a controversial topic, as it can lead to premature menopause and associated health risks. A more conservative approach, such as excision of endometriotic lesions with preservation of the ovaries, is generally preferred, especially in women who desire future fertility. Furthermore, postoperative hormone therapy may be necessary to control residual endometriosis and prevent recurrence. GnRH agonists and aromatase inhibitors are examples of such therapies.
3.3. Pelvic Inflammatory Disease (PID)
PID is an infection of the female reproductive organs, often caused by sexually transmitted infections. PID can lead to tubo-ovarian abscesses (TOAs), which are collections of pus and infected tissue involving the fallopian tubes and ovaries. In cases of large or unresponsive TOAs, oophorectomy (often with salpingectomy) may be necessary to remove the infected tissue and prevent further spread of infection.
3.4. Prophylactic Oophorectomy
Prophylactic oophorectomy, also known as risk-reducing salpingo-oophorectomy (RRSO), is the surgical removal of the ovaries and fallopian tubes in women at high risk of developing ovarian cancer. This procedure is most commonly performed in women with mutations in the BRCA1 and BRCA2 genes, which significantly increase the risk of breast and ovarian cancer. RRSO can reduce the risk of ovarian cancer by up to 90% in these women. The optimal timing for RRSO is a complex decision that should be made in consultation with a genetic counselor and a gynecologic oncologist, taking into account the patient’s age, reproductive plans, and overall health. While RRSO provides significant protection against ovarian cancer, it also leads to premature menopause and associated health risks. Hormone therapy may be considered to mitigate these risks, but the decision to use HT in women with BRCA mutations is complex and requires careful consideration of the potential benefits and risks of breast cancer development. Aromatase inhibitors may be used in such cases where HT is contraindicated.
3.5. Ovarian Cancer
Oophorectomy is a critical component of the surgical management of ovarian cancer. Surgical staging and cytoreduction (removal of as much tumor as possible) are essential for improving survival outcomes in women with ovarian cancer. In most cases, this involves bilateral salpingo-oophorectomy, hysterectomy, omentectomy (removal of the omentum, a fatty tissue in the abdomen), and lymph node dissection. The extent of surgery depends on the stage of the cancer and the patient’s overall health. Following surgery, most women with ovarian cancer receive chemotherapy.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
4. Long-Term Health Consequences of Oophorectomy
The long-term health consequences of oophorectomy, particularly when performed bilaterally and before natural menopause, are substantial and encompass a wide range of physiological systems.
4.1. Cardiovascular Health
Estrogen plays a protective role in cardiovascular health, influencing lipid profiles, blood vessel function, and inflammation. The loss of estrogen production following oophorectomy can increase the risk of cardiovascular disease, including coronary artery disease, stroke, and heart failure. Studies have shown that women who undergo bilateral oophorectomy before age 50 have a significantly higher risk of cardiovascular events compared to women who retain their ovaries. Hormone therapy can help mitigate this risk, but the optimal timing and duration of HT for cardiovascular protection remain a topic of ongoing research.
4.2. Bone Health
Estrogen is crucial for maintaining bone density and preventing osteoporosis. Estrogen deficiency following oophorectomy can lead to accelerated bone loss and an increased risk of fractures. Women who undergo bilateral oophorectomy before menopause are at significantly higher risk of developing osteoporosis and fragility fractures later in life. Regular bone density screening and calcium and vitamin D supplementation are important for maintaining bone health after oophorectomy. Hormone therapy can also help prevent bone loss and reduce the risk of fractures.
4.3. Cognitive Function and Alzheimer’s Disease
Estrogen has neuroprotective effects and plays a role in cognitive function and memory. Emerging evidence suggests that oophorectomy, particularly when performed before menopause, may increase the risk of cognitive decline and dementia, including Alzheimer’s disease. The exact mechanisms underlying this association are not fully understood, but may involve the loss of estrogen’s neurotrophic and anti-inflammatory effects. Several studies have reported an increased risk of Alzheimer’s disease in women who undergo bilateral oophorectomy before age 45 or 50. Hormone therapy may have a protective effect on cognitive function if initiated soon after oophorectomy, but the long-term effects of HT on cognitive function are still being investigated. The timing hypothesis suggests that HT is most beneficial for cognitive health when initiated close to the time of menopause (or oophorectomy), and may be less effective or even harmful if started many years later.
4.4. Sexual Function
Estrogen plays a crucial role in sexual function, influencing vaginal lubrication, libido, and orgasmic function. Estrogen deficiency following oophorectomy can lead to vaginal dryness, dyspareunia (painful intercourse), decreased libido, and difficulty achieving orgasm. These symptoms can significantly impact a woman’s quality of life and intimate relationships. Vaginal estrogen therapy, systemic hormone therapy, and other treatments such as lubricants and moisturizers can help alleviate these symptoms and improve sexual function. Additionally, addressing psychological factors such as body image and relationship issues is important for managing sexual dysfunction after oophorectomy.
4.5. Mood and Psychological Well-being
The hormonal changes following oophorectomy can significantly impact a woman’s mood and psychological well-being. Estrogen deficiency can contribute to symptoms such as depression, anxiety, irritability, and sleep disturbances. These symptoms can be particularly pronounced in women who undergo oophorectomy before menopause. Cognitive behavioral therapy (CBT), mindfulness-based interventions, and antidepressant medications may be helpful in managing mood and psychological symptoms after oophorectomy. Additionally, providing women with comprehensive information and support before and after surgery can help them cope with the emotional and psychological challenges associated with oophorectomy.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
5. Current Guidelines and Recommendations for Management After Oophorectomy
The management of women after oophorectomy should be individualized and based on their age, reproductive status, medical history, and specific symptoms. The goal of management is to alleviate symptoms, prevent long-term health consequences, and improve quality of life.
5.1. Hormone Therapy (HT)
Hormone therapy (HT) is the most effective treatment for alleviating menopausal symptoms such as hot flashes, vaginal dryness, and sleep disturbances. HT can also help prevent bone loss, reduce the risk of cardiovascular disease, and potentially protect against cognitive decline. The decision to use HT after oophorectomy should be made in consultation with a healthcare provider, taking into account the patient’s individual risks and benefits. Current guidelines generally recommend HT for women who undergo oophorectomy before menopause, unless there are contraindications such as a history of breast cancer, stroke, or blood clots. The lowest effective dose of HT should be used for the shortest duration necessary to control symptoms. The type of HT (estrogen alone or estrogen plus progestogen) depends on whether the woman has a uterus. Women who have a uterus need to take progestogen along with estrogen to protect the uterine lining from developing cancer. The WHI (Women’s Health Initiative) study showed increased risks associated with combined estrogen and progestin therapy, but these risks are generally lower with estrogen-only therapy and with lower doses of HT. The North American Menopause Society (NAMS) and other organizations provide comprehensive guidelines on the use of HT for menopausal symptoms and prevention of chronic diseases.
5.2. Non-Hormonal Therapies
Non-hormonal therapies can also be used to manage menopausal symptoms after oophorectomy. These therapies include lifestyle modifications such as regular exercise, a healthy diet, and stress reduction techniques. Certain medications, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), can help reduce hot flashes and improve mood. Vaginal moisturizers and lubricants can alleviate vaginal dryness and improve sexual function. Bisphosphonates and other medications can be used to prevent bone loss and reduce the risk of fractures.
5.3. Surveillance and Screening
Women who undergo oophorectomy should receive regular medical checkups and appropriate screening tests. Bone density screening is recommended to assess bone health and monitor for osteoporosis. Cardiovascular risk assessment and management are important for preventing heart disease. Cognitive screening may be considered for women who are at increased risk of cognitive decline. Pelvic exams and Pap smears are generally not necessary after bilateral oophorectomy, unless there is a history of cervical cancer or other gynecological conditions.
5.4. Lifestyle Modifications
Lifestyle modifications play a crucial role in maintaining health and well-being after oophorectomy. Regular exercise, a healthy diet, maintaining a healthy weight, and avoiding smoking are all important for preventing chronic diseases and improving quality of life. Calcium and vitamin D supplementation are essential for maintaining bone health. Stress reduction techniques, such as yoga, meditation, and deep breathing exercises, can help manage mood and psychological symptoms. Engaging in social activities and maintaining strong social connections can also improve emotional well-being.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
6. Future Directions and Research Needs
Despite significant advancements in our understanding of oophorectomy and its long-term health consequences, several important questions remain unanswered and warrant further investigation. Future research should focus on the following areas:
- Optimizing the timing and type of hormone therapy after oophorectomy: Further research is needed to determine the optimal timing, dose, and duration of hormone therapy for preventing long-term health consequences such as cardiovascular disease, cognitive decline, and osteoporosis. Studies are needed to compare different types of HT (estrogen alone vs. estrogen plus progestogen) and different routes of administration (oral, transdermal, vaginal).
- Identifying biomarkers for predicting cognitive decline after oophorectomy: Identifying biomarkers that can predict which women are at highest risk of cognitive decline after oophorectomy would allow for targeted interventions and personalized management strategies.
- Evaluating the long-term effects of salpingectomy alone versus salpingo-oophorectomy: Further research is needed to compare the long-term health outcomes of salpingectomy alone versus salpingo-oophorectomy in women at different risk levels for ovarian cancer. This will help clinicians make informed decisions about the optimal surgical approach for preventing ovarian cancer while minimizing the risks of premature menopause.
- Developing novel non-hormonal therapies for managing menopausal symptoms: Developing effective non-hormonal therapies for managing menopausal symptoms is important for women who cannot or choose not to use hormone therapy.
- Improving patient education and decision-making: Providing women with comprehensive information about the risks and benefits of oophorectomy, as well as the available management options, is crucial for empowering them to make informed decisions about their health.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
7. Conclusion
Oophorectomy remains a frequently performed gynecological procedure with diverse indications. While often necessary and life-saving, particularly in the context of malignancy, bilateral oophorectomy before natural menopause can have significant and far-reaching consequences for women’s health. These consequences encompass cardiovascular disease, bone loss, cognitive decline, sexual dysfunction, and mood disturbances. A comprehensive understanding of these long-term health risks, coupled with individualized management strategies, is crucial for optimizing outcomes for women undergoing oophorectomy. Hormone therapy remains the most effective treatment for mitigating many of the adverse effects of estrogen deficiency, but the decision to use HT should be made on a case-by-case basis, considering the patient’s individual risk factors and preferences. Future research should focus on optimizing HT regimens, identifying biomarkers for predicting long-term health consequences, and developing novel non-hormonal therapies. By prioritizing personalized care, providing comprehensive education, and fostering ongoing research, we can strive to improve the health and well-being of women who undergo oophorectomy.
Many thanks to our sponsor Esdebe who helped us prepare this research report.
References
- American College of Obstetricians and Gynecologists (ACOG). (2020). Management of adnexal masses. ACOG Practice Bulletin No. 183. Obstetrics & Gynecology, 135(1), e1-e17.
- Anderson, G. L., Limacher, M., Assaf, A. R., Bassford, T., Beresford, S. A. A., Black, H., … Writing Group for the Women’s Health Initiative Investigators. (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA, 291(14), 1701–1712.
- Babayeva, S., Özdemir, E., & İtil, İ. M. (2020). Effects of oophorectomy on the body: What should be done? Turkish Journal of Obstetrics and Gynecology, 17(4), 268–279.
- Brinton, L. A., Brogan, D. D., Janowsky, E., et al. (2005). Oophorectomy and hysterectomy as risk factors for Alzheimer’s disease. Annals of Neurology, 58(3), 392-399.
- Cagnacci, A., & Venier, M. (2019). The controversial history of postmenopausal hormone therapy. Climacteric, 22(4), 327–334.
- Chao, C., Wu, T., Gill, J., et al. (2015). Association of risk-reducing salpingo-oophorectomy with mortality in women with BRCA1 or BRCA2 mutations. JAMA, 313(1), 29.
- Curiel, R. E., & Miller, C. E. (2020). Hormone therapy in women with a history of breast cancer: A comprehensive review. International Journal of Women’s Health, 12, 955–967.
- Jacoby, V. L., Grady, D., Wactawski-Wende, J., et al. (2011). Oophorectomy vs hysterectomy with ovarian conservation for the risk of coronary heart disease. Annals of Internal Medicine, 155(6), 321-329.
- Lobo, R. A. (2017). Hormone therapy: current thinking. Nature Reviews Endocrinology, 13(4), 220–231.
- Rocca, W. A., Grossardt, B. R., Miller, V. M., Shuster, L. T., Stewart, K. J., & Kantarci, K. (2014). Oophorectomy, menopause, estrogen, and cognitive function: the Mayo Clinic Study of Aging. Brain: A Journal of Neurology, 137(Pt 4), 1246–1258.
- Rossouw, J. E., Prentice, R. L., Manson, J. E., Wu, L., Barad, D., Barnabei, V. M., … Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333.
- The North American Menopause Society. (2022). 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause, 29(7), 767-794.
Be the first to comment