Consultant Minimal Access Gynaecologist

(with special interest in Endometriosis and Keyhole Surgery)

 

 
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Why must women preserve their ovaries?

A hysterectomy (removal of the uterus) and bilateral oophorectomy (the removal of both ovaries) are the mainstays of therapy for the management of endometriosis following the failure of medical treatment. The ovaries are removed with the view to remove oestrogen milieu (produced by the ovaries). This is done due to the fact that the oestrogen helps endometriosis grow. However, when a hysterectomy and oophorectomy are undertaken, the endometriosis itself is not removed.

If the endometriosis itself is completely removed, there is no need for the ovaries to be removed.

Post menopausal ovaries until the age of 80 years produce up to 50% of male hormones (testosterone and androstenedione) which are converted in body fat, muscles and skin into the female hormone Oestrogen. Both male and female hormones are important for the body in terms of long term survival and the quality of life of women.

The life expectancy of women is now 78 years and so long term health issues are important.

The removal of the both ovaries may not relieve all the symptoms of endometriosis (Ref: Clayton 1999; Metzger DA et al 1991; Redwine DB 1994; O’Connor DT 1987). Moreover, the removal of both ovaries has adverse effects on the body which are listed below.

  • Parker et al (Am J  Obstet and Gynaecol 2005) used a Markov decision analysis model to conclude that ovarian conservation until age 65 benefits long term survival for women. Women with oophorectomy (removal of ovaries) before age 55 have 8.58% excess mortality (risk of death) by the age 80.

  • Loss of hormones due to removal of both ovaries (surgical menopausal) results in menopausal symptoms which are abrupt and dramatic (hot flushes, night sweats ,lack of sleep, vaginal dryness resulting in painful sex, depressed mood, lethargy/irritability, impaired body self image).

  • Male hormones (androgens) are critical for the maintenance of optimal levels of sexual functioning in postmenopausal women. The loss of the ovaries results in decreased sexual drive, decreased general sense of well being, adverse changes in libido (desire for sex) and orgasmic response. (Barbara B, et al. 1987. Psychosomatic Medicine), (Sands R. 1995. Am J Med)

  • Loss of hormone Androgen (increases bone formation) and Oestrogen (inhibits bone resorption) due to removal of both ovaries (Surgical menopausal) results in increased risk of bone fracture resulting in increased morbidity and mortality. (Davidson B J. 1982. J Clin Endocrinol Metab) (Cummings SR. 1998. NEJM, (Melton LJ. 2003. J Bone Miner Res ),(Graham S Keens,et al. 1993. BMJ)

  • Loss of hormones due to removal of both ovaries (surgical menopausal) increases the risk of cardiovascular (heart) disease, the major cause for death for women. (Wuest JH, 1953. Circulation), (Colditz GA,et al. 1987. NEJM), ( (GA Colditz,et al. 1987. NEJM), ( Stoney CM. 1997. Health Psychol), , (Hasia J,et al. WHI. 2003.Am J Cardiol) Kalantaridou SN, et al. 2004. Clin Endocrinol Metab)

  • Both unilateral and bilateral oophorectomy preceding the onset of menopause are associated with an increased risk of cognitive impairment or dementia. (Rocca et al. 2007, Neurology & Rocca et al. 2008, Neurodegenerative Diseases)

  • Both unilateral and bilateral oophorectomy performed prior to menopause may be associated with an increased risk of Parkinson's Disease and the effect may be age-dependent. (Rocca et al. 2008, Neurology)

  • Women have to go on to long term HRT (Hormone Replacement Treatment) if both ovaries are removed (Surgical menopausal) especially at a young age. Long term use of HRT increases risk of breast cancer, deep vein thrombosis (DVT - clots in the legs) resulting in pulmonary embolism (clots migrating to the lungs), strokes and coronary heart disease. In addition there are issues of cost and patient compliance. (WHI (Women Health Initiative), HERS study (Heart & Estrogen / Progesterone replacement study), A Million women study)

  • There are increased risks of recurrence of endometriosis with prolonged use of HRT. The recurrent disease may be more severe than the original disease with a greater chance that the ureters (tubes carrying urine to the bladder from the kidney) will be affected. In those patients where ureter has been affected, as many as 25% sustain irreversible kidney damage due to delay in diagnosis. (Moore JG. 1979, Am J Obstet Gynecol), (Lam AM. 1992, Aust NZ Obstet Gynaecol), ( Matorras R. 2002, Fertil Steril),

  • There have been more than 30 cases reported in literature where patients developed cancer in the residual endometriosis after prolonged unopposed Oestrogen (HRT). (Soliman NF et al. 2006. Climacteric)

In view of the above adverse effects of loosing both ovaries, the ovaries must be preserved. Mr Trehan practices and believes the both ovaries should not be removed (bilateral oophorectomy) especially in woman who are under 50 years of age. The ovaries can almost always be saved with excision operation for endometriosis (peeling off endometriosis) which Mr Trehan undertakes.

 

 

  
      ©Mr A K Trehan