Wednesday, November 28, 2012

Ovarian Conservation, Ethics, and Informed Consent

by Dr. Margaret Aranda

“Ovarian Conservation” refers to the practice of keeping the ovaries at the time of surgical menopause, or hysterectomy for a benign cause.  Specifically, in this case, to ‘conserve’ the ovaries, one does not take the ovaries out at the same time as a hysterectomy for a noncancerous uterus or ovary.  Please bear in mind that removing the normal ovaries equates to castration of the female. While this may seem to be a severe word, it is nonetheless a word that would be equally applied if we were talking about surgically removing the testes out of a man. And I just want you to get a picture of what we are talking about here. It's not a simple thing. It's not an easy thing. It is removing the ovaries. I think that is a big deal.  That's my opinion and I'm sticking to it. 

So how many women in America are castrated?  Well, if 40% of American women over age 45 have had a hysterectomy, and 60% of those had the ovaries removed in an oophorectomy, that means that millions of women are castrated.  It is important to know what an oophorectomy means to you.

In general, whenever any surgical procedure is to be considered, a written Informed Consent must be obtained.  Competency, or decision-making capability, is implied, and is a legal term.  Informed Consent is based on the ethical premise that you, as a patient, have autonomy.  This means that in the end, it is your body and you have the innate right to decide what you want done (or not done) to it. 

I have noticed that if a patient agrees to do what the doctor wants, then all is well and everything proceeds normally.  But having autonomy means that sometimes, a patient will not make a ‘good’ decision according to the doctors, and will instead opt for an alternative, or a non-treatment.  It is usually when the patient does not want to do what the doctors advise, that the issue of Competency comes into play.  This is an ethical issue that has long been discussed.  But the law presumes that most patients will consent to procedures that will save life or personal disability.  In case you are not able, an Advanced Directive would spell out what you did and did not want to be done if injury or illness prevented you from making your own decisions.

Failure to provide Informed Consent before performing an operation is a legal term that is called battery.  It is a form of assault, so these matters are pretty serious.  In fact, battery is not usually within the scope of medical malpractice insurance liability, as it is considered to be a wrong against society.  Punitive damages may be sought.

In cases of Medical Emergencies or legal Incompetence, the right for the patient to have Informed Consent is waived, and the physician may proceed within the boundaries of legal and medical Standards of Care.

The components of the Surgical Informed Consent as a legal document can be divided into five components:

1. It must be “informed” in that you have the capacity and ability to make the decision;
2. Risks and Benefits must be discussed in general, and
3. The Likelihood of each Risk and Benefit must be described for you as an individual;
4. You must exhibit comprehension after issues are explained;
5. Your Consent must be voluntary, without coercion, duress, or negative pressure.

The Informed Consent document will have the following parameters:
1. The patient’s full and legal name;
2. The diagnosis or reason why the procedure is indicated
3. The name of the procedure in both (a) layman’s language and in (b) surgical language;
4. The purpose or benefits of the surgery;
5. The risks of the surgery, including the risks of not having the procedure;
6. An explanation of the alternatives to the surgery, together with the risks and benefits thereof;
8. The document should be signed, dated, and Witnessed by an impartial Witness.

Older surgeons may be more prone to remove the uterus together with the entirety of the Fallopian tubes, ovaries, and cervix.  Although the risk of ovarian cancer is less than 1% (perhaps it is 0.45%), up to 60% of hysterectomies remove the ovaries.  Some cite the lifetime risk of ovarian cancer as low as 0.25%, with normal ovaries (Natural 2012). 

The sequelae of surgical menopause must be considered for the woman to have adequate Informed Consent of risks and benefits. If you are having a hysterectomy and the surgeon is taking out the ovaries too, And you don't know what "surgical menopause" is, ask your doctor.

So what is a woman to do?  The American College of Obstetricians and Gynecologists “encourages women to educate themselves about their midlife health issues and to talk with their ob-gyn about their concerns”  (ACOG Website, 2012). On this note, women should be aware that laproscopy and ultrasound of the pelvic floor and uterus are available as diagnostic tools to help assess whether hysterectomy and/or oophorectomy (removal of ovaries) is indicated.  A second opinion is valuable and warranted when hysterectomy is considered. 

With a hysterectomy and oophorectomy, the ovaries are removed and abruptly, the woman is in Surgical Menopause.  She does not have the benefit of gradual hormone loss through years of menopause, like her older counterparts who do not have surgery.  The symptoms of surgical menopause can be more severe and more prolonged. 

With loss of the ovaries, a woman’s cholesterol increases, particularly the low-density liproproteins (LDL).  I like to think of the “L”DL’s as being “Lethal”, not just “bad”.  With an increase in LDL, the surgical menopausal state makes the woman at increased risk of a cardiovascular event like a heart attack.  Heart disease is already the number one killer of women in America, leading breast cancer as the most common cause of death. 

Additional symptoms of Surgical Menopause include depression, hair loss, and osteoporosis.  The subsequent loss of endogenous testosterone production may also result in decreased libido, loss of assertiveness, decreased appetite, diminished lean body mass, decreased muscle strength.  All of these factors may be associated with a significant decrease in Quality of Life.

To boot, I tried to find one scientific reference that proved that removal of normal ovaries at the time of hysterectomy decreases the rate of ovarian cancer, versus women who did not have their ovaries removed.  One can imagine that a statistical analysis can be done, projecting the sequelae if every woman over 40 who has a hysterectomy also gets her ovaries removed.  The theoretical study suggested that over 1000 cases of ovarian cancer/year could be prevented.  Let’s put that in comparison with another study, which was actually performed.

There was a study that compared women up to age 65 for hysterectomy, looking at those who kept their ovaries, and those who had them removed.  They found that in women under age 55 who removed their ovaries, there was an increased mortality of 8.6% by age 80 (Shapiro 2006).  Also, it is thought that because the uterus no longer “talks” to the ovaries after hysterectomy, leaving the ovaries in results in less ‘uterine stimulation’.  Thus, hysterectomy without ovary removal actually does decrease the incidence of ovarian cancer by up to 50%.   This concludes the matter in the respect of cardiovascular risk and ovarian cancer, because the ovaries can still produce small amounts of estrogen, progestin, and testosterone for up to 10 years past the onset of menopause. So even a small amount of hormone production appears to be beneficial to coronary artery disease, bone density, and sexual libido.  Up to age 65, leaving the ovaries in with a benign hysterectomy has been a general recommendation since 2005 (Parker 2005). So this thought of "ovarian conservation" is not new, but why is it that it seems so new?  Perhaps it is because we are increasing awareness, and ladies, that is a good thing.

Bear in mind that if you have a history of ovarian cancer in your family, these results do not matter.  It is recommended that you undergo oophorectomy, or removal of the ovaries.  Hands down, no one wants you to keep your ovaries.  Also, if you have had breast cancer or have a family history of breast cancer, getting your ovaries out will decrease your incidence of breast cancer recurrence.

In my studies of this issue, I gained perspective of the surrounding issues that once again, focus on this decision being individual and based on the family history, age, and particulars of each woman. 
The lifetime risk of ovarian cancer can be 1 in 70.  But here's one thing you may not know: Over age 40, the risk of ovarian cancer decreases to 1 in 100 women (Reichman 2006).  This is a significant decrease, so that Age is an important factor in determining lifetime risk. Put this in comparison with the studies that show that every 37 seconds in America, some one is dying from cardiac disease.  Women without ovaries who are not on hormone replacement therapy are at risk of dying from heart disease and this is not acceptable. 

So this is what I learned:

Family History
Risk Factors
Number of Childbirths
Increases Risk
Decreases Risk
Over 40


Hx of Ovarian Cancer


Several Relatives have Colon or Breast Cancer


You used fertility drugs for > 6 mo and they did not work


Never using birth control pills


Never having a full-term pregnancy




Diet high in animal and milk fat


2 or more


Breastfed your children


Positive Genetic Testing, BRCA Gene


Figure.  Risk of Ovarian Cancer for Women.  Ovulating over and over again, with eggs released over and over again…this is what is thought to increase the risk of ovarian cancer.  If you have used OCs for 2 years, you decrease your risk by 40%.  If you have used OCs for > 10 years, you decrease your risk by 80%.  BRCA gene mutations may place a woman at an increased 40% risk of ovarian cancer.  The risk of “hormonal shock” with ovary removal at the time of hysterectomy has to be weighed into this major Quality of Life decision. Hx = history; OC = Oral contraceptives. 

The decision to take or leave the ovaries at the time of hysterectomy is based upon ‘absolute’ reasons for removal, such as a history of ovarian cancer in the family, history of breast cancer in the patient (see Table).   Without an absolute reason for removal, it is suggested that each patient discuss the issues with her surgeon, looking at absolute risk factors and quality of life factors.  Additionally, a second opinion is recommended for hysterectomy due to non-cancer, and perhaps any major surgery.

Here is an excerpt from a 2005 Abstract summary of research, by WH Parker, et al:

Approximately 78% of women between the ages of 45 and 64 years have prophylactic oophorectomy when hysterectomy is performed for benign disease to prevent the development of ovarian cancer. However, after menopause, the ovary continues to produce androstenedione and testosterone in significant amounts and these androgens are converted in fat, muscle, and skin into estrone. Evidence suggests that oophorectomy increases the subsequent risk of coronary heart disease (CHD) and osteoporosis and whereas 14,000 women die of ovarian cancer every year nearly 490,000 women die of heart disease and 48,000 women die within 1 year after hip fracture. PubMed and the Cochrane database were used to identify studies that examined the incidence of disease and mortality from 5 conditions that seem to be related to ovarian hormones: CHD, ovarian cancer, breast cancer, stroke and hip fracture, and also data for death from all other causes. The data were applied to a Markov decision analytic computer model to calculate risk estimates for mortality from these conditions until the age of 80. The model shows for a hypothetical cohort of 10,000 women undergoing hysterectomy and who chose oophorectomy (vs. ovarian conservation) between the ages of 50 and 54 [without estrogen therapy (ET)], that by the time they reach age 80, 47 fewer women will have died from ovarian cancer, but 838 more women will have died from CHD and 158 more will have died from hip fracture. Therefore, the decision to perform prophylactic oophorectomy should be approached with great caution for the majority of women who are at low risk of developing ovarian cancer.”

I am aware that the articles referenced and the practice of hysterectomy and taking out the ovaries, too...well, those are two different stories. I am not here to upset the cart but to inform.  In informing, I realize that there are many, many women who may have had their normal ovaries out during a 'routine' hysterectomy. And I'm fairly certain that this article has the potential to create a lot of emotion. 

We are speaking about an emotional topic. It's not just anatomy. It's not just physiology. It is a representation of womanhood, and surgical menopause is not a simple thing to undergo. For many women, it is traumatizing and it leaves more than just little permanent scars from the laparoscope. 

For many women with surgical menopause, there is hair loss, bone decay, cardiac disease, depression, hot flashes, insomnia, weight gain, and a myriad of other symptoms. We can't change the fact that you have had your ovaries removed. No one can change the past, and we can't contemplate the 'what if's' for too long or else it is counterproductive.

Don't beat yourself up if circumstances are beyond your control and even if mistakes were made. For our own good, we have to move forward, persevere, and gain something today and tomorrow.  

So what is a woman to do? Well, you can start by leaving a comment. Let's take it one step at a time and see where it leads us.  We are women. We are together.

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ACOG Website, 2012.

National Cancer Institute.    A guide to understanding informed consent. National Cancer Institute. 03/24/2006.

Natural-Progesterone-Advisory-Network.  The role a woman’s ovaries play after menopause. 2012.

Parker WH, et al.  Ovarian conservation at the time of hysterectomy for benign disease.  Obstet Gynecol.  2005 Aug;106(2):219-26.

Raab, Edward L.  The parameters of informed consent. Trans Am Ophthalmol Soc.  2004; December 102:225-232.

Shapiro S.  Does retention of the ovaries improve long-term survival after hysterectomy?  The validity of the epidemiological evidence.  Climacteric.  2006 Jun:9(3):161-3.

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No More Tears en Espanol
Face Book Page: Stepping from the Edge
Little Missy Two-Shoes Likes to go to School
From Menarche to Menopause: A Journey through Time

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  1. Thank you for writing about such a critical issue. My healthy ovaries were removed in 2007 without my consent. My doctor stated he removed my ovaries because of 'hormonal bloating'. I can't begin to comprehend this. I was castrated for something that all women experience - hormonal bloating.

    Since hysterectomy and removal of my ovaries, my health has declined to the point where I'm now disabled. I can no longer work. Actually, there are a lot of things I can no longer do. The quality of my life has been reduced significantly.

    I hope every woman who visits your site will take the time to read this post. You're right about this being an emotional subject... All the more reason why I applaud you for writing about it.

    1. I'm truly sorry for your loss, and I think you represent untold numbers of women. I can't explain what happened, or why. But it's done and perhaps the best thing we can do is to move forward by educating future women about this issue. Maybe together, we can stop this from happening to others; we can tip the scale in the other direction. Even if we help one person, it will matter.

      Let's hope and strive for the best.

      Dr. Margaret Aranda

  2. I applaud you for writing this blog! I was hysterectomized and castrated for a benign ovarian cyst at age 50. The cyst had a SMALL possibility of being cancerous. My GYNECOLOGIST of 20 YEARS (not sure he was even present in the OR) and TWO GYN RESIDENTS removed my one ovary and waited for the results of the frozen section. Even though it was benign, they then proceeded to remove my other ovary, uterus, and Fallopian tubes. This was despite the recommendation of the oncologist to whom my gyn referred me who recommended that just the one ovary be removed if it was benign.

    My health and quality of life have suffered greatly even though I'm on HRT. HRT is at best a crude "replacement" for what my body did so wondrously on its own. And now I'm dependent on the very system that harmed me. I don't even look the same - I aged 10 to 15 years within a few months post-op (major hair loss and skin aging).

    I recently developed back, hip, and rib cage pain due to the loss of pelvic integrity. And the post-hysterectomy big belly / "scrunched" midsection is pretty distressing too! It's been 6 long years and it still consumes me. But that's part of what keeps me speaking out against this horrible injustice and harm against women.

    The state medical board ruled that my gynecologist did nothing wrong. My insurance company, Cigna, said that the results of their investigation are confidential. My surgeon is still in Cigna's network so they must find this behavior acceptable. That's not surprising if you read the erroneous Hysterectomy information on Cigna's website. I discovered that the insurance authorization was for "hysterectomy" even though I had absolutely no history of uterine problems (was still having very normal 28 day cycles with normal bleeding as I had my entire life) and the biopsy done as part of pre-op workup was negative. So I'm not sure what was submitted to prove that my uterus needed to be removed...but maybe Cigna doesn't require that proof of any problem be submitted. They wouldn't reveal any information in my communications with them (maybe because it would have been self-incriminating). Ironically, the only problem I had was an ovarian cyst that SHOULD HAVE BEEN removed via cystectomy or, worst case, removal of JUST THE ONE OVARY yet the authorization request said NOTHING about cystectomy or oophorectomy.

    I wonder how many of the 22 million women who've been hysterectomized realize that their surgeries were probably unwarranted. And how many realize that their health problems are likely a result of the loss of their uterus and/or ovaries? This realization is tough to comprehend and accept but these women's voices can help us stop this horrific injustice and harm.

    1. It's so hard to know what to say. You must represent many other women who just have not yet taken the time to write. Let's just stick together for now and see what we can do to start making a difference. I'm thinking that maybe I could start asking some research questions so that we can put it into a solid format. It's a start.

      Dr. Margaret Aranda

  3. Absolutely fantastic article and I agree that this information NEEDS to be out there and I'm going to cover this topic in my magazine.

    1. Why thank you so much, Allison Brown. Let's keep talking!

  4. Thank you, Dr. Aranda! Here's a study (one of a number) that shows the harm of ovary removal -
    "estrogen deficiency, resulting from premenopausal or postmenopausal oophorectomy, is associated with higher risks of coronary artery disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression, and anxiety. These studies suggest that bilateral oophorectomy may do more harm than good."

    But the uterus also has life-long functions - anatomical, skeletal, hormonal, and sexual. There's a Youtube video titled "Female Anatomy: Functions of the Female Organs" that explains it all.

    1. Yes ~ this is a 2010 Study from the John Wayne Cancer Institute in Santa Monica, California. WH Parker also states "...These studies suggest that bilateral oophorectomy may do more harm than good." Great addition to the content of this discussion.

      Dr. Margaret Aranda

  5. I personally spoke with Dr. Parker a couple of years ago regarding the link between ovary removal and heart disease. He told me that he contacted ACOG and strongly advised them to include the risk of heart disease in their hysterectomy patient information pamphlet. Link to ACOG's pamphlet below.

    To date, nothing about the link between ovary removal and heart disease has been added. For this reason, I created a petition via asking ACOG to disclose to women the very serious consequences of ovary removal (castration). Please take the time to sign my petition. Link to my petition is below.

    Thank you Dr. Aranda and Alison Brown for caring about this issue and for your efforts toward educating and informing women about it!

    (Note: You may have to copy and paste links into your browser)


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