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Hysterectomy and ovarian preservation

Written by Dr. Furrat Amen

Introduction

Many patients in the outpatients clinics are about to undergo hysterectomy – but what about their ovaries – should they be preserved? Does hysterectomy precipitate the menopause even if the ovaries are preserved and what are the risks of preservation? All these questions are common in the clinic, so what does the research indicate is the answer to these very important questions.

Acute effects

Abdominal and vaginal hysterectomy, with ovarian preservation, causes a temporary, but significant, decrease in plasma levels of oestradiol-17-beta during the follicular phase of the menstrual cycle. During the luteal phase, levels of oestradiol-17-beta and progesterone drop, in the acute phase after hysterectomy (six weeks later, though, there seems to be no significant change in levels of oestradiol-17-beta and progesterone when compared with levels before hysterectomy (3)).

133xenon-clearance may be used as a measure for ovarian blood flow. In abdominal hysterectomy with adnexal preservation, 133xenon-clearance measurements before and after surgery indicate that clearance rates drop by as much as eighty-nine percent in women of premenopausal disposition. This may account for the acute, transient drop in ovarian steroid levels in plasma (4).

During laproscopy there are no significant alteration of steroid hormone levels in plasma. Both after diagnostic laproscopy and hysterectomy, plasma levels of gonadotrophins are unchanged.

By contrast, bilateral oophorectomy results in continually increasing levels of follicle stimulating hormone (FSH ) and luteinizing hormone (LH) as was observed in a study of twenty-one women in Italy, in conjunction with a increase in prolactin concentrations lasting two to three weeks (2).

This evidence suggests that hormonal changes following hysterectomy, with ovarian preservation, are a result of surgery in the ovarian region, and appear unrelated to the type of surgery, or the type of hysterectomy (1). Alternatively, altered ovarian function may be a result of the existence of a uterine endocrine function as yet undiscovered (9).

The uterus is known to be a fibrinolytic organ so there is a worry that hysterectomy, before the menopause, may increase the risk of cardiovascular and thromboembolic disease. Measuring euglobulin lysis time (ELT) gives a measure of plasma fibrinolytic activity. This, in conjunction with measurements of tissue plasminogen activator (tPA) and plasminogen activator inhibitor type 1 (PAI-1), show no change six weeks following pre-menopausal hysterectomy. A good indicator of thrombotic risk is the measurement of ELT after venous occlusion and this showed no significant change either. All these factors taken together suggest no overall change in plasma fibrinolytic activity as a result of pre-menopausal hysterectomy (3).
long term effects

Another worry is that hysterectomy with ovarian conservation may precipitate early menopause. This seems to be supported by a mean age of ovarian failure in hysterectomized women of 45.4 +/- 4.0 years (standard deviation (SD)) as opposed to a mean age of 49.5 +/- 4.04 years in a non-hysterectomized control group (5). According to the same study, the indication for carrying out a hysterectomy did not change the time of ovarian failure. Postal questionnaires sent to hysterectomized women, with ovarian preservation, suggest that 26.1% (8) to 39% show signs of ovarian failure (6). The type of incision appears not to have any bearing on the failure rate (8).

Smaller studies conflict with this evidence when hysterectomy is carried out for patients with cancer of the cervix. Ovarian preservation in fourteen patients, with accompanying transposition into the paracolic gutters, resulted in only one case of ovarian failure (7)

It is of interest that thirty-five percent of patients undergoing unilateral oophorectomy had impairment of ovarian function, as measured by FSH, LH and oestradiol-17-beta levels up to six months following hysterectomy, while no patients, six months following hysterectomy with bilateral preservation of ovaries, showed such failure. This suggests that preservation has better success if both ovaries are preserved (10).

But is dysfunctional uterine bleeding a sign of impending menopause or is it the hysterectomy, used to resolve the bleeding, the precipitating factor in causing menopause? Studies indicate that 6% of patients that underwent hysterectomy with ovarian preservation and 10% of endometrial ablation patients had FSH levels exceeding 40mIU/L after two years. This suggests that hysterectomy may well not be compromising ovarian function at least two years after the operation, in comparison with endometrial ablation – but as these figures are from a study of 101 patients further larger studies may well be required (13).

Advantages

Hysterectomy, with preservation of at least one ovary, does not seem to be associated with increased risk of angina, myocardial infarction, and heart failure (11). Women with hysterectomies and ovarian conservation have similar risk factor profiles for heart disease as women without hysterectomies. Oophorectomy, on the other hand, is associated with an increase in lipids, lipoproteins, glucose and insulin, and blood pressure, even with oestrogen therapy. These levels are particularly high in women twenty, plus, years after the menopause. In the long-term, heart disease risk factors are not totally reduced with oestrogen replacement (12)

In a study of ninety-three women, who had undergone hysterectomy up to nine years earlier (aged 29-44 years), 93.3% of intervals between pregnanediol peaks were between twenty-one and thirty-five days. These figures compare well with women of similar age who had no surgery suggesting that ovaries of women who have had hysterectomy behave as those of normal women (19).
Incidence of malignant change in preserved ovaries is 0.26% which is comparable to the rest of the population (20). Another study of 922 patients with conservation of at least one adnexa, showed only 13 (1.4%) required surgical re-exploration – and none were for ovarian malignancy – in the short term (21). This suggests that grossly normal ovaries in pre-menopausal women should be preserved.

Even in cases of unilateral malignant ovarian tumours, ovarian preservation is a possibility. Of 106 patients treated with this conservative approach the mean length of survival was not significantly reduced in comparison to radical surgery – fourteen percent recurrence and eleven deaths were noted. The main problem was that metastasis to the preserved ovary was high. Normal menses resumed rapidly after surgery, but was dependent on the chemotherapy administered. Anovulatory patients among the group mostly exhibited hypergonadotrophic hypogonadism. Sixteen women had twenty-seven pregnancies of which eighteen resulted in normal infants born. Abortion occurred if chemotherapy was started subsequent to conception. Childbearing capability may be preserved but it is necessary to have very close follow-up for the long run to detect recurrence of malignancy (25).

In the case of cervical carcinoma it is well worth considering preservation of the ovaries as metastasis to the ovaries is rare. Seventeen percent of those with bilateral transposition of ovaries at the time of hysterectomy, with subsequent radiotherapy developed elevated gonadotrophin levels consistent with the menopause. This is especially effective if paraaortic radiotherapy is not required and shielding of the ovaries is in place (27)
disadvantages

Hysterectomy, with preservation of at least one ovary, seems to predispose women to a significantly increased risk of hypertension, and an increased body mass index (BMI) when figures are adjusted for other risk factors. This suggests that either hysterectomy causes an increase in blood pressure, or that events leading to hysterectomy, eg. myomas, and high blood pressure have the same underlying cause (11).

Preservation of ovaries also results in residual ovary syndrome (ROS) in 2.85% of patients. Chronic pelvic pain required surgical re-exploration in 71% of these patients. Asymptomatic pelvic mass noticed on follow-up examination accounted for 24.6% of re-exploration on ROS patients. Pathology found included functional cysts (50.7%), benign neoplasm (42.6%), and ovarian carcinoma (12.3%). Dyspareunia also occurred in 67% (17). Other findings may include corpus luteum haematomata.

In considering oophorectomy age, individual and family risks, likely compliance with hormone replacement therapy, and the patient’s preferences must be taken into consideration – but the authors of this particular study recommend oophorectomy for pre-menopausal patients over 45 years of age (14). This recommendation is also supported by the fact that diagnosis and surgical removal in such cases of chronic pelvic pain is often difficult (15).

Patients with ovarian preservation are prone to pelvic lesions at some later time, especially when compared with patients who had undergone hysterectomy and bilateral salpingo-oophorectomy. This means that ovarian preservation requires follow-up in the clinical setting, as well as laboratory and sonographic investigation. Even surgery may be required to exclude neoplastic change (18).

Ovarian conservation combined with lateral ovary transposition in hysterectomy for carcinoma of the cervix can also cause much confusion. Such ovaries may appear to be enlarged nodal masses – suggestive of recurrence of the cervical tumour (16).

Hysterectomized patients with ovarian preservation complain more of climacteric complaints (vasomotor complaints and vaginal dryness) than normal climacteric women of a similar age. This is particularly the case for 39-41 year-olds. There is also an increased number of women of this group who succumb to osteoporosis, cardiovascular disease, osteoarthritis, depression, and sexual problems (22).

Premenopausal women with hysterectomy and preservation of ovaries will have significantly lower bone density in comparison to those with no surgery (28). Preservation of the ovaries seems to have no benefit in this respect. Oestrogen therapy helps to over come this loss of bone density in those who have ovaries preserved and those who do not (30). The development of pathological presenile cataracts may also occur following hysterectomy (29)

When hysterectomy is combined with ovarian transposition and radiotherapy - fifty percent of patients experienced ovarian failure, assessed by menopausal symptoms (vaginal dryness and hot flushes) and raised FSH levels. Without post-operative radiotherapy, the figure falls to 2.9% (23).

The preservation of ovarian function is directly related to the estimated scatter dose received. Only one of nine patients receiving less than 300cGy became menopausal, compared with three of five who received more than 300 cGy. All patients would develop menopause if the ovaries were below the iliac crest. A side-effect of lateral ovarian transposition was the development of symptomatic ovarian cysts (26)

Eleven percent of ovarian cancer patients, in a study of 382 patients, had previous hysterectomy for benign indications two to forty-three years before the cancer was diagnosed. Despite this it does not seem necessary to do a prophylactic extirpation for normal ovaries before the age of fifty – although an important exception may be rare genetically determined types of ovarian cancer (24).

Ten point conclusion

i Hormonal changes following hysterectomy, with ovarian preservation, are a result of surgery in the ovarian region, and appear unrelated to the strains of surgery, or the type of hysterectomy.

ii No overall change in plasma fibrinolytic activity as a result of pre-menopausal hysterectomy

iii Hysterectomy with ovarian conservation may precipitate early menopause. The indication for carrying out a hysterectomy does not change the time of ovarian failure. The type of incision appears not to have any bearing on the failure rate.

iv Preservation has better success if both ovaries are preserved.

v Hysterectomy, with preservation of at least one ovary, does not seem to be associated with increased risk of angina, myocardial infarction, and heart failure.

vi The ovaries of women who have had hysterectomy behave as those of normal women and the incidence of

vii Malignant change in preserved ovaries is low as in the general population.

viii Hysterectomy, with preservation of at least one ovary, seems to predispose women to a significantly increased risk of hypertension, and an increased body mass index (BMI).

ix Residual ovary syndrome (ROS) in 2.85% of patients.

x Premenopausal women with hysterectomy and preservation of ovaries will have significantly lower bone density in comparison to those with no surgery.

References

The acute effect of hysterectomy on ovarian function. (Stone SC; Am J Obstet Gynecol, 1975 Jan 15)

Crosignani PG, et al; Gonadotrophins and prolactin rise after bilateral oophorectomy for benign conditions. (Hum Reprod, 1995 Sep)

Influence of hysterectomy on the fibrinolytic activity of plasma of women with intact ovarian function.
Schubring C; Grulich-Henn J; Bauer S; Gips H; Müller-Berghaus G
Eur J Obstet Gynecol Reprod Biol, 1995 Mar, 59:1, 39-43

The acute effect of hysterectomy on ovarian blood flow. (Janson PO; Am J Obstet Gynecol, 1977 Feb 15)

The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. (Siddle N; Fertil Steril, 1987 Jan)

Riedel HH, et al; Ovarian failure phenomena after hysterectomy. (J Reprod Med, 1986 Jul)

Owens S, et al; Ovarian management at the time of radical hysterectomy for cancer of the cervix. (Gynecol Oncol, 1989 Dec)

Habelt K, et al; [Symptoms of ovarian failure after hysterectomy in premenopausal women. A retrospective study based on postoperative perception of 245 women] (Zentralbl Gynakol, 1996)

Nilas L, et al; [Ovarian function after premenopausal hysterectomy] (Ugeskr Laeger, 1993 Nov 22)
10

Bukovsky I, et al; Ovarian function following abdominal hysterectomy with and without unilateral oophorectomy. (Eur J Obstet Gynecol Reprod Biol, 1995 Jan)

Luoto R, et al; Cardiovascular morbidity in relation to ovarian function after hysterectomy. (Obstet Gynecol, 1995 Apr, Abstract available)

Hysterectomy, oophorectomy, and heart disease risk factors in older women.
Kritz-Silverstein D; Barrett-Connor E; Wingard DL
Am J Public Health, 1997 Apr, 87:4, 676-80

Bhattacharya S, et al; A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation. (Br J Obstet Gynaecol, 1996 Sep)

Dekel A, et al; The residual ovary syndrome: a 20-year experience. (Eur J Obstet Gynecol Reprod Biol, 1996 Sep)

Siddall-Allum J, et al; Chronic pelvic pain caused by residual ovaries and ovarian remnants [see comments] (Br J Obstet Gynaecol, 1994 Nov)

Reed DH, et al; Ovarian conservation at hysterectomy: a potential diagnostic pitfall [see comments] (Clin Radiol, 1989 May)

Christ JE, et al; The residual ovary syndrome. (Obstet Gynecol, 1975 Nov)

Zalel Y, et al; Is it necessary to perform a prophylactic oophorectomy during hysterectomy? (Eur J Obstet Gynecol Reprod Biol, 1997 May)

Metcalf MG, et al; Retention of normal ovarian function after hysterectomy. (J Endocrinol, 1992 Dec)

When hysterectomy is combined with ovarian transposition and radiotherapy - fifty percent of patients experienced ovarian failure. The residual ovary syndrome.
Hwu YM; Wu CH; Yang YC; Wang KG
Chung Hua I Hsueh Tsa Chih, 1989 May, 43:5, 335-40

Funt MI, et al; The residual adnexa—asset or liability? (Am J Obstet Gynecol, 1977 Oct 1)

Oldenhave A, et al; Hysterectomized women with ovarian conservation report more severe climacteric complaints than do normal climacteric women of similar age. (Am J Obstet Gynecol, 1993 Mar)

The fate of the ovaries after radical hysterectomy and ovarian transposition
Feeney DD; Moore DH; Look KY; Stehman FB; Sutton GP
Gynecol Oncol, 1995 Jan, 56:1, 3-7

Petru E, et al; [Significance of prophylactic ovariectomy at the time of uterus extirpation for prevention of an ovarian carcinoma] (Wien Med Wochenschr, 1991)

Miyazaki T, et al; Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors. (Gynecol Oncol, 1988 Jul)

Chambers SK, et al; Sequelae of lateral ovarian transposition in irradiated cervical cancer patients. (Int J Radiat Oncol Biol Phys, 1991 Jun)

The preservation of ovarian function in young women undergoing pelvic radiation therapy.
Husseinzadeh N; Nahhas WA; Velkley DE; Whitney CW; Mortel R
Gynecol Oncol, 1984 Jul, 18:3, 373-9

Bone loss after hysterectomy with ovarian conservation. (Watson NR; Obstet Gynecol, 1995 Jul)

Cernea P, et al; [Pathologic cataract due to ovarian failure] (Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Oftalmol, 1989 Jul-Sep)

Kritz-Silverstein D, et al; Oophorectomy status and bone density in older, hysterectomized women. (Am J Prev Med, 1996 Sep-Oct)


Write us an article. Ask us any questions about the websites, or give us suggestions.	Hysterectomy and ovarian preservation Written by Dr. Furrat Amen Introduction Many patients in the outpatients clinics are about to undergo hysterectomy – but what about their ovaries – should they be preserved? Does hysterectomy precipitate the menopause even if the ovaries are preserved and what are the risks of preservation? All these questions are common in the clinic, so what does the research indicate is the answer to these very important questions. Acute effects Abdominal and vaginal hysterectomy, with ovarian preservation, causes a temporary, but significant, decrease in plasma levels of oestradiol-17-beta during the follicular phase of the menstrual cycle. During the luteal phase, levels of oestradiol-17-beta and progesterone drop, in the acute phase after hysterectomy (six weeks later, though, there seems to be no significant change in levels of oestradiol-17-beta and progesterone when compared with levels before hysterectomy (3)). 133xenon-clearance may be used as a measure for ovarian blood flow. In abdominal hysterectomy with adnexal preservation, 133xenon-clearance measurements before and after surgery indicate that clearance rates drop by as much as eighty-nine percent in women of premenopausal disposition. This may account for the acute, transient drop in ovarian steroid levels in plasma (4). During laproscopy there are no significant alteration of steroid hormone levels in plasma. Both after diagnostic laproscopy and hysterectomy, plasma levels of gonadotrophins are unchanged. By contrast, bilateral oophorectomy results in continually increasing levels of follicle stimulating hormone (FSH ) and luteinizing hormone (LH) as was observed in a study of twenty-one women in Italy, in conjunction with a increase in prolactin concentrations lasting two to three weeks (2). This evidence suggests that hormonal changes following hysterectomy, with ovarian preservation, are a result of surgery in the ovarian region, and appear unrelated to the type of surgery, or the type of hysterectomy (1). Alternatively, altered ovarian function may be a result of the existence of a uterine endocrine function as yet undiscovered (9). The uterus is known to be a fibrinolytic organ so there is a worry that hysterectomy, before the menopause, may increase the risk of cardiovascular and thromboembolic disease. Measuring euglobulin lysis time (ELT) gives a measure of plasma fibrinolytic activity. This, in conjunction with measurements of tissue plasminogen activator (tPA) and plasminogen activator inhibitor type 1 (PAI-1), show no change six weeks following pre-menopausal hysterectomy. A good indicator of thrombotic risk is the measurement of ELT after venous occlusion and this showed no significant change either. All these factors taken together suggest no overall change in plasma fibrinolytic activity as a result of pre-menopausal hysterectomy (3). long term effects Another worry is that hysterectomy with ovarian conservation may precipitate early menopause. This seems to be supported by a mean age of ovarian failure in hysterectomized women of 45.4 +/- 4.0 years (standard deviation (SD)) as opposed to a mean age of 49.5 +/- 4.04 years in a non-hysterectomized control group (5). According to the same study, the indication for carrying out a hysterectomy did not change the time of ovarian failure. Postal questionnaires sent to hysterectomized women, with ovarian preservation, suggest that 26.1% (8) to 39% show signs of ovarian failure (6). The type of incision appears not to have any bearing on the failure rate (8). Smaller studies conflict with this evidence when hysterectomy is carried out for patients with cancer of the cervix. Ovarian preservation in fourteen patients, with accompanying transposition into the paracolic gutters, resulted in only one case of ovarian failure (7) It is of interest that thirty-five percent of patients undergoing unilateral oophorectomy had impairment of ovarian function, as measured by FSH, LH and oestradiol-17-beta levels up to six months following hysterectomy, while no patients, six months following hysterectomy with bilateral preservation of ovaries, showed such failure. This suggests that preservation has better success if both ovaries are preserved (10). But is dysfunctional uterine bleeding a sign of impending menopause or is it the hysterectomy, used to resolve the bleeding, the precipitating factor in causing menopause? Studies indicate that 6% of patients that underwent hysterectomy with ovarian preservation and 10% of endometrial ablation patients had FSH levels exceeding 40mIU/L after two years. This suggests that hysterectomy may well not be compromising ovarian function at least two years after the operation, in comparison with endometrial ablation – but as these figures are from a study of 101 patients further larger studies may well be required (13). Advantages Hysterectomy, with preservation of at least one ovary, does not seem to be associated with increased risk of angina, myocardial infarction, and heart failure (11). Women with hysterectomies and ovarian conservation have similar risk factor profiles for heart disease as women without hysterectomies. Oophorectomy, on the other hand, is associated with an increase in lipids, lipoproteins, glucose and insulin, and blood pressure, even with oestrogen therapy. These levels are particularly high in women twenty, plus, years after the menopause. In the long-term, heart disease risk factors are not totally reduced with oestrogen replacement (12) In a study of ninety-three women, who had undergone hysterectomy up to nine years earlier (aged 29-44 years), 93.3% of intervals between pregnanediol peaks were between twenty-one and thirty-five days. These figures compare well with women of similar age who had no surgery suggesting that ovaries of women who have had hysterectomy behave as those of normal women (19). Incidence of malignant change in preserved ovaries is 0.26% which is comparable to the rest of the population (20). Another study of 922 patients with conservation of at least one adnexa, showed only 13 (1.4%) required surgical re-exploration – and none were for ovarian malignancy – in the short term (21). This suggests that grossly normal ovaries in pre-menopausal women should be preserved. Even in cases of unilateral malignant ovarian tumours, ovarian preservation is a possibility. Of 106 patients treated with this conservative approach the mean length of survival was not significantly reduced in comparison to radical surgery – fourteen percent recurrence and eleven deaths were noted. The main problem was that metastasis to the preserved ovary was high. Normal menses resumed rapidly after surgery, but was dependent on the chemotherapy administered. Anovulatory patients among the group mostly exhibited hypergonadotrophic hypogonadism. Sixteen women had twenty-seven pregnancies of which eighteen resulted in normal infants born. Abortion occurred if chemotherapy was started subsequent to conception. Childbearing capability may be preserved but it is necessary to have very close follow-up for the long run to detect recurrence of malignancy (25). In the case of cervical carcinoma it is well worth considering preservation of the ovaries as metastasis to the ovaries is rare. Seventeen percent of those with bilateral transposition of ovaries at the time of hysterectomy, with subsequent radiotherapy developed elevated gonadotrophin levels consistent with the menopause. This is especially effective if paraaortic radiotherapy is not required and shielding of the ovaries is in place (27) disadvantages Hysterectomy, with preservation of at least one ovary, seems to predispose women to a significantly increased risk of hypertension, and an increased body mass index (BMI) when figures are adjusted for other risk factors. This suggests that either hysterectomy causes an increase in blood pressure, or that events leading to hysterectomy, eg. myomas, and high blood pressure have the same underlying cause (11). Preservation of ovaries also results in residual ovary syndrome (ROS) in 2.85% of patients. Chronic pelvic pain required surgical re-exploration in 71% of these patients. Asymptomatic pelvic mass noticed on follow-up examination accounted for 24.6% of re-exploration on ROS patients. Pathology found included functional cysts (50.7%), benign neoplasm (42.6%), and ovarian carcinoma (12.3%). Dyspareunia also occurred in 67% (17). Other findings may include corpus luteum haematomata. In considering oophorectomy age, individual and family risks, likely compliance with hormone replacement therapy, and the patient’s preferences must be taken into consideration – but the authors of this particular study recommend oophorectomy for pre-menopausal patients over 45 years of age (14). This recommendation is also supported by the fact that diagnosis and surgical removal in such cases of chronic pelvic pain is often difficult (15). Patients with ovarian preservation are prone to pelvic lesions at some later time, especially when compared with patients who had undergone hysterectomy and bilateral salpingo-oophorectomy. This means that ovarian preservation requires follow-up in the clinical setting, as well as laboratory and sonographic investigation. Even surgery may be required to exclude neoplastic change (18). Ovarian conservation combined with lateral ovary transposition in hysterectomy for carcinoma of the cervix can also cause much confusion. Such ovaries may appear to be enlarged nodal masses – suggestive of recurrence of the cervical tumour (16). Hysterectomized patients with ovarian preservation complain more of climacteric complaints (vasomotor complaints and vaginal dryness) than normal climacteric women of a similar age. This is particularly the case for 39-41 year-olds. There is also an increased number of women of this group who succumb to osteoporosis, cardiovascular disease, osteoarthritis, depression, and sexual problems (22). Premenopausal women with hysterectomy and preservation of ovaries will have significantly lower bone density in comparison to those with no surgery (28). Preservation of the ovaries seems to have no benefit in this respect. Oestrogen therapy helps to over come this loss of bone density in those who have ovaries preserved and those who do not (30). The development of pathological presenile cataracts may also occur following hysterectomy (29) When hysterectomy is combined with ovarian transposition and radiotherapy - fifty percent of patients experienced ovarian failure, assessed by menopausal symptoms (vaginal dryness and hot flushes) and raised FSH levels. Without post-operative radiotherapy, the figure falls to 2.9% (23). The preservation of ovarian function is directly related to the estimated scatter dose received. Only one of nine patients receiving less than 300cGy became menopausal, compared with three of five who received more than 300 cGy. All patients would develop menopause if the ovaries were below the iliac crest. A side-effect of lateral ovarian transposition was the development of symptomatic ovarian cysts (26) Eleven percent of ovarian cancer patients, in a study of 382 patients, had previous hysterectomy for benign indications two to forty-three years before the cancer was diagnosed. Despite this it does not seem necessary to do a prophylactic extirpation for normal ovaries before the age of fifty – although an important exception may be rare genetically determined types of ovarian cancer (24). Ten point conclusion i Hormonal changes following hysterectomy, with ovarian preservation, are a result of surgery in the ovarian region, and appear unrelated to the strains of surgery, or the type of hysterectomy. ii No overall change in plasma fibrinolytic activity as a result of pre-menopausal hysterectomy iii Hysterectomy with ovarian conservation may precipitate early menopause. The indication for carrying out a hysterectomy does not change the time of ovarian failure. The type of incision appears not to have any bearing on the failure rate. iv Preservation has better success if both ovaries are preserved. v Hysterectomy, with preservation of at least one ovary, does not seem to be associated with increased risk of angina, myocardial infarction, and heart failure. vi The ovaries of women who have had hysterectomy behave as those of normal women and the incidence of vii Malignant change in preserved ovaries is low as in the general population. viii Hysterectomy, with preservation of at least one ovary, seems to predispose women to a significantly increased risk of hypertension, and an increased body mass index (BMI). ix Residual ovary syndrome (ROS) in 2.85% of patients. x Premenopausal women with hysterectomy and preservation of ovaries will have significantly lower bone density in comparison to those with no surgery. References 1 The acute effect of hysterectomy on ovarian function. (Stone SC; Am J Obstet Gynecol, 1975 Jan 15) 2 Crosignani PG, et al; Gonadotrophins and prolactin rise after bilateral oophorectomy for benign conditions. (Hum Reprod, 1995 Sep) 3 Influence of hysterectomy on the fibrinolytic activity of plasma of women with intact ovarian function. Schubring C; Grulich-Henn J; Bauer S; Gips H; Müller-Berghaus G Eur J Obstet Gynecol Reprod Biol, 1995 Mar, 59:1, 39-43 4 The acute effect of hysterectomy on ovarian blood flow. (Janson PO; Am J Obstet Gynecol, 1977 Feb 15) 5 The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. (Siddle N; Fertil Steril, 1987 Jan) 6 Riedel HH, et al; Ovarian failure phenomena after hysterectomy. (J Reprod Med, 1986 Jul) 7 Owens S, et al; Ovarian management at the time of radical hysterectomy for cancer of the cervix. (Gynecol Oncol, 1989 Dec) 8 Habelt K, et al; [Symptoms of ovarian failure after hysterectomy in premenopausal women. A retrospective study based on postoperative perception of 245 women] (Zentralbl Gynakol, 1996) 9 Nilas L, et al; [Ovarian function after premenopausal hysterectomy] (Ugeskr Laeger, 1993 Nov 22) 10 Bukovsky I, et al; Ovarian function following abdominal hysterectomy with and without unilateral oophorectomy. (Eur J Obstet Gynecol Reprod Biol, 1995 Jan) 11 Luoto R, et al; Cardiovascular morbidity in relation to ovarian function after hysterectomy. (Obstet Gynecol, 1995 Apr, Abstract available) 12 Hysterectomy, oophorectomy, and heart disease risk factors in older women. Kritz-Silverstein D; Barrett-Connor E; Wingard DL Am J Public Health, 1997 Apr, 87:4, 676-80 13 Bhattacharya S, et al; A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation. (Br J Obstet Gynaecol, 1996 Sep) 14 Dekel A, et al; The residual ovary syndrome: a 20-year experience. (Eur J Obstet Gynecol Reprod Biol, 1996 Sep) 15 Siddall-Allum J, et al; Chronic pelvic pain caused by residual ovaries and ovarian remnants [see comments] (Br J Obstet Gynaecol, 1994 Nov) 16 Reed DH, et al; Ovarian conservation at hysterectomy: a potential diagnostic pitfall [see comments] (Clin Radiol, 1989 May) 17 Christ JE, et al; The residual ovary syndrome. (Obstet Gynecol, 1975 Nov) 18 Zalel Y, et al; Is it necessary to perform a prophylactic oophorectomy during hysterectomy? (Eur J Obstet Gynecol Reprod Biol, 1997 May) 19 Metcalf MG, et al; Retention of normal ovarian function after hysterectomy. (J Endocrinol, 1992 Dec) 20 When hysterectomy is combined with ovarian transposition and radiotherapy - fifty percent of patients experienced ovarian failure. The residual ovary syndrome. Hwu YM; Wu CH; Yang YC; Wang KG Chung Hua I Hsueh Tsa Chih, 1989 May, 43:5, 335-40 21 Funt MI, et al; The residual adnexa—asset or liability? (Am J Obstet Gynecol, 1977 Oct 1) 22 Oldenhave A, et al; Hysterectomized women with ovarian conservation report more severe climacteric complaints than do normal climacteric women of similar age. (Am J Obstet Gynecol, 1993 Mar) 23 The fate of the ovaries after radical hysterectomy and ovarian transposition Feeney DD; Moore DH; Look KY; Stehman FB; Sutton GP Gynecol Oncol, 1995 Jan, 56:1, 3-7 24 Petru E, et al; [Significance of prophylactic ovariectomy at the time of uterus extirpation for prevention of an ovarian carcinoma] (Wien Med Wochenschr, 1991) 25 Miyazaki T, et al; Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors. (Gynecol Oncol, 1988 Jul) 26 Chambers SK, et al; Sequelae of lateral ovarian transposition in irradiated cervical cancer patients. (Int J Radiat Oncol Biol Phys, 1991 Jun) 27 The preservation of ovarian function in young women undergoing pelvic radiation therapy. Husseinzadeh N; Nahhas WA; Velkley DE; Whitney CW; Mortel R Gynecol Oncol, 1984 Jul, 18:3, 373-9 28 Bone loss after hysterectomy with ovarian conservation. (Watson NR; Obstet Gynecol, 1995 Jul) 29 Cernea P, et al; [Pathologic cataract due to ovarian failure] (Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Oftalmol, 1989 Jul-Sep) 30 Kritz-Silverstein D, et al; Oophorectomy status and bone density in older, hysterectomized women. (Am J Prev Med, 1996 Sep-Oct)