Oophorectomy: Indications, Procedure, and Risks

Oophorectomy is the process by which a surgeon removes one (unilateral oophorectomy) or both (bilateral oophorectomy) ovaries. Oophorectomy is often combined with the removal of the fallopian tubes (salpingo-oophorectomy). It can also be done as a part of a complete or total hysterectomy (removal of the uterus). 

Approximately half of the women who have undergone hysterectomy also have their ovaries removed within the same procedure. Doctors may recommend salpingo-oophorectomy along with hysterectomy to reduce the risk of developing ovarian cancer in the future.

Hysterectomy and oophorectomy should be the last resort in the treatment of endometriosis.

About the uterus and ovaries

The uterus is a pear-shaped muscular structure about the size of a fist in the lower pelvic region. It is part of the female reproductive system and is the place where a growing fetus develops.

The uterus has three primary layers: the endometrium (inner layer), myometrium (middle layer), and serosa (outer layer). The endometrium is shed during monthly periods but is maintained during pregnancy.

The uterus connects on either side to the ovaries via the fallopian tubes. Ovaries are the sites of egg development. Ovulation is the release of an egg cell from the ovary into the fallopian tube midway during the menstrual cycle. In the absence of pregnancy, a woman releases about 400 to 500 eggs during her reproductive life. The key hormones produced by the ovaries are estrogen and progesterone. 

n the first 14 days of the menstrual cycle, enables the egg to mature. It also plays a role in thickening the lining of the uterus and promotes breast development along with an increase in bone and cartilage density. Progesterone prepares the endometrium between the 14^th and 28^th days of the menstrual cycle to allow the implantation of a fertilized egg (zygote) inside the uterus. If fertilization does not occur, the levels of progesterone fall, and the endometrium is shed during monthly periods.

What are the indications for oophorectomy?

Your healthcare provider may recommend the removal of one or both ovaries for the following reasons:

• endometriosis
• non-cancerous cyst formation
• preventive surgery (prophylactic oophorectomy) for those with a high risk of breast and ovarian cancer
• ovarian cancer
• necrotic ovary undergoing torsion or twisting around the blood vessels
• pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA)
• cryopreservation of ovarian tissue

What are the types of oophorectomies?

A surgeon may opt for one of the following types of oophorectomies depending on the symptoms and pathology:

• unilateral oophorectomy (removal of one ovary)
• bilateral oophorectomy (removal of both ovaries)
• salpingo-oophorectomy (removal of the fallopian tube along with the ovary)
• bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries)
• hysterectomy with salpingo-oophorectomy (removal of the uterus along with fallopian tube(s) and ovary/ovaries)

How do surgeons perform oophorectomy?

There are several ways to perform an oophorectomy with each having its own sets of risks and recovery times. Your surgeon should discuss these procedures and their associated risks with you beforehand.

Laparotomy or abdominal incision

In this procedure, the surgeon makes a vertical or horizontal cut across the abdomen. He or she then pulls apart the abdominal muscles to get a better view of the ovaries and ties the blood vessels to prevent bleeding. He or she then staples or stitches the cut. Laparotomy often requires a longer recovery time and presents a higher risk of complications.

Laparoscopy

This is a minimally invasive surgical approach in which the surgeon inserts a camera into the abdomen via a small cut near the navel. This camera relays the video feed to an external monitor. The surgeon makes other cuts to insert special tools to cut and tie the blood vessels and detach the ovaries. He or she then removes them usually through the larger port in the belly button. Since the cuts on the skin are small, they leave less scarring and heal more quickly.

Vaginal removal

Sometimes, a surgeon may remove the ovaries via the vagina in a minimally invasive approach. They generally do this when they also perform hysterectomy along with oophorectomy and when vaginal removal of the uterus is feasible. This causes almost no abdominal scarring and carries a smaller risk of infection and faster recovery. Sometimes, the surgeon uses a separate incision in the vagina to remove a larger ovary if he or she does not perform a hysterectomy concurrently.

How can oophorectomy help treat endometriosis?

There is currently no cure for endometriosis. Hysterectomy and oophorectomy should be the last resort when all other treatment options, including laparoscopic excision surgery, fail and the patient is sure she does not want to preserve her fertility. It is important to note that while the removal of the ovaries can help reduce symptoms such as pain, there is still a risk the symptoms will recur. 

The risk of developing ovarian cancer is one in 80 in the general population. However, that risk is marginally greater in those with endometriosis (approximately 2% to 3%). In the presence of known or suspected ovarian cancer, a specialist gynecologic surgeon will make an informed treatment decision with the patient, which will usually include an oophorectomy. 

Oophorectomy for the purpose of risk-reducing surgery may be warranted in cases of familial cancer or the like. However, it should not be routine in women with endometriosis. 

Oophorectomy, as the last resort treatment for a patient with endometriosis, may aid in the alleviation of pain by completely stopping menstrual cycles, causing “surgical menopause”. If endometriosis lesions or scar tissue remain in the pelvis without surgical removal, there is a chance that pain caused by endometriosis continues even after oophorectomy, especially if hormone replacement therapy is used. This is the reason why the decision to pursue an oophorectomy should be a well-thought-out discussion between the patient and the surgeon. 

What is the recovery process after oophorectomy?

After the procedure, you will be taken to a recovery room till the general anesthesia wears off. Depending on the procedure, you may require anywhere between a few hours (for minimally invasive procedures) and a few days (laparotomy) of hospital stay.

In most cases, you will be able to carry on with your daily activities on the same day of surgery. However, you should avoid lifting heavy weights or exercising for a few weeks. You will also receive instructions on how to clean and care for the incision sites.

What are the risks?

Though oophorectomy is a relatively low-risk surgery, it does present a few risks depending on the type of procedure. These include:

• large blood vessel injury. This is rare and typically occurs in 0.1% to 0.64% of cases.
• genitourinary tract injury (ureter). This may occur in 1% to 2% of gynecological surgical interventions.
• neuropathies (nerve injuries). This occurs in about 2% of cases depending on whether the patient is over or underweight and has pre-existing mobility issues. 

Other risks during surgery include infection, excess bleeding, pain, blood clot formation, scarring, and reaction to anesthesia. 

How long does the procedure take?

A typical oophorectomy procedure can take between one to four hours. You will be moved to a recovery area and the excised ovaries sent for clinical examination. 

Does oophorectomy lead to infertility?

Unilateral oophorectomy i.e., removal of a single ovary will not greatly affect fertility if the remaining ovary and fallopian tube are healthy.

Bilateral oophorectomy will lead to loss of fertility, so discuss all available options for fertility preservation (such as egg freezing) with your healthcare provider first before committing to the procedure.

What are some of the menopausal symptoms after oophorectomy?

Bilateral oophorectomy will result in immediate surgical menopause. Early menopause can lead to symptoms such as hot flashes, vaginal dryness, depression and anxiety, loss of sex drive, cognitive changes, sleep disturbance, and osteoporosis.

What are some of the post-procedure steps to follow?

After the surgery, your healthcare team will monitor your progress. They may instruct you to sit up and walk a short distance and wear special socks or boots to prevent blood clots. 

At home, do not push yourself, lift heavy loads, or have sexual intercourse for a few weeks until your doctor gives the go-ahead. If you experience emotional changes due to surgery-induced menopause, consider contacting local support groups for support.

Is hormone therapy necessary after oophorectomy? 

There is still no consensus on whether post-menopausal hormone therapy should be indicated for women who are in natural menopause. Younger women who undergo surgery-induced menopause may need low-dose hormone therapy at least up to the age of 51 for cardiovascular protection and for bone health.

Our approach

At Seckin Endometriosis Center, we avoid oophorectomy unless absolutely necessary. Excision surgery is the gold standard for the treatment of endometriosis and an oophorectomy alone cannot be a treatment for endometriosis as endometrial lesions must be meticulously removed to treat the disease.

We always discuss all available options with our patients before going ahead with any procedure and fertility preservation is of utmost importance whenever feasible.