Hend Hassan, Isaac Allen, Eleni Sofianopoulou, Yvonne Walburga, Clare Turnbull, Diana M. Eccles, Marc Tischkowitz, Paul Pharoah, Antonis C. Antoniou
5 min
This systematic review and meta-analysis evaluates the long-term health consequences of performing a bilateral salpingo-oophorectomy (BSO) alongside a hysterectomy. While BSO is often performed to prevent ovarian cancer, the procedure induces immediate surgical menopause, which may have systemic health implications. The authors analyzed data from 38 studies, comparing women who underwent hysterectomy with BSO against those who had a hysterectomy with ovarian conservation or no surgery.
The researchers found that BSO is highly effective at reducing ovarian cancer risk across all age groups and breast cancer risk in younger women. However, these benefits are offset by significant long-term risks. For women undergoing the procedure before age 50, there is an increased risk of cardiovascular diseases (including coronary heart disease and stroke), colorectal cancer, and all-cause mortality. Furthermore, the procedure is linked to higher rates of metabolic conditions like diabetes, hypertension, and hyperlipidemia, as well as neuropsychiatric outcomes such as dementia and depression.
The study highlights that the decision to remove the ovaries during a hysterectomy requires a careful balance between cancer prevention and the potential for chronic health decline. The authors emphasize that age at surgery is a critical modifier of these outcomes. They suggest that while hormone replacement therapy (HRT) might mitigate some adverse effects of premature estrogen loss, further research is needed to confirm its efficacy and to better understand the long-term trade-offs for patients.
Structured abstract: Objective To provide an up-to-date systematic review on "the long-term outcomes of bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy" and perform a meta-analysis for the reported associations. Data sources We updated a previous systematic review by searching the literature using PubMed, Web of science and Embase for publications between January 2015 and August 2022. Study eligibility criteria We included studies of women who had hysterectomy with BSO compared to hysterectomy with ovarian conservation or no surgery. Study appraisal and Synthesis methods Quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Adjusted hazard ratios were extracted and combined to obtain fixed effect estimates. Results Hysterectomy with BSO in young women compared to hysterectomy or no surgery was associated with decreased risk of breast cancer (HR:0.78, 95% CI: 0.73-0.84), but with increased risk of colorectal cancer (HR:1.27, 95%CI:1.10-1.47). Additionally, it was associated with increased risk of total cardiovascular diseases, coronary heart disease and stroke with hazard ratios 1.18 (95%CI: 1.11-1.25), 1.17 (95%CI: 1.10-1.25), 1.20(95% CI: 1.10-1.31), respectively. Compared to no surgery hysterectomy with BSO before the age of 50 was associated with increased risk of hyperlipidaemia (HR:1.44, 95% CI:1.25-1.65), diabetes (HR:1.16, 95%CI:1.09-1.24), hypertension (HR:1.13, 95%CI:1.06-1.20), dementia (HR:1.70, 95%CI:1.07-2.69) and depression (HR:1.39, 95%CI:1.22-1.60). Evidence on the association with all-cause mortality in young women showed substantial heterogeneity between the studies (I 2 :85%, p-value: <0.01). Conclusion Hysterectomy with BSO is associated with multiple long-term outcomes . The benefits of the addition of BSO to hysterectomy should be balanced against the risks.
Sam: Right, and the language matters. These are hazard ratios from observational data, some rated low certainty. The accurate framing is a trade between a well-established reduction in cancer risk and an increased risk of several chronic conditions, with the strength of evidence varying by condition.
Alex: So how should a clinician put that to a patient?
Sam: The authors suggest personalized risk-benefit counseling. For a patient at high genetic risk of ovarian cancer, the cancer benefit may outweigh the long-term uncertainty. For a patient at average risk, the evidence points toward preserving the ovaries and their endocrine function. That moves away from the "while you're in there" default toward age-stratified decisions.
Alex: There's also the move toward opportunistic salpingectomy for benign conditions. Is that the logical endpoint of this research?
Sam: It fits the direction of travel. Many high-grade serous tumors are thought to originate in the fallopian tubes, so removing the tubes and sparing the ovaries can reduce ovarian cancer risk without surgical menopause. That decouples the cancer-prevention goal from the endocrine cost, though it's a clinical development beyond what this meta-analysis tested directly.
Alex: And for carriers of BRCA mutations?
Sam: They remain the exception. Their baseline risk is high enough that the benefit-to-harm balance shifts. The argument is to reserve bilateral oophorectomy for high-risk groups rather than offering it as a routine add-on.
Alex: So surgical success is judged on long-term systemic health, not just the immediate outcome. The main caveat is that the evidence for that shift is strongest on the benefit side and weakest on the neuropsychiatric harms.
Sam: That's a fair summary. If you want the figures and the method choices we skipped, you can generate a deep dive of this paper. The paper has the rest either way.
Alex: Thanks for listening.