The residual ovary syndrome: a 20-year experience

Long-term risk of adnexal operation after vaginal hysterectomy for pelvic organs prolapse repair

OBJECTIVE

To determine if women who undergo vaginal hysterectomy for pelvic floor prolapse repair without concomitant opportunistic bilateral salpingo-oophorectomy are at increased risk of further complications related to the remaining adnexa later in life.

STUDY DESIGN

The database of a tertiary university medical center was searched for all women who underwent vaginal hysterectomy as part of the treatment for pelvic organ prolapse, without opportunistic adnexectomy, from 2006 to 2015 to provide adequate time for long-term evaluation. Demographic and clinical data including surgeries performed during the long-term follow-up were collected from all medical insurer electronic medical records.

RESULTS

The cohort included 427 women of mean age 63 ± 9.3 years; 90.9 % were postmenopausal. Mean duration of follow-up was 10.7 ± 2.6 years. During the follow-up period, only 3 patients (0.7 %) were re-operated for left adnexal pathology, non-malignant in all cases.

CONCLUSION

In women undergoing vaginal hysterectomy for pelvic organ prolapse without opportunistic adnexectomy, preservation of the adnexa poses only a very low risk for adnexal pathology or need for reoperation later in life.

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE

To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain.

BURDEN OF SUFFERING

CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.

OUTCOMES

Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.

EVIDENCE

Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.

VALUES

The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Impact of prior hysterectomy on surgical outcomes for laparoscopic adnexal surgery

BACKGROUND

Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning.

METHODS

We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval.

RESULTS

Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046).

CONCLUSIONS

Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.

Adnexal lesions after hysterectomy: A retrospective observational study

Objective:

To characterize adnexal lesions detected in patients who had undergone previous hysterectomy with one or both ovaries conserved, and to define the clinical, pathologic, and surgical characteristics of the adnexal lesions in these patients.

Material and Methods:

A retrospective observational study was conducted on patients who had undergone a previous abdominal hysterectomy with one or both adnexa preserved and who had subsequently presented with an adnexal lesion. Characteristics of lesions, operative, and pathologic findings in patients who required a re-operation were noted.

Results:

One hundred thirty-seven patients presented with an adnexal lesion after hysterectomy. Of the 137 patients, 71 (51.8%) had undergone a re-operation (re-operated group), the rest of the patients (n=66, 48.1%) remained on follow-up (follow-up group) in whom the lesion disappeared during follow-up period. Adnexal lesions that were re-operated were significantly larger (p<0.001), more complicated (p=0.04), and had more septations (p=0.01) than in the follow-up group. The origin of the adnexal lesion was confirmed as the ovary in 59 (83%) patients, and as the peritoneum in 8 (11.2%) patients during surgery. All of the adnexal lesions arising after hysterectomy and required a re-operation were confirmed to be benign.

Conclusion:

Almost half of the lesions detected after hysterectomy disappeared during the follow-up period. The adnexal lesions that were re-operated were more symptomatic, larger, and had more complicated lesions. All lesions that were re-operated were found to be benign, mostly originating from the ovary.

Surgically Induced Menopause-A Practical Review of Literature

Menopause can occur spontaneously (natural menopause) or it can be surgically induced by oophorectomy. The symptoms and complications related to menopause differ from one patient to another. We aimed to review the similarities and differences between natural and surgically induced menopause by analyzing the available data in literature regarding surgically induced menopause and the current guidelines and recommendations, the advantages of bilateral salpingo-oophorectomy in low and high risk patients, the effects of surgically induced menopause and to analyze the factors involved in decision making.

Residual ovarian syndrome: A case report with classic symptoms, imaging and pathology findings, and treatment

OBJECTIVE

Residual ovarian syndrome (ROS) occurs after a hysterectomy in which one or both ovaries have been preserved and cause chronic pelvic pain, an asymptomatic pelvic mass, or dyspareunia. We present a case with classic symptoms and imaging and pathology findings, and review the treatment of residual ovarian syndrome.

CASE REPORT

A 35-year-old woman with a diagnosis of ROS.

CONCLUSION

Based on previous literature, almost 50% of patients with ROS require surgery for their symptoms. Treatment of ROS with gonadotropin-releasing hormone analogs or high dose progestogens may be helpful. However, there are limited data supporting the efficacy of pharmacologic therapy. Patients receiving pharmacologic therapy should be counseled about the limited data supporting the efficacy of this approach, the lack of a histologic diagnosis, and the risk of ovarian cancer in residual tissue.

Laparoscopic Oophorectomy to Treat Pelvic Pain FollowingOvary-Sparing Hysterectomy: Factors Associated with Surgical Complications and Pain Persistence

STUDY OBJECTIVE

To examine the surgical management and outcomes of patients treated laparoscopically for pelvic pain following ovary-sparing hysterectomy.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

General gynecology unit at a tertiary university hospital.

PATIENTS

A total of 99 patients treated with laparoscopic oophorectomy for pelvic pain following ovary-sparing hysterectomy between January 2008 and December 2016.

INTERVENTIONS

Laparoscopic oophorectomy was performed in all patients.

MEASUREMENTS AND MAIN RESULTS

The patients undergoing surgery had a mean age of 48.9 years and a mean body mass index (BMI) of 28.1. They reported a mean of 3.0 previous abdominal surgeries. Sixty percent of patients reported previous abdominal hysterectomy, 21% had previous laparoscopic hysterectomy, and 19% had previous vaginal hysterectomy. At a 6-week follow-up, 59.5% of patients reported resolution of symptoms, 10.7% reported persistent symptoms, and 29.8% reported improved but not resolved symptoms. Younger patients and those reporting a previous history of gastrointestinal disease were more likely to report persistent pain at follow-up. Thirteen percent of patients had intraoperative (6%) or postoperative complications (7%), and there was a 2% rate of conversion to laparotomy. Patients at greater risk of intraoperative complications were those with a higher BMI, a greater number of previous open abdominal surgeries, or severe adhesions noted at the time of procedure.

CONCLUSIONS

Laparoscopic oophorectomy to treat pelvic pain following ovary-sparing hysterectomy is a feasible yet challenging procedure. Despite a significant rate of complications and a small proportion of patients reporting persistent symptoms, most experience symptom resolution or improvement after such surgery. Further studies are needed to assess long-term outcomes. Careful patient selection and counseling are critical before this procedure.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review

OBJECTIVE

To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy.

DATA SOURCES

MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries.

METHODS OF STUDY SELECTION

Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14-0.7% compared with 0.02-0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04-1.92). Coronary heart disease (HR 1.26, 95% CI 1.04-1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27-2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results.

CONCLUSION

Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.

Management Strategies for the Ovaries at the Time of Hysterectomy for Benign Disease

Gynecologists performing hysterectomy for benign disease must universally counsel women about ovarian management. The beneficial effect of elective bilateral salpingo-oophorectomy (BSO) on incident ovarian and breast cancer and elimination of need for subsequent adnexal surgery must be weighed against the risks of ovarian hormone withdrawal. Ovarian conservation rates have increased significantly over the past 15 years. In postmenopausal women, however, BSO can reduce ovarian and breast cancer rates without an adverse impact on coronary heart disease, sexual dysfunction, hip fractures, or cognitive function.

Risk of oophorectomy after hysterectomy

OBJECTIVE

To compare the risk of subsequent oophorectomy among women who underwent hysterectomy for benign indications and those who did not.

METHODS

Using Rochester Epidemiology Project resources, we compared the risk of oophorectomy through December 31, 2008, among 4,931 women in Olmsted County, Minnesota, who underwent ovary-sparing hysterectomy for benign indications (case group) between 1965 and 2002, with 4,931 age-matched women who did not undergo hysterectomy (referent group). The cumulative incidence of subsequent oophorectomy was estimated by the Kaplan-Meier method, and comparisons were evaluated by Cox proportional hazard models using age as the time scale to allow for complete age adjustment.

RESULTS

The median follow-up times for case group and referent group participants were 19.6 and 19.4 years, respectively. At 10, 20, and 30 years after hysterectomy, the respective cumulative incidences of subsequent oophorectomy were 3.5%, 6.2%, and 9.2% among case group participants and 1.9%, 4.8%, and 7.3% among referent group participants. The overall risk of subsequent oophorectomy among case group participants was significantly higher than among referent group participants (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.02-1.42; P=.03). Furthermore, among case group participants, the risk of subsequent oophorectomy was significantly higher (HR 2.15, 95% CI 1.51-3.07; P<.001) in women who had both ovaries preserved compared with those who initially had one ovary preserved.

CONCLUSION

The incidence of oophorectomy after hysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentage points higher than the incidence of oophorectomy in referent women with intact reproductive organs.

LEVEL OF EVIDENCE

II.

Advice given to women undergoing gynaecological surgery in relation to menopause, symptoms and hormone replacement therapy: could and should we improve the service we provide?

A retrospective case-note study was undertaken to look at recorded details relating to information/advice given to women prior to or at the time of their gynaecological surgery with regard to possible effects of menopause/menopausal symptoms or advice given about hormone replacement therapy.

Effect of bilateral oophorectomy on women's long-term health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced in order to prevent the subsequent development of ovarian cancer or other ovarian pathology that might require additional surgery. At present, bilateral oophorectomy is performed in 78% of women aged between 45 and 64 years having a hysterectomy, and a total of approximately 300,000 prophylactic oophorectomies are performed in the USA every year. Estrogen deficiency resulting from pre- and post-menopausal oophorectomies has been associated with higher risks of coronary heart disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression and anxiety in many studies. While ovarian cancer accounts for 14,800 deaths per year in the USA, coronary heart disease accounts for 350,000 deaths per year. In addition, 100,000 cases of dementia may be attributable annually to prior bilateral oophorectomy. At present, observational studies suggest that bilateral oophorectomy may do more harm than good. In women who are not at high risk of developing ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer

Women who do not have a documented germline mutation or who do not have a strong family history suspicious for a germline mutation are considered to be at average risk of ovarian cancer. Women who have confirmed deleterious BRCA1 and BRCA2 germline mutations are high risk of ovarian cancer. In addition, women who have a strong family history of either ovarian or breast cancer may carry a deleterious mutation and must be presumed to be at higher-than-average risk, even if they have not been tested, because there could be other mutations that are either untested or yet undiscovered that confirm higher-than-average risk of these diseases. We reviewed studies pertaining to prophylactic bilateral salpingo-oophorectomy in women at average risk of ovarian cancer who are undergoing hysterectomy for benign disease. We also reviewed the role of prophylactic bilateral salpingo-oophorectomy in preventing ovarian cancer based on the level of risk of the patient. For women at average risk of ovarian cancer who are undergoing a hysterectomy for benign conditions, the decision to perform prophylactic bilateral salpingo-oophorectomy should be individualized after appropriate informed consent, including a careful analysis of personal risk factors. Several studies suggest an overall negative health effect when prophylactic bilateral salpingo-oophorectomy is performed before the age of menopause. Ovarian conservation before menopause may be especially important in patients with a personal or strong family history of cardiovascular or neurological disease. Conversely, women at high risk of ovarian cancer should undergo risk-reducing bilateral salpingo-oophorectomy.

Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem. Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management.

Bilateral oophorectomy versus ovarian conservation: effects on long-term women's health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced to prevent the subsequent development of ovarian cancer. Currently, bilateral oophorectomy is performed in 55% of all U.S. women having a hysterectomy, with approximately 300,000 prophylactic oophorectomies performed every year. Observational studies show that 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. In women not at high risk for development of ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Prophylactic bilateral oophorectomy or removal of remaining ovary at the time of hysterectomy in the United States, 1979-2004

OBJECTIVE

The purpose of this study was to describe national rates and trends of prophylactic bilateral oophorectomy or remaining oophorectomy (BO/RO) at hysterectomy in women without specific gynecologic disease.

STUDY DESIGN

Data from the National Hospital Discharge Survey were analyzed for 1979-2004. Hysterectomies were divided into 2 groups: (1) hysterectomy with BO/RO and (2) hysterectomy alone (> or =1 ovary remaining). Age-adjusted rates (AARs) were calculated with 2000 US census data.

RESULTS

Approximately 3,686,000 hysterectomies with BO/RO were performed from 1979-2004. AARs of hysterectomy with BO/RO decreased during this period; the AARs in women > or =50 years old increased. The number of hysterectomies alone was 5,461,100, and AARs of hysterectomy alone decreased significantly from 2.9 per 1000 women in from 1979-1981 to 1.1 per 1000 women in 2001 (P < .001). The proportion of women who underwent hysterectomy with BO/RO increased from 29% in 1979 to 45% in 2004.

CONCLUSION

Although AARs of prophylactic BO/RO decreased from 1979-2004, the actual proportion of BO/RO at hysterectomy increased.

[Ovarian remnant syndrome: diagnostic difficulties and management]

OBJECTIVES

The ovarian remnant syndrome is a rare condition after unilateral or bilateral oophorectomy, with or without a hysterectomy. This syndrome occurs when a fragment of ovarian tissue is left behind and becomes functional and cystic. The purpose of this study is to report the cases of patients treated surgically for an ovarian remnant syndrome during the last 10 years and to recall the diagnostic and therapeutic difficulties.

PATIENTS AND METHODS

A retrospective, observational study was carried out between 1997 and 2006. Seven patients were treated surgically for an ovarian remnant syndrome. Perioperative data analysis (history, surgical techniques, and postoperative follow-up) was carried out.

RESULTS

The mean age of the patients was 46 years (36-55). The number of previous abdominal surgical procedures ranged from 2 to 5. The syndrome appeared after a mean period of 4 years and 4 months (range 5 months-12 years) after oophorectomy. Among the 7 patients, 3 had had a previous hysterectomy. Pelvic pain was found in all cases. Gonadotropin-releasing hormones agonists were used in 1 patient without success. Aspiration was performed in 2 cases before surgical treatment. Two patients underwent a laparotomy in the first place. Laparoscopy was performed in 5 cases and laparoconversion was necessary in 1 case. Intraoperative difficulties and anatomic variations were found in all cases. Ureteral catheters were placed in 2 cases. Radiotherapy was performed in 1 patient who had a recurrent ovarian remnant.

DISCUSSION AND CONCLUSION

The ovarian remnant syndrome is a rare complication. Surgery, either by laparoscopy or by laparotomy, is the recommended treatment. These operations are often difficult and associated with a high risk of complications. Histologically, remnant ovarian tissue associated with hemorragic corpus luteum cysts is the most common finding. The prevention of the ovarian remnant syndrome is based on rigorous surgical treatment during the oophorectomy so as not to leave behind ovarian tissue.

Late aortic lymphocele and residual ovary syndrome after gynecological surgery

Background

Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough.

Case presentation

We describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells.

Conclusion

The tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection (urinoma, lymphocele, seroma, hematoma, abscess) in gynecologic oncology follow-up to properly differentiated from tumor recurrence.

Elective oophorectomy in the gynecological patient: when is it desirable?

PURPOSE OF REVIEW

Oophorectomy is electively performed in approximately 300,000 US women per year who are having hysterectomy for benign disease.

RECENT FINDINGS

New studies have suggested that elective oophorectomy may not be advisable for the majority of women, as it may lead to a higher risk of death from cardiovascular disease and hip fracture, and may result in a higher incidence of dementia and Parkinson's disease. Women with known BRCA 1/2 germ-line mutations clearly benefit from oophorectomy after childbearing.

SUMMARY

Prophylactic oophorectomy should be undertaken with caution in the majority of women with an average risk of ovarian cancer who are having a hysterectomy for benign disease.

Ovarian conservation at the time of hysterectomy for benign disease

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.

Elective oophorectomy for benign gynecological disorders

OBJECTIVE

To review the risks and benefits of elective oophorectomy and to make a clinical recommendation for an appropriate age when benefits of this procedure outweigh the risks.

DESIGN

The risks and benefits of oophorectomy as detailed in published articles are reviewed with regard to quality-of-life issues and mortality outcomes in oophorectomized versus non-oophorectomized women from five diseases linked to ovarian hormones (coronary heart disease, ovarian cancer, breast cancer, stroke, and hip fracture).

RESULTS

Numerous reports link oophorectomy to higher rates of cardiovascular disease, osteoporosis, hip fractures, dementia, short-term memory impairment, decline in sexual function, decreased positive psychological well-being, adverse skin and body composition changes, and adverse ocular changes, as well as more severe hot flushes and urogenital atrophy. The potential benefits associated with oophorectomy include prevention of ovarian cancer, a decline in breast cancer risk, and a reduced risk of pelvic pain and subsequent ovarian surgery. In our study of long-term mortality after oophorectomy using Markov modeling, preservation of ovaries until women are at least aged 65 years was associated with higher survival rates. For women between ages 50 and 54 with hysterectomy and ovarian preservation, the probability of surviving to age 80 was 62% versus 54% if oophorectomy was performed. This 8% difference in survival is primarily due to fewer women dying from cardiovascular heart disease and/or hip fracture. This survival advantage far outweighs the 0.47% increased mortality rate from ovarian cancer prevented by oophorectomy. If surgery occurred between ages 55 and 59, the survival advantage was 4%. After age 64 there were no significant differences in survival rates. Prior literature supports our conclusion of a benefit over risk for ovarian conservation.

CONCLUSIONS

Elective oophorectomy is associated with short-and long-term health consequences that merit serious consideration. For women with an average risk of ovarian cancer, ovarian conservation until at least age 65 seems to benefit long-term survival.

Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE

To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.

OUTCOMES

Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.

EVIDENCE

Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.

VALUES

The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; (j) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Ovarian Conservation at the Time of Hysterectomy for Benign Disease

OBJECTIVE

Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease. The optimal age for this recommendation in women at average risk for ovarian cancer has not been determined.

METHODS

Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease, hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to estimate the optimal strategy for maximizing survival for women at average risk of ovarian cancer. For each 5-year age group from 40 to 80 years, 4 strategies were compared: ovarian conservation or oophorectomy, and use of estrogen therapy or nonuse. Outcomes, as proportion of women alive at age 80 years, were measured. Sensitivity analyses were performed, varying both relative and absolute risk estimates across the range of reported values.

RESULTS

Ovarian conservation until age 65 benefits long-term survival for women undergoing hysterectomy for benign disease. Women with oophorectomy before age 55 have 8.58% excess mortality by age 80, and those with oophorectomy before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease.

CONCLUSION

Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease.

Effect of total abdominal hysterectomy on ovarian blood supply in women of reproductive age

OBJECTIVE

The purpose of this study was to evaluate the effect of total abdominal hysterectomy on ovarian blood supply using transvaginal color Doppler ultrasonography in women of reproductive age.

METHODS

This prospective study included 61 women aged 40 years or younger who were divided into 2 groups: group 1, comprising 31 patients who underwent total abdominal hysterectomy (TAH); and group 2, comprising 30 women with no abnormalities. Inclusion criteria included normal ovarian function at baseline, with basal follicle-stimulating hormone levels of less than 15 mUI/mL, normal body weight, no tobacco use, and no history of laparotomy or ovarian disease. Ovarian arterial blood supply by determination of the pulsatility index (PI) on Doppler analysis and ovarian volume on transvaginal ultrasonography were assessed at baseline and at 6 and 12 postoperative months. The Student t test, profile analysis, and Friedman and Mann-Whitney tests were used in the statistical analysis of data.

RESULTS

Statistical analysis of baseline data revealed that both groups were homogeneous. At months 6 and 12, greater ovarian volumes and lower PI values were observed in patients who underwent TAH (P < .05). By the end of the study, in 8 of the 31 patients who underwent TAH (25.5%), benign ovarian cysts were observed. In the control group, all the parameters studied remained unchanged.

CONCLUSIONS

The reduced PI values observed on Doppler ultrasonography suggested a decrease in the resistance flow in the ovarian arteries in women of reproductive age who underwent TAH.

[Value of ureteral catheterization in laparoscopy]

OBJECTIVE

Describe indications and procedures of ureteral retrograde catheter placement in operative laparoscopy. Assess the security that allows this technique to avoid or detect ureteral injury.

STUDY DESIGN

A cohort study over a five year period was performed on 1722 patients who underwent an operative gynecologic laparoscopy.

SURGICAL TECHNIQUE

When presumptive evidence of ureter adhesiolysis (dense adhesions from previous surgery, endometriosis), or suspicion of iatrogenic ureter transection, laparoscopic procedure was interrupted. A cystoscopy was performed and an internalized stent was inserted.

RESULTS

In nine cases (preventive indications), patients required this procedure in adnexal surgery (dense adhesions from previous operations endometriosis), in oophorectomy for residual ovary syndrome and ovarian remnant syndrome and in hysterectomy with an intraligamentary leiomyomata. In one case (diagnostic indication), ureteral catheter placement was performed after use of an endoscopic linear stapler during a laparoscopically assisted vaginal hysterectomy.

CONCLUSION

This intra-operative procedure can allow better ureter recognition and its safe dissection when complex operative laparoscopy is foreseen.

Operative laparoscopic treatment of ovarian retention syndrome

STUDY OBJECTIVE

To evaluate the ability to treat ovarian retention syndrome (ORS) by operative laparoscopy.

DESIGN METHODS

Retrospective observational analysis (Canadian Task Force classification II-2).

SETTING

Pelvic pain referral practice in an university-affiliated community hospital.

PATIENTS

Thirty consecutive women with ORS.

INTERVENTION

Operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Salpingo-oophorectomy or oophorectomy was completed laparoscopically in 26 women; conversion to laparotomy was necessary in 4 (13.3%). Mean operating time was 159 +/- 63 minutes, mean blood loss was 119 +/- 152 ml, and mean hospital stay was 1.1 +/- 1.4 days. Complications occurred in four patients (13. 3%); in two (6.6%) they were intraoperative. The mean time interval between hysterectomy and symptoms of ORS was 6.4 +/- 4.6 years. Mean preoperative duration of pain was 40.11 +/- 41.3 months. Of 27 patients with adequate follow-up, 13 (48%) were pain free postoperatively with a mean follow-up of 12.9 +/- 8.2 months. Fourteen women (52%) had recurrent pain with mean time to recurrence of 8.8 +/- 10 months. Mean visual analog pain scores were 7.5 +/- 2. 4 preoperatively and 2.3 +/- 3.1 postoperatively (p <0.001). Endometriosis at time of surgery was associated with a significantly higher risk of recurrent pelvic pain (relative risk = 2.3, 95% confidence intervals 1.1, 5.1). Ovarian preservation was significantly related to recurrence of pain (RR = 2.6, 95% CI 1.52, 4.53) and risk of repeat surgery (RR = 4.4, 95% CI 1.69, 11.33).

CONCLUSIONS

Ovarian retention syndrome can usually be treated by laparoscopy. Removal of both ovaries, if present, may be necessary to prevent recurrent pain. In our series, 48% of women experienced prolonged relief. (J Am Assoc Gynecol Laparosc 6(3):297-302, 1999)