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

Sexual dimorphism in the gut microbiota and sexual dimorphism in chronic diseases: Association or causation?

Understanding the sexual dimorphism in diseases is essential to investigate the pathogenesis of some chronic diseases (e.g., autoimmune diseases, etc). The gut microbiota has been found to show a notable impact on the pathology of several chronic diseases in recent years. Intriguingly, the composition of the gut microbiota varies between sexes. Here, we reviewed 'facts and fiction' regarding sexual dimorphism in chronic diseases and sexual dimorphism in the gut microbiota respectively. The association and causative relationship between them aiming to elucidate the pathological mechanisms of sexual dimorphism in chronic diseases were further explored. The development of gender-special food products based on the sexual dimorphism in the gut microbiota were recommended, which would be beneficial to facilitating the personalized treatment.

Gynecological surgery in adulthood imparts cognitive and brain changes in rats: A focus on hysterectomy at short-, moderate-, and long-term intervals after surgery

Premenopausal hysterectomy is associated with a greater relative risk of dementia. We previously demonstrated cognitive impairments in adult rats six weeks after hysterectomy with ovarian conservation compared with intact sham-controls and other gynecological surgery variations. Here, we investigated whether hysterectomy-induced cognitive impairments are transient or persistent. Adult rats received sham-control, ovariectomy (Ovx), hysterectomy, or Ovx-hysterectomy surgery. Spatial working memory, reference memory, and anxiety-like behavior were tested either six-weeks post-surgery, in adulthood; seven-months post-surgery, in early middle-age; or twelve-months post-surgery, in late middle-age. Hysterectomy in adulthood yielded spatial working memory deficits at short-, moderate-, and long-term post-surgery intervals. Serum hormone levels did not differ between ovary-intact, but differed from Ovx, groups. Hysterectomy had no significant impact on healthy ovarian follicle or corpora lutea counts for any post-surgery timepoint compared with intact sham-controls. Frontal cortex, dorsal hippocampus, and entorhinal cortex were assessed for activity-dependent markers. In entorhinal cortex, there were alterations in FOSB and ΔFOSB expression during the early middle-age timepoint, and phosphorylated ERK1/2 levels at the adult timepoint. Collectively, results suggest a primary role for the uterus in regulating cognition, and that memory-related neural pathways may be modified following gynecological surgery. This is the first preclinical report of long-term effects of hysterectomy with and without ovarian conservation on cognition, endocrine, ovarian, and brain assessments, initiating a comprehensive framework of gynecological surgery effects. Translationally, findings underscore critical needs to decipher how gynecological surgeries, especially those involving the uterus, impact the brain and its functions, the ovaries, and overall aging from a systems perspective.

A systematic review and meta-analysis on tubal ligation and breast cancer risk

BACKGROUND

Based on previous studies, it has been hypothesized that tube sterilization may be associated with a lower risk of breast cancer. This study aims to investigate the relationship between tubal ligation and the risk of breast cancer through a systematic review and meta-analysis.

METHODS

In this systematic review and meta-analysis, PubMed/Medline, Web of Science, Scopus, and Google Scholar were searched for relevant non randomized studies published up to November 2020. Then, we screened the papers to include the eligible papers in the meta-analysis. Finally, we pooled the extracted results of individual studies to estimate the summary effect size. All analyses were done using Stata software version 13 (Stata Corp, College Station, TX).

RESULTS

Four hundred sixty-four papers were retrieved from PubMed/Medline (160), Scopus (165), and Web of Science (139), and 21 papers from Google Scholar and manual search of references in selected full texts. After the removal of duplicates and screening of the papers, 11 articles (6 cohort and 5 case-control study) were included in the final analysis. The results of cohort (RR = 0.99, 95% CI = 0.97-1.0, I² = 21.1%) and case control studies (OR = 0.87, 95% CI = 0.62-1.12, I² = 88.9%) revealed that tubal ligation was not significantly associated with breast cancer risk.

CONCLUSION

According to our findings, tubal ligation cannot be considered as a risk factor associated with breast cancer risk.

Attitudes of Israeli gynecologists towards risk reduction salpingo-oophorectomy at hysterectomy for benign conditions and the use of hormonal therapy

OBJECTIVES

To investigate the perspectives and attitudes of gynecologists towards risk reduction bilateral salpingo-oophorectomy (RRBSO) in average-risk women at the time of hysterectomy procedure for benign indications divided by age groups, and whether they recommend the use of hormonal therapy post oophorectomy.

METHODS

A questionnaire was distributed during staff meetings either by a printed questionnaire or by a link to a total number of 360 gynecologists include seniors and practitioners. Three hundred and one gynecologists participated in a national survey. Participants completed a structured questionnaire including three different scenarios. The subject group included both attending (senior) and second-year and above resident gynecologists, from divergent subspecialties. The demographic information of the survey responders included sex, age, years of experience, working domain, and subspecialty.

RESULTS

There was a 95% consensus rate among Israeli gynecologists, in favor of the ovarian conservation approach among 45-year-old women, elected for hysterectomy due to benign indications. Whereas in 50-year-old perimenopause women, without any evident family history of ovarian cancer, 39% of gynecologists advocated BSO at the time of hysterectomy, for benign indications. As for 46-year-old women, with a first-degree relative diagnosed with ovarian cancer at the age of 65 years old, 70.4% voted for prophylactic BSO. For the second part of the questionnaire regarding the utilization of hormone therapy (HT) after BSO, 66.1% of our responders proclaimed they would always encourage the use of HT in 45-year-old-women, while 52.8% recommended HT in 46-year-old-women with a family history of ovarian cancer and 39.5% for 50-year-old perimenopause women.

CONCLUSION

Our national survey confirms the wide variability in attitudes among gynecologists towards performing RRBSO at hysterectomy for a benign indication in women aged 45-50, with family history being a major factor in the decision.

Estrogen and Progesterone Receptor Immunoexpression in Fallopian Tubes among Postmenopausal Women Based on Time since the Last Menstrual Period

Existing data on the expression of estrogen receptor (ERα) and progesterone receptor (PR) in fallopian tubes in postmenopausal women are mostly inconclusive. Therefore, we assessed ERα and PR immunoexpression in the oviducts of these women. One hundred postmenopausal women were divided into three groups based on time elapsed since the last menstrual period: (A) 1–5 years, (B) 6–10 years, and (C) ≥11 years. In all groups, both in the glandular epithelium and stroma of the ampulla and isthmus of the oviduct, immunolocalization of ERα and PR were noted. The glandular epithelium of the ampulla showed a higher percentage of PR-positive cells than the isthmus in each group. Regarding ERα, there were no significant differences. In the glandular epithelium in both the ampulla and isthmus, the percentage of ERα- and PR-positive cells was significantly higher than that in the stroma in each study group and higher in the A group than in the C group. In conclusion, in postmenopausal women, time elapsed since the last menstrual period in the fallopian tubes was positively correlated with the following: (1) the epithelium showed vacuolation of cytoplasm with greater frequency, (2) the proportion of ciliated cells decreased, and (3) the percentage of ERα- and PR-positive cells also decreased. The obtained results indicate a significant decrease in ERα and PR expression depending on the time that has elapsed since the last menstruation, which is undoubtedly related to the loss of the reproductive function of the patients.

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

BACKGROUND

Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown.

OBJECTIVE

This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research.

STUDY DESIGN

We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications.

RESULTS

Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records.

CONCLUSION

Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.

The impact of recent power morcellator risk information on inpatient surgery and patient outcomes

Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.

Analysis of 1135 gut metagenomes identifies sex-specific resistome profiles

Several gastrointestinal diseases show a sex imbalance, although the underlying (patho)physiological mechanisms behind this are not well understood. The gut microbiome may be involved in this process, forming a complex interaction with host immune system, sex hormones, medication and other environmental factors. Here we performed sex-specific analyses of fecal microbiota composition in 1135 individuals from a population-based cohort. The overall gut microbiome composition of females and males was significantly different (p = 0.001), with females showing a greater microbial diversity (p = 0.009). After correcting for the effects of intrinsic factors, smoking, diet and medications, female hormonal factors such as the use of oral contraceptives and undergoing an ovariectomy were associated with microbial species and pathways. Females had a higher richness of antibiotic-resistance genes, with the most notable being resistance to the lincosamide nucleotidyltransferase (LNU) gene family. The higher abundance of resistance genes is consistent with the greater prescription of the Macrolide-Lincosamide-Streptogramin classes of antibiotics to females. Furthermore, we observed an increased resistance to aminoglycosides in females with self-reported irritable bowel syndrome. These results throw light upon the effects of common medications that are differentially prescribed between sexes and highlight the importance of sex-specific analysis when studying the gut microbiome and resistome.

Surgical prevention strategies in ovarian cancer

Given the current lack of effective screening for ovarian cancer, surgical removal of at-risk tissue is the most successful strategy to decrease risk of cancer development. However, the optimal timing of surgery and tissues to remove, as well as the appropriate patients to undergo preventive procedures are poorly understood. In this review, we first discuss the origin and precursors of ovarian epithelial carcinomas, focusing on high-grade serous carcinomas and endometriosis-associated carcinomas, which cause the majority of the mortality and incidence of ovarian cancer. In addition, we summarize the implications of current understanding of specific pathogenic origins for surgical prevention and remaining gaps in knowledge. Secondly, we review evidence from the epidemiologic literature on the associations of various surgical prevention strategies, including endometriosis excision, tubal procedures, and bilateral salpingo-oophorectomy, with risk of future ovarian cancer development, as well as the short- and long-term consequences of these strategies on women's health and quality and life. We conclude with recommendations for surgical prevention in women with high-risk genetic mutations and average-risk women, and a brief discussion of ongoing research that will help clarify optimal surgical approaches that balance risk-reduction with maintenance of women's quality of life.

Ovarian conservation vs removal at the time of benign hysterectomy

Over the last 2 decades, the rate of oophorectomy at the time of hysterectomy in the United States has consistently been between 40-50%. A decline in hormone use has been observed since the release of the principal results of the Women's Health Initiative. Oophorectomy appears to be associated with an increased risk of coronary heart disease, as well as deleterious effects on overall mortality, cognitive functioning, and sexual functioning. Estrogen deficiency from surgical menopause is associated with bone mineral density loss and increased fracture risk. While hormone therapy may mitigate these effects, at no age does there appear to be a survival benefit associated with oophorectomy. Reduction of ovarian cancer risk may be accomplished with salpingectomy at the time of hysterectomy.

In-hospital complications of bilateral salpingo-oophorectomy at benign hysterectomy: a population-based cohort study

OBJECTIVE

The study compared the in-hospital complications and related outcomes between women who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases and those who had hysterectomy only.

METHODS

We conducted a population-based, retrospective cohort study using data from Taiwan's National Health Insurance program. Women who underwent concurrent bilateral salpingo-oophorectomy at hysterectomy for benign indications (n = 34,509) were compared with those who had hysterectomy only (n = 176,305). Separate models were estimated to account for the effect of baseline comorbid condition, age, and hysterectomy approach on the relationship between bilateral salpingo-oophorectomy and study outcomes. A secondary analysis was also performed to evaluate the association of inpatient readmission within 30 days and complications among women who underwent bilateral salpingo-oophorectomy.

RESULTS

The addition of a bilateral salpingo-oophorectomy to hysterectomy was associated with a lower risk of surgical complications, a longer length of hospital stay, and an increased risk of inpatient readmission within 30 days. Among women who underwent bilateral salpingo-oophorectomy, women with complications were also more likely to require inpatient readmission within 30 days than those without complications. Our data also suggested that bilateral salpingo-oophorectomy was not associated with an overall risk of medical complications, with the exception of urethral obstruction. The relationships remained even after adjustments by age, surgical indications, hysterectomy approach, and health-related risk factors, such as baseline comorbid condition and status of any prior catastrophic illness.

CONCLUSIONS

Bilateral salpingo-oophorectomy at hysterectomy for benign conditions is not associated with an increased risk of in-hospital complications.

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.

Estimating the Prevalence of Ovarian Cancer Symptoms in Women Aged 50 Years or Older: Problems and Possibilities

Diagnostic testing is recommended in women with "ovarian cancer symptoms." However, these symptoms are nonspecific. The ongoing Diagnosing Ovarian Cancer Early (DOVE) Study in Montreal, Quebec, Canada, provides diagnostic testing to women aged 50 years or older with symptoms lasting for more than 2 weeks and less than 1 year. The prevalence of ovarian cancer in DOVE is 10 times that of large screening trials, prompting us to estimate the prevalence of these symptoms in this population. We sent a questionnaire to 3,000 randomly sampled women in 2014-2015. Overall, 833 women responded; 81.5% reported at least 1 symptom, and 59.7% reported at least 1 symptom within the duration window specified in DOVE. We explored whether such high prevalence resulted from low survey response by applying inverse probability weighting to correct the estimates. Older women and those from deprived areas were less likely to respond, but only age was associated with symptom reporting. Prevalence was similar in early and late responders. Inverse probability weighting had a minimal impact on estimates, suggesting little evidence of nonresponse bias. This is the first study investigating symptoms that have proven to identify a subset of women with a high prevalence of ovarian cancer. However, the high frequency of symptoms warrants further refinements before symptom-triggered diagnostic testing can be implemented.

Associations of Premenopausal Hysterectomy and Oophorectomy With Breast Cancer Among Black and White Women: The Carolina Breast Cancer Study, 1993-2001

Black women experience higher rates of hysterectomy than other women in the United States. Although research indicates that premenopausal hysterectomy with bilateral oophorectomy decreases the risk of breast cancer in black women, it remains unclear how hysterectomy without ovary removal affects risk, whether menopausal hormone therapy use attenuates inverse associations, and whether associations vary by cancer subtype. In the population-based, case-control Carolina Breast Cancer Study of invasive breast cancer in 1,391 black (725 cases, 666 controls) and 1,727 white (939 cases, 788 controls) women in North Carolina (1993-2001), we investigated the associations of premenopausal hysterectomy and oophorectomy with breast cancer risk. Compared with no history of premenopausal surgery, bilateral oophorectomy and hysterectomy without oophorectomy were associated with lower odds of breast cancer (for bilateral oophorectomy, multivariable-adjusted odds ratios = 0.60, 95% confidence interval: 0.47, 0.77; for hysterectomy without oophorectomy, multivariable-adjusted odds ratios = 0.68, 95% confidence interval: 0.55, 0.84). Estimates did not vary by race and were similar for hormone receptor-positive and hormone receptor-negative cancers. Use of estrogen-only menopausal hormone therapy did not attenuate the associations. Premenopausal hysterectomy, even without ovary removal, may reduce the long-term risk of hormone receptor-positive and hormone receptor-negative breast cancers. Varying rates of hysterectomy are a potentially important contributor to differences in breast cancer incidence among racial/ethnic groups.

African Americans and Hispanics Remain at Lower Risk of Ovarian Cancer Than Non-Hispanic Whites after Considering Nongenetic Risk Factors and Oophorectomy Rates

BACKGROUND

Risk factors for invasive epithelial ovarian cancer (IEOC) among Hispanics and African Americans are understudied despite notable differences in incidence relative to non-Hispanic whites.

METHODS

We used multivariate logistic regression to examine parity, oral contraceptive use, tubal ligation, endometriosis, family history of ovarian cancer, and talc use and risk of IEOC among Hispanics (308 cases and 380 controls), African Americans (128 cases and 143 controls), and non-Hispanic whites (1,265 cases and 1,868 controls) using four case-control studies we conducted in Los Angeles County. We expressed each of these factors in the form of increasing risk and calculated population attributable risk percentage (PAR%) estimates for the six risk factors separately and jointly in the three groups.

RESULTS

The risk associations with these six well-accepted factors were comparable in the three groups. The significant racial/ethnic differences in the prevalence of these factors and differences in their oophorectomy rates explained 31% of the lower incidence in African Americans compared with non-Hispanic whites, but only 13% of the lower incidence in Hispanics. The PAR%s ranged from 27.5% to 31.0% for no tubal ligation, 15.9% to 22.2% for not using oral contraceptives, and 12.2% to 15.1% for using talc in the three groups.

CONCLUSIONS

All six risk factors are comparably important in the three groups. Differences in the prevalence of these factors and their oophorectomy rates explained approximately one third of the difference in incidence between African Americans and non-Hispanic whites.

IMPACT

Devising strategies to lessen the burden of IEOC will be applicable to all three racial/ethnic groups.

Why have ovarian cancer mortality rates declined? Part I. Incidence

The age-adjusted mortality rate from ovarian cancer in the United States has declined over the past several decades. The decline in mortality might be the consequence of a reduced number of cases (incidence) or a reduction in the proportion of patients who die from their cancer (case-fatality). In part I of this three-part series, we examine rates of ovarian cancer incidence and mortality from the Surveillance Epidemiology and End Results (SEER) registry database and we explore to what extent the observed decline in mortality can be explained by a downward shift in the stage distribution of ovarian cancer (i.e. due to early detection) or by fewer cases of ovarian cancer (i.e. due to a change in risk factors). The proportion of localized ovarian cancers did not increase, suggesting that a stage-shift did not contribute to the decline in mortality. The observed decline in mortality paralleled a decline in incidence. The trends in ovarian cancer incidence coincided with temporal changes in the exposure of women from different birth cohorts to various reproductive risk factors, in particular, to changes in the use of the oral contraceptive pill and to declining parity. Based on recent changes in risk factor propensity, we predict that the trend of the declining age-adjusted incidence rate of ovarian cancer in the United States will reverse and rates will increase in coming years.

Pre-diagnosis oophorectomy, estrogen therapy and mortality in a cohort of women diagnosed with breast cancer

Introduction

Pre-diagnosis oophorectomy and estrogen therapy could impact mortality due to breast cancer and cardiovascular disease (CVD) among breast cancer survivors. Elective bilateral oophorectomy at the time of hysterectomy for benign conditions is not uncommon among US women.

Methods

We examined the association between pre-diagnosis total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) and both overall and cause-specific mortality in the Collaborative Breast Cancer Studies cohort. Medical history and prior estrogen use were collected during standardized telephone interviews. Vital status, including date and cause of death, was obtained by linkage with the National Death Index. Multivariate hazard ratios (HR) and 95% confidence intervals (CI) for cause-specific mortality were calculated using Cox proportional hazards regression.

Results

Seventeen percent (N = 1,778) of breast cancer survivors (mean age at diagnosis = 63.5) reported pre-diagnosis TAHBSO. During follow-up (mean = 9.5 years), 2,856 deaths occurred, including 1,060 breast cancer deaths and 459 CVD deaths. Breast cancer deaths occurred a median of 5.1 years after diagnosis; CVD deaths occurred further from diagnosis (median = 9.7 years). Women who reported pre-diagnosis TAHBSO had a 16% decrease in all-cause mortality (HR = 0.84; 95% CI: 0.76, 0.92) compared to those with an intact uterus and ovaries. This overall decrease reflected a 27% lower breast cancer mortality among women who never used postmenopausal hormones (HR = 0.73; CI: 0.55, 0.96) and 43% lower CVD risk among women who reported using estrogen (HR = 0.57; CI: 0.39, 0.83) after TAHBSO.

Conclusions

Information on prior TAHBSO and estrogen use can inform risk of death from both breast cancer and cardiovascular disease among breast cancer survivors.

Tubal ligation in relation to menopausal symptoms and breast cancer risk

Background:

Local inflammation after tubal ligation may affect ovarian function and breast cancer risk.

Methods:

We analysed tubal ligation, menopausal characteristics, and breast cancer risk in the Sister Study cohort (N=50 884 women).

Results:

Tubal ligation was associated with hot flashes (hazard ratio (HR) 1.09; 95% confidence interval (CI): 1.06–1.12) but not menopausal age (HR 0.99; 95% CI: 0.96–1.02). Tubal ligation did not have an impact on breast cancer overall (HR 0.95; 95% CI: 0.85–1.06), but had a suggested inverse relation with oestrogen receptor+/progesterone receptor+ invasive tumours (HR 0.84; 95% CI: 0.70–1.01), possibly because of subsequent hysterectomy/bilateral oophorectomy.

Conclusion:

Tubal ligation does not influence overall breast cancer risk.

Variation in ovarian conservation in women undergoing hysterectomy for benign indications

OBJECTIVE

Emerging data suggest that oophorectomy at the time of hysterectomy for benign indications may increase long-term morbidity and mortality. We performed a population-based analysis to estimate the rates of oophorectomy in women undergoing hysterectomy for benign indications.

METHODS

The Perspective database was used to estimate the rate of ovarian preservation in women aged 40-64 years who underwent hysterectomy for benign indications. Hierarchical mixed-effects regression models were developed to estimate the influence of patient, procedural, physician, and hospital characteristics on ovarian conservation. Between-hospital variation in ovarian preservation also was estimated.

RESULTS

Among 752,045 women, 348,972 (46.4%) underwent bilateral oophorectomy, whereas 403,073 (53.6%) had ovarian conservation. Stratified by age, the rate of ovarian conservation was 74.3% for those younger than 40 years of age; 62.7% for those 40-44 years of age; 40.8% for those 45-49 years of age; 25.2% for those 50-54 years of age; 25.5% for those 55-59 years of age; and 31.0% for those 60-64 years of age. Younger age and more recent year of surgery had the strongest association with ovarian conservation. The observed patient, procedural, physician, and hospital characteristics accounted for only 46% of the total variation in the rate of ovarian conservation; 54% of the variability remained unexplained, suggesting a large amount of intrinsic between-hospital variation in the decision to perform oophorectomy.

CONCLUSION

The rate of ovarian conservation is increasing, particularly among women younger than 50 years old. Although demographic and clinical factors influence the decision to perform oophorectomy, there appears to be substantial between-hospital variation in performance of oophorectomy that remains unexplained by measurable patient, physician, or hospital characteristics.

LEVEL OF EVIDENCE

II.

Oophorectomy: the debate between ovarian conservation and elective oophorectomy

Ovarian cancer remains the fifth deadliest cancer among women because of its early asymptomatic nature and lack of efficacious screening methods, leading to frequent late-stage diagnosis. Elective oophorectomy is an option for women undergoing benign hysterectomy as a means of reducing their ovarian cancer risk. Benefits also include reduced risk of repeat surgical operation due to adnexal masses and reduced anxiety related to perceived risk of ovarian and breast cancer. The potential negative side effects of elective oophorectomy, such as decreased cognition and sexual function and increased risk of osteoporosis and cardiac mortality, offer support for ovarian conservation. The implications of this elective procedure and the possible consequences without it require physicians to review the pros and cons with patients in light of the patient's individual circumstances and ovarian cancer risk.

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.

Hysterectomy surgery trends: a more accurate depiction of the last decade?

OBJECTIVE

The objective of the study was to describe trends in hysterectomy route at a large tertiary center.

STUDY DESIGN

We reviewed all hysterectomies performed at Magee-Womens Hospital from 2000 to 2010. This database was chosen over larger national surveys because it has been tracking laparoscopic procedures since 2000, well before laparoscopic hysterectomy International Classification of Diseases, ninth revision (ICD-9) procedure codes were developed.

RESULTS

There were 13,973 patients included who underwent hysterectomy at Magee-Womens Hospital. In 2000, 3.3% were laparoscopic (LH), 74.5% abdominal (AH), and 22.2% vaginal hysterectomy (VH). By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and 3.0% laparoscopic converted to open (LH→AH). Hysterectomies performed for gynecological malignancy represented 24.4% of cases. The average length of stay for benign LH and VH, 1.0 ± 1.0 and 1.6 ± 1.0 days respectively, was significantly shorter than the average 3.1 ± 2.3 day stay associated with AH (P < .001). The average patient age was 46.9 ± 10.9 years for LH, 51.5 ± 12.1 years for AH, and 51.7 ± 14.1 years for VH, and over the study period there was a significant trend of increasing patient age (b1 = 0.517, 0.583, and 0.513, respectively [P < .001 for all]).

CONCLUSION

The percentage of LH increased over the last decade and by 2010 had surpassed AH. The 43.4% LH rate in 2010 is much higher than previously reported in national surveys. This likely is due to an increase in the number of laparoscopic procedures being performed over the last few years as well as the ability of our study to capture LH prior to development of appropriate ICD-9 procedure codes. Our unique ability to determine hysterectomy route, which predates appropriate coding, may provide a more accurate characterization of hysterectomy trends.

Sexual function in older women after oophorectomy

OBJECTIVE

To compare the sexual function of older women who had bilateral oophorectomy with that of older women who had retained their ovaries.

METHODS

This cross-sectional study involved analysis of 1,352 women aged 57 to 85 years from the National Social Life, Health, and Aging Project. Women with previous bilateral oophorectomy were compared with women who retained their ovaries. The primary outcome of interest was self-report of sexual ideation, chosen because having thoughts about sexual experiences is not prohibited by either a partner or a woman's own physical limitations.

RESULTS

Three hundred fifty-six (25.8%) women reported previous bilateral oophorectomy. Our analysis achieved 90% power to detect a difference of 10% in sexual ideation. No significant difference in the report of sexual ideation was found between women with previous bilateral oophorectomy and women who retained their ovaries (54.5% and 95% confidence interval [CI] 48.1-61.0 compared with 49.9% and 95% CI 45.3-54.5, P=.230), even after adjusting for current hormone therapy, age, education, and race (adjusted odds ratio 1.32, 95% CI 0.96-1.80).

CONCLUSION

Bilateral oophorectomy may not play a pivotal role in sexual ideation and function among older women.

LEVEL OF EVIDENCE

II.

Trends in bilateral oophorectomy at the time of hysterectomy for benign disease

OBJECTIVE

To identify patient characteristics associated with bilateral oophorectomy or removal of remaining ovary at the time of benign hysterectomy, and to estimate trends in the performance of oophorectomy from 2001 to 2006.

METHODS

This was a cross-sectional analysis using the New York State Department of Health Statewide Planning and Research Cooperative System. Women aged 18 years or older undergoing hysterectomies for benign gynecologic conditions were included. We evaluated factors associated with oophorectomy on both univariable and multivariable analyses and assessed for changes in performance of oophorectomy over the course of the study.

RESULTS

Forty-seven percent of 144,877 hysterectomies included oophorectomy. Women who underwent oophorectomy were older and were more likely to have a family history of breast or ovarian cancer, a personal history of breast cancer, ovarian cysts, or endometriosis. Women who underwent vaginal or laparoscopic hysterectomy or had uterine prolapse were less likely to undergo oophorectomy. Both race and insurance status were associated with performance of oophorectomy. From 2001 to 2006, there was an 8% absolute decrease in the performance of oophorectomy at the time of benign hysterectomy for women of all ages, with a 10.4% decrease in women aged younger than 55 (P for trend <.001).

CONCLUSION

Age, route of hysterectomy, and concomitant gynecologic diagnoses influence oophorectomy rate. From 2001 to 2006, a significant decrease in the performance of oophorectomy at the time of benign hysterectomy was noted in women aged younger than 55 years. Recent studies of complications of hormone therapy and prophylactic oophorectomy may have influenced patients' and physicians' decision-making, leading to lower oophorectomy rates.

LEVEL OF EVIDENCE

II.

Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery (GRACES) in a Tertiary Referral Centre

Introduction: Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the first 40 cases operated under the GRACES (Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore. Materials and Methods: A review was performed for the first 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used. Results: Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault. Conclusion: Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the first 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery – basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme. Key words: Clinical outcomes, Cost effectiveness, Gynaecology, Learning curve, Robotics

Bilateral oophorectomy in relation to risk of postmenopausal breast cancer: confounding by nonmalignant indications for surgery?

Bilateral oophorectomy is often performed during hysterectomy for benign conditions and can reduce breast cancer risk by 20%-50% when performed at younger ages. Accuracy of estimating the decrease in breast cancer risk associated with bilateral oophorectomy could be affected by common conditions that lead to surgery, such as uterine fibroids or endometriosis. The authors examined the potential for confounding by nonmalignant indications for surgery on breast cancer risk estimates in a population-based case-control study of invasive breast cancer newly diagnosed in 1992-1995. Breast cancer cases (N = 4,935) aged 50-79 years were identified from Wisconsin, Massachusetts, and New Hampshire tumor registries; similarly aged controls (N = 5,111) were selected from driver's license and Medicare lists. Reproductive and medical history was obtained from structured telephone interviews. Odds ratios and 95% confidence intervals were estimated with multivariate logistic regression. Women who underwent bilateral oophorectomy with hysterectomy at age ≤ 40 years had significantly reduced odds of breast cancer (odds ratio = 0.74, 95% confidence interval: 0.60, 0.90) compared with women with intact ovaries and uterus. Effect estimates were virtually unchanged after adjustment for uterine fibroids or endometriosis history. Results indicate that breast cancer risk reductions conferred by bilateral oophorectomy are not strongly confounded by failure to account for nonmalignant indications for surgery.

Elective oophorectomy in the United States: trends and in-hospital complications, 1998-2006

OBJECTIVES

To examine trends in rates of elective bilateral salpingo-oophorectomy in the United States and to assess the association of perioperative complications with elective bilateral salpingo-oophorectomy.

METHODS

This cross-sectional study uses 1998-2006 data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, a nationally representative sample of inpatient hospitalizations. Analyses were limited to women aged 15 years or older at average risk for ovarian cancer who underwent hysterectomy for a benign gynecologic condition. Tests for trends in elective bilateral salpingo-oophorectomy rates were performed using weighted least squares regression for two time periods, 1998 to 2001 and 2002 to 2006. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for risks of complications associated with elective bilateral salpingo-oophorectomy were estimated using logistic regression.

RESULTS

During the period from 1998 to 2006, 39% of the 2,250,041 women who underwent hysterectomy for benign gynecologic indications had elective bilateral salpingo-oophorectomy (rate, 8.3 per 10,000). The elective bilateral salpingo-oophorectomy rate increased from 7.8 per 10,000 in 1998 to 9.0 per 10,000 in 2001 (P trend <.05) and decreased from 9.0 per 10,000 in 2002 to 7.4 per 10,000 in 2006 (P trend <.05). The largest decline from 2002 to 2006 (20.3%) occurred among those aged 45 to 49 years. Compared with hysterectomy only, elective bilateral salpingo-oophorectomy was associated with an increased risk of complications when performed vaginally (OR 1.12; 95% CI 1.08-1.17) and a decreased risk of complications when performed abdominally (OR 0.91; 95% CI 0.89-0.94) or laparoscopically (OR 0.89; 95% CI 0.83-0.94).

CONCLUSION

Elective bilateral salpingo-oophorectomy rates declined since 2002. However, the risks compared with the benefits of the procedure have not been clearly established. Prospective studies examining elective bilateral salpingo-oophorectomy with and without estrogen therapy are needed to guide practice patterns.

LEVEL OF EVIDENCE

III.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures

OBJECTIVES

To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan.

METHODS

Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed.

RESULTS

More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime.

CONCLUSION

Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women.

LEVEL OF EVIDENCE

III.