Ovarian conservation vs removal at the time of benign hysterectomy

Patient preferences regarding the cervix, ovaries, and fallopian tubes at the time of hysterectomy: a qualitative study

Our objective is to understand patients' preexisting values, beliefs, and preferences regarding removal or preservation of the cervix, ovaries, and fallopian tubes at the time of hysterectomy for benign indications. We performed semi-structured interviews from August 2021 to March 2022 with patients referred for hysterectomy. Participants were recruited according to pre-specified diversity axes. The interview guide was informed by literature review, expert stakeholders, and pilot testing. pers. comm. occurred prior to scheduled consultation. Responses were analyzed for themes, with thematic saturation reached. Age of participants (n = 13) ranged from 24 to 60 years. Identified themes included knowledge, decision-making, treatment goals, short- and long-term consequences, fertility, identity, and lack of concern. Many participants expressed lacking necessary knowledge of the risks and benefits of removing the cervix and adnexa. Treatment goals included symptom relief and definitive treatment. Long-term consequences included concerns about menopause and future cancer. Many patients expressed some degree of lack of knowledge, desire to remove most or all pelvic structures, or no attachment to their reproductive organs. Many patients expressed decision-making based on the effects of organ removal on long-term consequences and the relief of current symptoms, rather than immediate surgical risk. This information can help to inform patient-centered surgical counseling.

Hysterectomy-a possible risk factor for operative intervention in female patients for degenerative lumbar spine conditions: a case control and cohort study

BACKGROUND CONTEXT

Researchers have recently linked hysterectomy, which alters sex hormone levels, to diseases like osteoporosis, lumbar spondylolisthesis, hypertension and diabetes etc. However, the association between hysterectomy and lumbar disc herniation (LDH)/lumbar spinal stenosis (LSS) remains unclarified.

PURPOSE

To determine whether there is a correlation between hysterectomy and surgical intervention for LDH/LSS in women, further substantiated through imaging and clinical research.

STUDY DESIGN

A case control and cohort study.

PATIENT SAMPLE

The study group comprised 1202 female patients aged 45 and older who had undergone operative treatment due to LDH/LSS (825 for LDH and 377 for LSS), and the comparison group comprised 1168 females without lumbar diseases who visited health examination clinic during the same period. One hundred and 2 hysterectomized patients were further selected (Hysterectomy cohort) and matched approximately with the control cohort at a 1:2 ratio from the study group with a minimum follow-up of 2 years.

OUTCOME MEASURES

Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to assess the association between hysterectomy and surgical intervention for LDH/LSS in women after adjusted by confounding factors. Patients from both the hysterectomy and control cohorts underwent a comprehensive assessment. This assessment included the evaluation of several parameters: the functional cross-sectional area, fat infiltration rate, relative functional cross-sectional area of the lumbar paravertebral muscles, facet joint degeneration grade, cartilage endplate damage, Modic changes for the L3/4-L5/S1 segments, Pfirrmann grade of lumbar disc degeneration, and disc height index for the L1/2-L5/S1 segments. Additionally, the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were recorded preoperatively and at the last follow-up.

METHODS

Associations between hysterectomy and patients treated surgically for LDH or LSS were analyzed using multivariate binomial logistic regression analysis. Lumbar X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) were used to evaluate the imaging variables. Imaging and clinical variables were compared.

RESULTS

Hysterectomized women were associated with requiring surgery due to LDH/LSS, with ORs of 2.613 (p<.001) and 2.084 (p=.006), respectively. The imaging evaluation further revealed that the hysterectomy cohort had more severe degeneration of the paraspinal muscles, facet joints, endplates, and intervertebral discs, Modic changes at L3/4-L5/S1 segments, and intervertebral height reduction at L1/2-L5/S1 segments when compared to the control cohort (p<.01). Compared to the control cohort, the hysterectomy cohort exhibited higher preoperative and last follow-up VAS scores for low back pain, and last follow-up JOA scores (p<.01).

CONCLUSIONS

Based on the findings of this study, it seems that women who have had a hysterectomy are correlated with requiring surgical intervention due to LDH/LSS. Imaging and clinical studies also indicate that hysterectomized patients exhibited more severe lumbar degeneration and back pain.

Osteoporosis and Fracture Risk Following Benign Hysterectomy Among Female Patients in Korea

IMPORTANCE

Prior research about the association between hysterectomy and osteoporosis risk had limitations.

OBJECTIVE

To assess osteoporosis and fracture risk among female patients who underwent hysterectomy due to benign conditions.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, female patients aged 40 to 59 years with benign hysterectomy between 2003 and 2011 were selected from Korean National Health Insurance Data and matched by 1:1 propensity score with female patients who had health checkups and indicated that they had not had a hysterectomy. A Cox proportional hazard model was used to analyze osteoporosis and fracture risk, with participants monitored until December 31, 2020. Data analysis was performed from July 16, 2022, to January 12, 2023.

EXPOSURES

Hysterectomy with or without adnexal surgical procedure.

MAIN OUTCOMES AND MEASURES

The primary outcome was the risk of osteoporosis. Secondary outcomes included the risk of vertebral fracture, hip fracture, other fractures, and total fracture.

RESULTS

The study population included 25 910 patients; the median (IQR) age was 47 (44-50) years, and median (IQR) follow-up period was 10.9 (9.4-12.7) years. In the stratified-extended Cox proportional analysis, female patients who underwent hysterectomy without an adnexal surgical procedure were associated with a higher risk of osteoporosis within 7 years compared with female patients who did not undergo hysterectomy (hazard ratio [HR], 1.28 [95% CI, 1.19-1.37]); the analysis was divided into 7 years due to a violation of the Cox assumption, and the risk did not differ after 7 years (HR, 0.99 [95% CI, 0.93-1.06]). However, the hysterectomy group with an adnexal surgical procedure had an association with higher risk of osteoporosis compared with the nonhysterectomy group both within 7 years of study entry (HR, 1.56 [95% CI, 1.33-1.82]) and after 7 years (HR, 1.20 [95% CI, 1.04-1.40]). In the hysterectomy group without an adnexal surgical procedure, the risks of vertebral fracture, hip fracture, and total fracture were similar to those in the nonhysterectomy group. Similar trends were observed in the hysterectomy group with an adnexal surgical procedure.

CONCLUSIONS AND RELEVANCE

Hysterectomy without an adnexal surgical procedure was associated with an increased osteoporosis risk within 7 years, but not afterwards, compared with the nonhysterectomy group. Hysterectomy was not associated with vertebral and hip fractures.

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.

Long-Term Follow Up of Sexual Function and Steroid Levels in Women after Perimenopausal Hysterectomy with or without Concomitant Oophorectomy

Hysterectomy, most often performed because of bleeding disorders or uterine leiomyoma, is one of the most common major surgical procedures in women and is usually performed during the perimenopausal period on ages 45-55 years. Hysterectomy may be combined with bilateral salpingo-oophorectomy, as a risk-reducing procedure to minimize the risk of ovarian cancer. An open question is whether concomitant oophorectomy, with cessation of ovarian androgen secretion, has any long-term effects on sexual function. In the present prospective cohort study of women undergoing benign hysterectomy, the long-term (10-12 years) effects on sexual function and changes in sex hormone levels were investigated in women having undergone perimenopausal hysterectomy, with or without concomitant bilateral salpingo-oophorectomy. Originally, 491 women (mean age around 50 years) were operated with (patient preference) either only hysterectomy (HYST) or hysterectomy plus bilateral salpingo-oophorectomy (HYST + BSO), and 441 women (90%; HYST; n = 271 and HYST + BSO; n = 170) completed a one-year survey. In the present study, 185 women (42%) of the cohort with one-year follow up participated in the long-term follow up after 10-12 years. Follow-up was with the 10-item McCoy Female Sex Questionnaire and blood analysis of levels of testosterone, estradiol and sexual-hormone-binding globulin. The results showed that specific aspects of sexual function were lower after HYST + BSO compared to HYST 10-12 years after surgery. These lowered items were frequency of sexual fantasies, enjoyment of sexual activity, sexual arousal, and orgasmic frequency. No long-term differences in sex hormone levels were found between the two groups. In conclusion, some items related to sexual function were lower after HYST + BSO in a long-term perspective study, although the levels of testosterone were unaltered. This finding may have implications for clinical recommendations concerning prophylactic salpingo-oophorectomy or for hysterectomy during the perimenopausal age.

Correlation analysis of hysterectomy and ovarian preservation with depression

The relationship between hysterectomy and ovarian preservation and depression is controversial. This study aimed to determine the association of hysterectomy and ovarian preservation with depression using National Health and Nutrition Examination Survey. To assess the association between hysterectomy with or without ovariectomy and depression, we used 3 methods. Method 1: propensity score model (PSM) was established. Method 2 was logistics regression analysis of hysterectomy and depression before and after PSM. Method 3 was a logistics regression analysis of the relationship between hysterectomy and different depressive symptoms. At the same time, in order to evaluate the association between hysterectomy with or without oophorectomy and depression, we explored the effect of four different surgical procedures on depression using logistic regression equations. We enrolled 12,097 women, of whom 2763 underwent hysterectomy, 34.455% were positive for depression. After weighting, 33.825% of the total sample had a PHQ ≥ 5. Finally, a total of 2778 women were successfully matched by propensity score, and 35.537% of them were positive for depression. The OR for PHQ ≥ 5 was 1.236 after crude adjustment of covariates and 1.234 after exact adjustment. This suggests that Hysterectomy is strongly associated with positive depression. Positive depression (PHQ ≥ 5) was associated with little interest, feeling down and trouble concentrating. It was not associated with trouble sleeping, feeling tired, poor appetite, feeling bad, slow moving or speaking, and suicidal thoughts. Oophorectomy-alone is not associated with depression. Hysterectomy-alone is a risk factor for depression, but Hysterectomy combined with Oophorectomy has a stronger correlation with depression than Hysterectomy-alone. Women who have had a Hysterectomy are at higher risk of depression than women who have not had a Hysterectomy, and this risk may be exacerbated if the uterus and ovaries are removed. When clinically appropriate, surgeons should try to preserve the patient's ovaries.

Radical cystectomy and women's sexual health - can we do better?

PURPOSE OF REVIEW

Female sexual function after radical cystectomy is a crucial, but historically overlooked component of bladder cancer survivorship. This review focuses on recent studies, which have investigated pelvic health and sexual function after radical cystectomy. We discuss modifiable factors, which may contribute to decreased sexual function after radical cystectomy and techniques, which may lead to improved outcomes.

RECENT FINDINGS

Sexual function is important to women and there is a significant desire (and unmet need) for more perioperative counseling and discussion regarding sexual function changes and quality of life impacts. Sexual function may be altered due to a combination of hormonal changes from ovarian removal, anatomic changes from vaginal alteration, and sensation changes due to damage to the neurovascular bundle. Techniques to preserve these structures have been developed.

SUMMARY

Sexual function is an important component of survivorship and increasing attention is being focused on this area. Long term studies with objective measures are needed for to compare various techniques and ensure oncologic safety. Ovarian preservation, anterior vaginal wall preservation, and vaginal estrogen replacement should be carefully considered for most patients.

Alu hypomethylation in naturally and surgically postmenopausal women; a cross-sectional study

Menopause, which may accelerate the hallmarks of the natural aging process, represents a point in time characterized by the permanent cessation of menstruation following the loss of ovarian estrogen production. Unlike natural menopause, which is characterized by a gradual decrease in estrogen production, when both ovaries are removed before the natural age of menopause, the onset of estrogen deprivation is abrupt. Further, a decrease in genome methylation frequently occurs in aging cells, and the major interspersed repetitive DNA elements in humans are Alu elements. In blood cells, Alu demethylation starts at an age of approximately 40 years, and increases with age. Here, we explored the Alu methylation levels corresponding to age-matched pre-menopausal, naturally postmenopausal, and surgically postmenopausal women aged 45–55 years (n = 60 in each group). Our results indicated that the body mass index (BMI), time-since-menopause, and Alu methylation levels corresponding to the three groups were significantly different. However, no correlations between Alu methylation level and BMI, time-since-menopause, or age were observed. Additionally, the Alu methylation level corresponding to the natural post-menopause group was significantly lower those corresponding to the pre-menopausal (p = 0.001) and surgical post-menopausal (p = 0.037) groups. In conclusion, Alu hypomethylation occurs in naturally postmenopausal women, implying that when women reach the age of natural menopause, the cell aging process may progress significantly with genome hypomethylation. These findings, notwithstanding, further studies are necessary to clarify whether bilateral oophorectomy before the age of menopause affects the cell aging process to a greater extent than natural menopause, and whether estrogen therapy or other interventions can delay cell aging in this regard.

Avoidable bilateral salpingo-oophorectomy at hysterectomy: a large retrospective study

OBJECTIVES

Evaluate the proportion of justified bilateral salpingo-oophorectomy (BSO) at hysterectomy, based on pathologic diagnosis, and determine prevalence of avoidable BSO based on pre- and intraoperative considerations and pathologic diagnosis.

METHODS

Retrospective review of hysterectomies at seven Ontario, Canada hospitals from 2016 to 2019. Surgeries completed by oncologists or for invasive placentation were excluded. Patient, case, and surgeon characteristics were recorded along with pathologic diagnoses. Avoidable BSO criteria were: preoperative diagnosis of cervical dysplasia or benign diagnosis other than endometriosis, gender dysphoria, risk reduction or premenstrual dysphoric disorder; age < 51 years; absence of intraoperative endometriosis and adhesions; unjustified pathology (where "justified" pathology was endometriosis or (pre)malignant diagnosis except for cervical dysplasia). Patients with avoidable BSO were compared to those having at least one criterion for BSO. Binary logistic regression identified factors most strongly associated with avoidable BSO.

RESULTS

Four thousand one hundred ninety-one hysterectomies were completed with 1,422 (33.9%) patients having concomitant BSO. Pathologic diagnosis justified BSO in most patients (1,035/1,422, 72.8%) with endometrial cancer being most common (439/1,422, 30.9%). When preoperative characteristics, intraoperative findings, and pathologic diagnoses were considered, 79 of 1,422 (5.6%) BSOs were avoidable. Compared to cases with at least one criterion for BSO, avoidable BSOs were more frequently completed by generalists (OR 1.80, 95% CI 1.10-2.99, P  = 0.021), for preoperative diagnoses of abnormal uterine bleeding/menorrhagia (OR 3.82, 95% CI 2.35-6.30, P  = 0.001) and fibroids (OR 4.25, 95% CI 2.63-6.92, P  < 0.001).

CONCLUSION

Pathologic diagnosis justified most BSOs at hysterectomy. BSO was avoidable in 5.6% of patients, underscoring the need to standardize practice of BSO.

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.

The long-term association between bilateral oophorectomy and depression: a prospective cohort study

OBJECTIVE

Depression is a leading cause of disability globally and affects more women than men. Ovarian sex steroids are thought to modify depression risk in women and interventions such as bilateral oophorectomy that permanently change the sex steroid milieu may increase the risk of depression. This study aimed to investigate the associations between unilateral and bilateral oophorectomy and depression over a 25-year period (1993-2018) and whether this varied by age at oophorectomy or use of menopausal hormone therapy.

METHODS

Twenty-five thousand one hundred eighty-eight nurses aged ≥45 years from the Danish Nurse Cohort were included. Nurses with depression prior to baseline were excluded. Poisson regression models, with log-transformed person-years as offset, were used to assess the associations between oophorectomy and incident depression. Nurses who retained their ovaries were the reference group.

RESULTS

Compared with nurses with retained ovaries, bilateral oophorectomy was associated with a slightly higher rate of depression (rate ratio [RR], 1.08; 95% confidence interval [CI], 0.95-1.23), but without statistical significance. However, when stratified by age at oophorectomy, compared with nurses with retained ovaries, bilateral oophorectomy at age ≥51 years was associated with higher rates of depression (RR 1.16; 95% CI, 1.00-1.34), but not bilateral oophorectomy at age <51 years (RR 0.86; 95% CI, 0.69-1.07); P value for difference in estimates = 0.02. No association between unilateral oophorectomy and depression was observed.

CONCLUSIONS

In this cohort of Danish female nurses, bilateral oophorectomy at age ≥51 years, but not at younger ages, was associated with a slightly higher rate of depression compared with those who retained their ovaries.

Adverse childhood experiences are associated with increased risk of hysterectomy and bilateral oophorectomy: A national retrospective cohort study of women in England

Objective

To examine the associations between adverse childhood experiences (ACE) and the risk of hysterectomy and bilateral oophorectomy in a national sample of women in England.

Design

Retrospective cohort study.

Setting

A stratified random sample of households across England.

Population

2648 women aged ≥55 years in 2007 from the English Longitudinal Study of Ageing (ELSA) were included in the bilateral oophorectomy analyses and 2622 in the hysterectomy analyses.

Methods

Logistic and multinomial logistic regression analyses of the associations between categories of the ACE summary score (0, 1, 2, ≥3 ACE), eight individual ACE, and hysterectomy and bilateral oophorectomy.

Results

615 women had undergone hysterectomy and 259 women bilateral oophorectomy. We found graded associations between the summary ACE score and risk of hysterectomy and bilateral oophorectomy. In the fully adjusted model, compared with women with no ACE, those with ≥3 ACE had double the odds of hysterectomy (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.30–3.11) and more than double the odds of bilateral oophorectomy (OR 2.61, 95% CI 1.54–4.42). The exclusion of women with cancer history made the associations stronger, especially in women who underwent hysterectomy at age <40 years or bilateral oophorectomy at age ≤44 years. Several individual ACE were positively associated with both outcomes.

Conclusions

ACE are associated with increased risk of hysterectomy and bilateral oophorectomy. Individual‐level covariates did not explain these associations. Our findings highlight the importance of a life course approach to understanding surgical menopause and add to our knowledge of the societal and public health impact of ACE.

Tweetable abstract

Adverse childhood experiences are associated with increased risk of hysterectomy and bilateral oophorectomy in a national sample of women in England.

Adverse childhood experiences are associated with increased risk of hysterectomy and bilateral oophorectomy in a national sample of women in England.

Linked article: This article is commented on by Walter A. Rocca, pp. 1491–1492 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17105.

[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]

OBJECTIVE

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.

DESIGN

A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.

METHODS

The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.

RESULTS

The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.

CONCLUSIONS

A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

Opportunistic Salpingectomy at the Time of Urogynecologic Surgery: Why, in Whom, and How?

OBJECTIVES

This review aims to (1) describe evidence supporting the fallopian tube as a site of high-grade serous carcinoma, (2) review literature regarding salpingectomy in high- and average-risk women, and (3) discuss feasibility and safety of salpingectomy in urogynecologic surgery.

METHODS

PubMed and university library resources were used to retrieve relevant English-language publications via keyword search, including "ovarian cancer," "salpingectomy," "risk," "safety," "hysterectomy," "trends," "technique," and "urogynecology." Each publication was reviewed in detail and references incorporated, where relevant.

RESULTS

Evidence supports the fimbriated portion of the fallopian tube as a site of high-grade serous carcinoma in both hereditary and sporadic cases. Routine opportunistic salpingectomy in average-risk women may reduce ovarian cancer risk by 42% to 65% and prevent future surgery for benign tubal disease. Opportunistic salpingectomy is cost-effective for sterilization and cost-saving during hysterectomy. For genetically predisposed women, salpingo-oophorectomy remains the recommended strategy for ovarian cancer risk reduction. Despite being feasible, safe, and cost-effective, concomitant salpingectomy is least commonly performed during vaginal hysterectomy compared with other hysterectomy routes. Salpingectomy rates during vaginal hysterectomy are influenced by geographic factors, surgeon experience, and adhesive disease.

CONCLUSIONS

Opportunistic salpingectomy holds promise as a risk-reducing intervention for ovarian cancer. The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommend that physicians counsel average-risk women regarding opportunistic salpingectomy when planning pelvic surgery. Randomized controlled trials are needed to evaluate long-term implications of salpingectomy. Urogynecologic surgeons should discuss salpingectomy as part of surgical informed consent. Vaginal salpingectomy should be incorporated into residency and fellowship training programs.

Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation

OBJECTIVE

To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy.

METHODS

Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions.

RESULTS

Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749).

CONCLUSIONS

Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.

Menopausal Estrogen-Alone Therapy and Health Outcomes in Women With and Without Bilateral Oophorectomy: A Randomized Trial

BACKGROUND

Whether health outcomes of menopausal estrogen therapy differ between women with and without bilateral salpingo-oophorectomy (BSO) is unknown.

OBJECTIVE

To examine estrogen therapy outcomes by BSO status, with additional stratification by 10-year age groups.

DESIGN

Subgroup analyses of the randomized Women's Health Initiative Estrogen-Alone Trial. (ClinicalTrials.gov: NCT00000611).

SETTING

40 U.S. clinical centers.

PARTICIPANTS

9939 women aged 50 to 79 years with prior hysterectomy and known oophorectomy status.

INTERVENTION

Conjugated equine estrogens (CEE) (0.625 mg/d) or placebo for a median of 7.2 years.

MEASUREMENTS

Incidence of coronary heart disease and invasive breast cancer (the trial's 2 primary end points), all-cause mortality, and a "global index" (these end points plus stroke, pulmonary embolism, colorectal cancer, and hip fracture) during the intervention phase and 18-year cumulative follow-up.

RESULTS

The effects of CEE alone did not differ significantly according to BSO status. However, age modified the effect of CEE in women with prior BSO. During the intervention phase, CEE was significantly associated with a net adverse effect (hazard ratio for global index, 1.42 [95% CI, 1.09 to 1.86]) in older women (aged ≥70 years), but the global index was not elevated in younger women (P trend by age = 0.016). During cumulative follow-up, women aged 50 to 59 years with BSO had a treatment-associated reduction in all-cause mortality (hazard ratio, 0.68 [CI, 0.48 to 0.96]), whereas older women with BSO had no reduction (P trend by age = 0.034). There was no significant association between CEE and outcomes among women with conserved ovaries, regardless of age.

LIMITATIONS

The timing of CEE in relation to BSO varied; several comparisons were made without adjustment for multiple testing.

CONCLUSION

The effects of CEE did not differ by BSO status in the overall cohort, but some findings varied by age. Among women with prior BSO, in those aged 70 years or older, CEE led to adverse effects during the treatment period, whereas women randomly assigned to CEE before age 60 seemed to derive mortality benefit over the long term.

PRIMARY FUNDING SOURCE

The WHI program is funded by the National Heart, Lung, and Blood Institute; National Institutes of Health; and U.S. Department of Health and Human Services. Wyeth Ayerst donated the study drugs.

Hysterectomy with opportunistic salpingectomy versus hysterectomy alone

BACKGROUND

Ovarian cancer has the highest mortality rate of all gynaecological malignancies with an overall five-year survival rate of 30% to 40%. In the past two decades it has become apparent and more commonly accepted that a majority of ovarian cancers originate in the fallopian tube epithelium and not from the ovary itself. This paradigm shift introduced new possibilities for ovarian cancer prevention. Salpingectomy during a hysterectomy for benign gynaecological indications (also known as opportunistic salpingectomy) might reduce the overall incidence of ovarian cancer. Aside from efficacy, safety is of utmost importance, especially due to the preventive nature of opportunistic salpingectomy. Most important are safety in the form of surgical adverse events and postoperative hormonal status. Therefore, we compared the benefits and risks of hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy.

OBJECTIVES

To assess the effect and safety of hysterectomy with opportunistic salpingectomy versus hysterectomy without salpingectomy for ovarian cancer prevention in women undergoing hysterectomy for benign gynaecological indications; outcomes of interest include the incidence of epithelial ovarian cancer, surgery-related adverse events and postoperative ovarian reserve.

SEARCH METHODS

The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trial registers were searched in January 2019 together with reference checking and contact with study authors.

SELECTION CRITERIA

We intended to include both randomised controlled trials (RCTs) and non-RCTs that compared ovarian cancer incidence after hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For assessment of surgical and hormonal safety, we included RCTs that compared hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcomes were ovarian cancer incidence, intraoperative and short-term postoperative complication rate and postoperative hormonal status. Secondary outcomes were total surgical time, estimated blood loss, conversion rate to open surgery (applicable only to laparoscopic and vaginal approaches), duration of hospital admission, menopause-related symptoms and quality of life.

MAIN RESULTS

We included seven RCTs (350 women analysed). The evidence was of very low to low quality: the main limitations being a low number of included women and surgery-related adverse events, substantial loss to follow-up and a large variety in outcome measures and timing of measurements.No studies reported ovarian cancer incidence after hysterectomy with opportunistic salpingectomy compared to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For surgery-related adverse events, there were insufficient data to assess whether there was any difference in both intraoperative (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.11 to 3.94; 5 studies, 286 participants; very low-quality evidence) and short-term postoperative (OR 0.13, 95% CI 0.01 to 2.14; 3 studies, 152 participants; very low-quality evidence) complication rates between hysterectomy with opportunistic salpingectomy and hysterectomy without opportunistic salpingectomy because the number of surgery-related adverse events was very low. For postoperative hormonal status, the results were compatible with no difference, or with a reduction in anti-Müllerian hormone (AMH) that would not be clinically relevant (mean difference (MD) -0.94, 95% CI -1.89 to 0.01; I2 = 0%; 5 studies, 283 participants; low-quality evidence). A reduction in AMH would be unfavourable, but due to wide CIs, the postoperative change in AMH can still vary from a substantial decrease to even a slight increase.

AUTHORS' CONCLUSIONS

There were no eligible studies reporting on one of our primary outcomes - the incidence of ovarian cancer specifically after hysterectomy with or without opportunistic salpingectomy. However, outside the scope of this review there is a growing body of evidence for the effectiveness of opportunistic salpingectomy itself during other interventions or as a sterilisation technique, strongly suggesting a protective effect. In our meta-analyses, we found insufficient data to assess whether there was any difference in surgical adverse events, with a very low number of events in women undergoing hysterectomy with and without opportunistic salpingectomy. For postoperative hormonal status we found no evidence of a difference between the groups. The maximum difference in time to menopause, calculated from the lower limit of the 95% CI and the natural average AMH decline, would be approximately 20 months, which we consider to be not clinically relevant. However, the results should be interpreted with caution and even more so in very young women for whom a difference in postoperative hormonal status is potentially more clinically relevant. Therefore, there is a need for research on the long-term effects of opportunistic salpingectomy during hysterectomy, particularly in younger women, as results are currently limited to six months postoperatively. This limit is especially important as AMH, the most frequently used marker for ovarian reserve, recovers over the course of several months following an initial sharp decline after surgery. In light of the available evidence, addition of opportunistic salpingectomy should be discussed with each woman undergoing a hysterectomy for benign indication, with provision of a clear overview of benefits and risks.

Changes in Bone Mineral Density After Prophylactic Bilateral Salpingo-Oophorectomy in Carriers of a BRCA Mutation

IMPORTANCE

Preventive surgery is strongly recommended for individuals with a BRCA mutation at a young age to prevent ovarian cancer and improve overall survival. The overall effect of early surgical menopause on various health outcomes, including bone health, has not been clearly elucidated.

OBJECTIVE

To evaluate the association of prophylactic bilateral salpingo-oophorectomy with bone mineral density (BMD) loss among individuals with a BRCA mutation.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of participants with a BRCA mutation who underwent oophorectomy through the University Health Network, Toronto, Ontario, Canada, recruited participants from January 2000 to May 2013. Eligibility criteria included having a BRCA mutation, at least 1 ovary intact prior to surgery, and no history of any cancer other than breast cancer. Bone mineral density was measured using dual-energy x-ray absorptiometry before and after surgery. Data analysis began in December 2018 and finished in January 2019.

MAIN OUTCOMES AND MEASURES

The annual change in BMD from baseline to follow-up was calculated for the following 3 anatomical locations: (1) lumbar spine, (2) femoral neck, and (3) total hip.

RESULTS

A total of 95 women had both a baseline and postsurgery BMD measurement with a mean (SD) follow-up period of 22.0 (12.7) months. The mean (SD) age at oophorectomy was 48.0 (7.4) years. Among women who were premenopausal at time of surgery (50 [53%]), there was a decrease in BMD from baseline to follow-up across the lumbar spine (annual change, -3.45%; 95% CI, -4.61% to -2.29%), femoral neck (annual change, -2.85%; 95% CI, -3.79% to -1.91%), and total hip (annual change, -2.24%; 95% CI, -3.11% to -1.38%). Self-reported hormone therapy use was associated with significantly less bone loss at the lumbar spine (-2.00% vs -4.69%; P = .02) and total hip (-1.38% vs -3.21; P = .04) compared with no hormone therapy use. Among postmenopausal women at time of surgery (45 [47%]), there was also a significant decrease in BMD across the lumbar spine (annual change, -0.82%; 95% CI, -1.42% to -0.23%) and femoral neck (annual change, -0.68%; 95% CI, -1.33% to -0.04%) but not total hip (annual change, -0.18%; 95% CI, -0.82% to 0.46%).

CONCLUSIONS AND RELEVANCE

This study found that oophorectomy was associated with postoperative bone loss, especially among women who were premenopausal at the time of surgery. Targeted management strategies should include routine BMD assessment and hormone therapy use to improve management of bone health in this population.

Contemporary management of adnexa at the time of benign hysterectomy: a review of the literature

Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.

Potential Mechanisms of Age Acceleration Caused by Estrogen Deprivation: Do Endocrine Therapies Carry the Same Risks?

Longer duration of endocrine therapy decreases breast cancer recurrence and mortality, but these benefits need to be weighed against potential risks to overall health. Notable side effects of endocrine therapy include cataracts, uterine cancer, thromboembolic events, osteoporosis and fracture risk, chronic musculoskeletal complaints, as well as vaginal dryness and discharge, and vasomotor symptoms. Estrogen deprivation in healthy women younger than 50 years undergoing bilateral oophorectomy has been shown to accelerate the development of diseases related to aging, including coronary artery disease, cardiac arrhythmias, stroke, dementia, and osteoporosis, raising concern that even less dramatic modulation of estrogen homeostasis may adversely affect health outcomes. Diminished available estrogen at the cellular and molecular level may facilitate mechanisms that underlie the aging process, often termed the hallmarks of aging. In this review, we describe estrogen's role in normal physiology across tissues, review the effects of estrogen deprivation on health outcomes in the setting of both surgical and natural menopause, and examine the hallmarks of aging with attention to the effects of estrogen and estrogen blockade on each molecular mechanism underlying the aging process.