Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada

Opportunistic Salpingectomy Between 2017 and 2020: A Descriptive Analysis

OBJECTIVES

Opportunistic salpingectomy (OS) is the removal of fallopian tubes during another pelvic surgery for the purpose of ovarian cancer prevention. Herein, we describe the rates of OS at the time of hysterectomy and tubal sterilization between 2017 and 2020.

METHODS

This study uses the Canadian Institute of Health Information's Discharge Abstract Database and National Ambulatory Care Reporting System for all Canadian provinces and territories except for Quebec between the fiscal years 2017 and 2020. A descriptive analysis on all people aged 15 years and older who had hysterectomies or tubal sterilizations was conducted to determine the proportion of hysterectomies that included bilateral salpingectomy (OS) and the proportion of tubal sterilizations that were OS compared to tubal ligation.

RESULTS

There were 174 006 people included in the study. The proportion of hysterectomies that included OS increased from 31.7% in 2017 to 39.9% by 2020. With respect to tubal sterilizations, rates of OS increased from 26.3% of all tubal sterilizations in 2017 to 42.5% in 2020. British Columbia remained the jurisdiction with the highest rates of OS, but rates increased significantly in many jurisdictions, particularly at the time of tubal sterilization.

CONCLUSION

The rates of OS have continued to increase in all Canadian jurisdictions following the official Society of Obstetricians and Gynaecologists of Canada recommendation to consider OS in 2015. Assuming that all tubal ligations could have been OS and 75% of hysterectomies with ovarian conservation could have included OS, our data indicate 76 932 missed opportunities for ovarian cancer prevention.

Complications after opportunistic salpingectomy compared with tubal ligation at cesarean section: a retrospective cohort study

OBJECTIVE

To compare perioperative and postoperative complications in patients who underwent opportunistic salpingectomy (OS) (removal of the fallopian tubes for ovarian cancer risk reduction during another surgery) at the time of cesarean section (C-section) with those in patients who underwent tubal ligation.

DESIGN

A population-based, retrospective cohort study.

SETTING

British Columbia, Canada.

PATIENT(S)

A total of 18,184 patients were included in this study, of whom 8,440 and 9,744 underwent OS and tubal ligation, respectively.

INTERVENTION(S)

Patients who underwent OS during a C-section were compared with those who underwent tubal ligation during a C-section.

MAIN OUTCOME MEASURE(S)

We examined the perioperative outcomes, including operating room time, length of hospital stay, surgical complications such as infections, anemia, incision complications, injury to a pelvic organ, or operating room return; postoperative complications, including physician visits for a postoperative infection or visits that resulted in ultrasound or laboratory examinations and hospital readmissions in the 6 weeks after discharge; and likelihood to fill a prescription for antibiotics or analgesics.

RESULT(S)

The OS group had decreased odds of perioperative complications compared with the tubal ligation group (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.61-0.99). Patients who underwent OS did not have increased risks of physician visits for surgical complications, such as infection, or hospital readmissions in the 6 weeks after hospital discharge. In addition, these patients had 18% and 23% increased odds of filling prescriptions for nonsteroidal anti-inflammatory drugs (aOR, 1.18; 95% CI, 1.07-1.28) and opioids (aOR, 1.23%; 95% CI, 1.12-1.35), respectively.

CONCLUSION(S)

In this population-based, real-world study of OS at C-section, we report decreased perioperative complications and no difference in postoperative complications between patients who underwent OS and those who underwent tubal ligation. Patients who underwent OS had an increased likelihood of filling a prescription for nonsteroidal anti-inflammatory drugs and opioids in the 6 weeks after hospital discharge. This result should be interpreted with caution because we did not have data on over-the-counter medication use and, thus, not all prescription analgesics were captured in our data. Our data suggest that OS after C-section is a safe way to provide effective contraception and ovarian cancer risk reduction.

Complete Compared With Partial Salpingectomy for Postpartum Sterilization

In this narrative review, we describe evidence regarding the associated risks, benefits, and cost effectiveness of postpartum complete salpingectomy compared with partial salpingectomy. Permanent contraception can be performed via several methods, but complete salpingectomy is becoming more common secondary to its coincident benefit of ovarian cancer risk reduction. Small prospective studies and larger retrospective cohort studies have demonstrated the feasibility and safety of complete salpingectomy in the postpartum period. Additionally, multiple cost-effectiveness analyses have demonstrated the cost effectiveness of this method secondary to ovarian cancer reduction over the life span. Although future larger cohort studies will allow for more precise estimates of the effect of complete salpingectomy on ovarian cancer risk and incidence of rare complications, current data suggest that complete salpingectomy should be offered to patients as a method of permanent contraception in the postpartum period.

Ovarian Cancer: From Precursor Lesion Identification to Population-Based Prevention Programs

Epithelial ovarian cancer (EOC) is a heterogeneous group of malignancies, including high-grade serous ovarian cancer (HGSC). HGSC is often diagnosed at advanced stages and is linked to TP53 variants. While BRCA variants elevate risk, most HGSC cases occur in individuals without known genetic variants, necessitating prevention strategies for people without known high-risk genetic variants. Effective prevention programs are also needed due to the lack of traditional screening options. An emerging primary prevention strategy is opportunistic salpingectomy, which involves removing fallopian tubes during another planned pelvic surgery. Opportunistic salpingectomy offers a safe and cost-effective preventative option that is gaining global adoption. With the publication of the first cohort study of patients who underwent salpingectomy, specifically for cancer prevention, attention has turned to broadening opportunities for salpingectomy in addition to more targeted approaches. Prevention opportunities are promising with increasing adoption of salpingectomy and the increased understanding of the etiology of the distinct histotypes of ovarian cancer. Yet, further research on targeted risk-reducing salpingectomy with thoughtful consideration of equity is necessary to reduce death and suffering from ovarian cancer.

Salpingectomy for the Primary Prevention of Ovarian Cancer: A Systematic Review

Importance

Most ovarian cancers originate in the fimbriated end of the fallopian tube. This has led to the hypothesis that surgical resection of the fallopian tubes at the time of gynecologic and nongynecologic surgical procedures-referred to as an opportunistic salpingectomy-may prevent the development of epithelial ovarian cancer for women at an average risk of developing the disease.

Objective

To compile a comprehensive, state-of-the-science review examining the current landscape of performing bilateral salpingectomy for ovarian cancer prevention.

Evidence Review

A systematic review of the literature was performed on March 4, 2022, to identify studies examining salpingectomy for ovarian cancer prevention. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. Four databases were selected: PubMed via the National Library of Medicine's PubMed.gov, Embase via Elsevier's Embase.com, Cochrane Central Register of Controlled Trials (CENTRAL) via Wiley's Cochrane Library, and Northern Light Life Sciences Conference Abstracts via Ovid. A total of 20 gray literature sources, including 1 database, 2 registers, 1 repository, 1 index, 1 archive, 1 preprint server, 1 agency, and 12 organizations, were also searched.

Findings

The initial search produced 1089 results; a total of 158 publications were included in the final review. Salpingectomy has been associated with ovarian cancer risk reduction of approximately 80%. Studies have demonstrated that salpingectomy was safe, cost-effective, and was not associated with an earlier age of menopause onset. With widespread implementation, salpingectomy has the potential to reduce ovarian cancer mortality in the US by an estimated 15%. Both physician and patient awareness regarding the adnexa as the origin for most ovarian cancers, as well as the existence of salpingectomy and its potential benefits in reducing ovarian cancer risk, has increased during the past decade. Raising awareness and developing effective implementation strategies are essential.

Conclusions and Relevance

The results of this systematic review suggest that bilateral salpingectomy for ovarian cancer prevention was safe and feasible and has the potential to be a cost-effective and cost-saving strategy across the population. Prospective studies to demonstrate long-term survival outcomes and feasibility in nongynecologic surgical procedures are warranted.

SALpingectomy for STERilisation (SALSTER): study protocol for a Swedish multicentre register-based randomised controlled trial

INTRODUCTION

Salpingectomy is currently suggested as an alternative to tubal ligation for sterilisation. Precursor lesions of ovarian carcinoma can be found in the fallopian tubes; thus, salpingectomy could possibly reduce the incidence. Most of the existing trials on safety are small, on caesarean section and report on surrogate ovarian function measures. Randomised trials in laparoscopy are lacking. Well-designed trials are needed to evaluate safety of laparoscopic opportunistic salpingectomy.

METHODS AND ANALYSIS

In SALSTER, a national register-based randomised controlled non-inferiority trial, 968 women <50 years, wishing laparoscopic sterilisation will be randomised to either salpingectomy or tubal ligation. The Swedish National Quality Register of Gynecological Surgery (GynOp) will be used for inclusion, randomisation and follow-up. Primary outcomes are any complication up to 8 weeks postoperatively, and age at menopause. Both outcomes are measured with questionnaires, complications are also assessed by a gynaecologist. In a nested trial, ovarian function will be evaluated comparing the mean difference of anti-Müllerian hormone (AMH), assessed preoperatively and 1 year after surgery.

ETHICS AND DISSEMINATION

Performing salpingectomy for sterilisation has become increasingly common, despite the unclear risk-benefit balance. SALSTER studies the safety of salpingectomy compared with tubal ligation. Regardless of the result, SALSTER will provide gynaecologists with high quality evidence to inform women to decide on salpingectomy or not. The central ethical review board of Gothenburg, Sweden (Dnr. 316-18) approved the trial in 2018. Results will be presented at scientific congresses and published in peer-reviewed scientific journals. The results will be communicated through professional organisations and research networks.

TRIAL REGISTRATION NUMBER

NCT03860805.

Salpingectomy and the Risk of Ovarian Cancer in Ontario

Importance

A body of pathological and clinical evidence supports the position that the fallopian tube is the site of origin for a large proportion of high-grade serous ovarian cancers. Consequently, salpingectomy is now considered for permanent contraception (in lieu of tubal ligation) or ovarian cancer prevention (performed opportunistically at the time of surgical procedures for benign gynecologic conditions).

Objective

To evaluate the association between salpingectomy and the risk of invasive epithelial ovarian, fallopian tube, and peritoneal cancer.

Design, Setting, and Participants

This population-based retrospective cohort study included all women aged 18 to 80 years who were eligible for health care services in Ontario, Canada. Participants were identified using administrative health databases from Ontario between January 1, 1992, and December 31, 2019. A total of 131 516 women were included in the primary (matched) analysis. Women were followed up until December 31, 2021.

Exposures

Salpingectomy (with and without hysterectomy) vs no pelvic procedure (control condition) among women in the general population.

Main Outcomes and Measures

Women with a unilateral or bilateral salpingectomy in Ontario between April 1, 1992, and December 31, 2019, were matched 1:3 to women with no pelvic procedure from the general population. Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) and 95% CIs for ovarian, fallopian tube, and peritoneal cancer combined.

Results

Among 131 516 women (mean [SD] age, 42.2 [7.6] years), 32 879 underwent a unilateral or bilateral salpingectomy, and 98 637 did not undergo a pelvic procedure. After a mean (range) follow-up of 7.4 (0-29.2) years in the salpingectomy group and 7.5 (0-29.2) years in the nonsurgical control group, there were 31 incident cancers (0.09%) and 117 incident cancers (0.12%), respectively (HR, 0.82; 95% CI, 0.55-1.21). The HR for cancer incidence was 0.87 (95% CI, 0.53-1.44) when comparing those with salpingectomy vs those with hysterectomy alone.

Conclusions and Relevance

In this cohort study, no association was found between salpingectomy and the risk of ovarian cancer; however, this observation was based on few incident cases and a relatively short follow-up time. Studies with additional years of follow-up are necessary to define the true level of potential risk reduction with salpingectomy, although longer follow-up will also be a challenge unless collaborative efforts that pool data are undertaken.

Postpartum Opportunistic Salpingectomy Compared With Bilateral Tubal Ligation After Vaginal Delivery for Ovarian Cancer Risk Reduction: A Cost-Effectiveness Analysis

OBJECTIVE

To compare the cost effectiveness of opportunistic salpingectomy and bilateral tubal ligation for sterilization immediately after vaginal delivery.

METHODS

A cost-effectiveness analytic decision model was used to compare opportunistic salpingectomy with bilateral tubal ligation during vaginal delivery admission. Probability and cost inputs were derived from local data and available literature. Salpingectomy was assumed to be performed with a handheld bipolar energy device. The primary outcome was the incremental cost-effectiveness ratio (ICER) in 2019 U.S. dollars per quality-adjusted life-year (QALY) at a cost-effectiveness threshold of $100,000/QALY. Sensitivity analyses were performed to determine the proportion of simulations in which salpingectomy would be cost effective.

RESULTS

Opportunistic salpingectomy was more cost effective than bilateral tubal ligation with an ICER of $26,150/QALY. In 10,000 patients desiring sterilization after vaginal delivery, opportunistic salpingectomy would result in 25 fewer ovarian cancer cases, 19 fewer ovarian cancer deaths, and 116 fewer unintended pregnancies than bilateral tubal ligation. In sensitivity analysis, salpingectomy was cost effective in 89.8% of simulations and cost saving in 13% of simulations.

CONCLUSION

In patients undergoing sterilization immediately after vaginal deliveries, opportunistic salpingectomy is more cost effective and may be more cost saving than bilateral tubal ligation for reducing ovarian cancer risk.

HOPPSA update: changes in the study protocol of Hysterectomy and OPPortunistic SAlpingectomy, a registry-based randomized controlled trial

BACKGROUND

The HOPPSA trial is a multi-center national registry-based randomized controlled trial to test the safety and effectiveness of performing opportunistic salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer (EOC). The study protocol was first published in January 2019 and is available at https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3083-8 . Here, we report amendments made to the study protocol since commencement of the trial.

CHANGES IN METHODS AND ANALYSIS

The primary outcomes analyses have been changed. (1) Complications will be analyzed using binomial generalized estimating equation (GEE) with log link function, while the unadjusted analyses according to Miettinen and Nurminen will be performed as a sensitivity analysis. (2) Absolute change in Menopause Rating Scale (MRS) will primarily be analyzed using a mixed effects model, adjusted for baseline MRS and center as a random effect. (3) Time to EOC will be analyzed using the mixed effects Cox regression model with center as random effect, while the unadjusted log-rank test will be performed as a sensitivity analysis. The primary outcome Complications will be based solely on the specific assessment in the GynOp quality registry. The Clavien-Dindo classification will be evaluated as a secondary outcome. Furthermore, MRS is also measured three years postoperatively to better pinpoint the onset of menopausal symptoms.

DISCUSSION

The changes to the protocol mainly concern the analyses of data. No changes to recruitment, randomization, intervention, or follow-up of primary outcomes have been made. An interim analysis during 2021 concluded that the study should continue until the target sample size is reached.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03045965 . Registered 8 February 2017.

Prophylactic Salpingectomy during Hysterectomy for Benign Disease: A Prospective Study to Evaluate High-Grade Serous Ovarian Carcinoma Precursors

Recent findings suggest that high-grade serous ovarian cancer can originate in the fallopian tube. Not only has that made the identification of precursor lesions pivotal in early detection and prevention of these cancers, prophylactic salpingectomy alongside hysterectomy for benign indications has been increasingly proposed as well. The present prospective single-center study included 273 women who underwent opportunistic salpingectomy alongside laparoscopic supracervical hysterectomy. Uterine and tubal histopathological results as well as intra- and postoperative complications were evaluated. The complication rate was 3.3%, of which none were caused by salpingectomy. Uterine histopathology diagnosed 181 patients (66.8%) with uterine myomas, 60 patients (22.1%) with adenomyosis, 29 patients (10.7%) with adenomyomatosis, and, 1 patient (0.4%) without pathological abnormality. p53 signatures were detected in 221 right fallopian tubes (80.9%) and in 229 left tubes (83.9%). In total, 8 patients showed bilateral STIL (2.9%), whereas in 1 patient (0.4%) STIL was detected in the left tube only. No STIC were detected. Laparoscopic opportunistic salpingectomy is demonstrated to be both safe and feasible. It appears to be promising to reduce the risk for ovarian cancer, yet more studies are needed to undoubtedly confirm this.

A Standardized Protocol for Post-Partum Salpingectomy with Suture Ligation: A Prospective Feasibility Study

Our objective is to define a standard protocol for post-partum salpingectomy and provide a prospective assessment of safety and feasibility of such a procedure. Thus, a protocol for performing post-partum salpingectomy in limited-resource environments was created based on contemporary practices for tubal ligation. Gravidae presenting for post-partum tubal ligation following vaginal delivery or at time of cesarean were prospectively approached and, if consent was obtained, enrolled. Outcomes were compared to a historical cohort of gravidae who underwent standard post-partum tubal ligation following vaginal birth or at the time of cesarean as per institutional standard of care. The primary outcome was operative time. One hundred and fifty-seven subjects underwent post-partum salpingectomy following cesarean or vaginal delivery (on post-partum days 0–2). Post-partum salpingectomy performed after vaginal delivery (n = 97) resulted in slightly longer operative times (39.1 ± 11.8 vs. 34.3 ± 13.1 min, p = 0.003) and slightly greater blood loss (21.0 ± 22.0 vs. 13.4 ± 17.3 mL, p = 0.001) than modified Pomeroy tubal ligation (n = 200). Post-partum salpingectomy at cesarean resulted in no difference in estimated blood loss, but slightly longer operative times compared to Parkland tubal ligations (99.5 ± 47.3 vs. 86.5 ± 33.9 min, p = 0.048). Surgical complications for post-partum salpingectomy were similar to controls, regardless of when the procedure was performed. In conclusion, a standardized protocol created for post-partum salpingectomy using suture ligation is feasible and safe.

Opportunistic salpingectomy between 2011 and 2016: a descriptive analysis

BACKGROUND

Opportunistic salpingectomy (OS) is the removal of fallopian tubes during hysterectomy for benign indications or instead of tubal ligation, for the purpose of preventing ovarian cancer. We determined rates of OS at the time of hysterectomy and tubal sterilization and examined how they changed over the study period.

METHODS

Using data from the Canadian Institute for Health Information's Discharge Abstract Database and National Ambulatory Care Reporting System for all Canadian provinces and territories (except Quebec) between the fiscal years 2011 and 2016, we conducted a descriptive analysis of all patients aged 15 years or older who underwent hysterectomy or tubal sterilization. We excluded those with diagnostic codes for any gynecologic cancer and those who underwent unilateral salpingectomy. We examined the proportion who had OS during their hysterectomy and compared the proportion of tubal sterilizations that were OS with the proportion that were tubal ligations.

RESULTS

A total of 318 528 participants were included in the study (mean age 42.5 yr). The proportion of hysterectomies that included OS increased from 15.4% in 2011 to 35.5% by 2016. With respect to tubal sterilization, the rate of OS increased from 6.5% of all tubal sterilizations in 2011 to 22.0% in 2016. There was considerable variation across jurisdictions in 2016, with British Columbia having the highest rates (53.2% of all hysterectomies and 74.0% of tubal sterilizations involved OS).

INTERPRETATION

The rates of OS increased between 2011 and 2016, but there was considerable variation across the included jurisdictions. Our study indicates room for rates of OS to increase across many of the included jurisdictions.

Benefits and Risks of Bilateral Salpingectomy Compared With Standard Tubal Ligation During Cesarean Delivery for Permanent Postpartum Contraception

Importance

Ovarian cancer is the second most common gynecologic malignancy, but the most deadly female reproductive cancer in the United States. Epithelial ovarian cancer makes up approximately 90% of all cases and is responsible for more than 90% of ovarian cancer deaths. Elective salpingectomy has been shown to reduce ovarian cancer risk when performed at the time of a benign hysterectomy. Data regarding the risks and benefits of opportunistic bilateral salpingectomy performed at the time of cesarean delivery are limited.

Objective

We aim to review the current evidence regarding safety and benefits of opportunistic bilateral salpingectomy at the time of cesarean delivery compared with bilateral tubal ligation.

Evidence Acquisition

Original research articles, review articles, and guidelines on contraception were reviewed.

Conclusions and Relevance

Opportunistic bilateral salpingectomy at the time of cesarean delivery is feasible and safe. Operative time may be increased up to 15 minutes for salpingectomy performed by suture ligation compared with standard tubal ligation. Women with a history of 3 or more cesarean deliveries are more likely to require an alternative procedure. It is important to counsel women that although opportunistic bilateral salpingectomy may significantly decrease the risk of ovarian cancer, it does not eliminate the risk entirely.

Outcomes From Opportunistic Salpingectomy for Ovarian Cancer Prevention

IMPORTANCE

Opportunistic salpingectomy (OS), which is the removal of fallopian tubes during hysterectomy or instead of tubal ligation without removal of ovaries, is recommended to prevent ovarian cancer, particularly serous ovarian cancer. However, the effectiveness of OS is still undetermined.

OBJECTIVE

To examine observed vs expected rates of ovarian cancer among individuals who have undergone OS.

DESIGN, SETTING, AND PARTICIPANTS

This is a population-based, retrospective cohort study of all individuals in British Columbia, Canada, who underwent OS or a control surgery (hysterectomy alone or tubal ligation) between 2008 and 2017, with follow-up until December 31, 2017. Those with any gynecological cancer diagnosed before or within 6 months of their procedure were excluded. Data analysis was performed from April to August 2021.

EXPOSURES

Removal of both fallopian tubes at the time of hysterectomy or instead of tubal ligation while leaving ovaries intact.

MAIN OUTCOMES AND MEASURES

An ovarian cancer diagnosis listed in the British Columbia Cancer Registry. Age-specific rates of epithelial and serous ovarian cancer in the control group were combined with the specific follow-up time in the OS group to calculate expected numbers (and 95% CIs) of ovarian cancers in the OS group. These were compared with observed numbers. Age-adjusted expected and observed numbers of breast and colorectal cancers were also examined in the OS group.

RESULTS

There were 25 889 individuals who underwent OS (mean [SD] age, 40.2 [7.1] years; median [IQR] follow-up, 3.2 [1.6-5.1] years) and 32 080 who underwent hysterectomy alone or tubal ligation (mean [SD] age, 38.2 [7.9] years; median [IQR] follow-up, 7.3 [4.6-8.7] years). There were no serous ovarian cancers in the OS group and 5 or fewer epithelial ovarian cancers. The age-adjusted expected number was 5.27 (95% CI, 1.78-19.29) serous cancers and 8.68 (95% CI, 3.36-26.58) epithelial ovarian cancers. Age-adjusted expected vs observed numbers of breast cancers (22.1 expected vs 23 observed) and colorectal cancers (9.35 expected vs 8 observed) were not significantly different.

CONCLUSIONS AND RELEVANCE

In this cohort study, the OS group had significantly fewer serous and epithelial ovarian cancers than were expected according to the rate at which they arose in the control group. These findings suggest that OS is associated with reduced ovarian cancer risk.

Bone health after RRBSO among BRCA1/2 mutation carriers: a population-based study

Objective

Examine the risks of fractures and osteoporosis after risk-reducing bilateral salpingo-oophorectomy (RRBSO) among women with BRCA1/2 mutations.

Methods

In this retrospective population-based study in British Columbia, Canada, between 1996 to 2017, we compared risks of osteoporosis and fractures among women with BRCA1/2 mutations who underwent RRBSO before the age of 50 (n=329) with two age-matched groups without known mutations: 1) women who underwent bilateral oophorectomy (BO) (n=3,290); 2) women with intact ovaries who had hysterectomy or salpingectomy (n=3,290). Secondary outcomes were: having dual-energy X-ray absorptiometry (DEXA) scan, and bisphosphonates use.

Results

The mean age at RRBSO was 42.4 years (range, 26–49) and the median follow-up for women with BRCA1/2 mutations was 6.9 years (range, 1.1–19.9). There was no increased hazard of fractures for women with BRCA1/2 mutations (adjusted hazard ratio [aHR]=0.80; 95% confidence interval [CI]=0.56–1.14 compared to women who had BO; aHR=1.02; 95% CI=0.65–1.61 compared to women with intact ovaries). Among women who had DEXA-scan, those with BRCA1/2 mutations had higher risk of osteoporosis (aHR=1.60; 95% CI=1.00–2.54 compared to women who had BO; aHR=2.49; 95% CI=1.44–4.28 compared to women with intact ovaries). Women with BRCA1/2 mutations were more likely to get DEXA-scan than either control groups, but only 46% of them were screened. Of the women with BRCA1/2 mutations diagnosed with osteoporosis, 36% received bisphosphonates.

Conclusion

Women with BRCA1/2 mutations had higher risk of osteoporosis after RRBSO, but were not at increased risk of fractures during our follow-up. Low rates of DEXA-scan and bisphosphonates use indicate we can improve prevention of bone loss.

BRCA mutations carriers had higher osteoporosis risk after risk-reducing bilateral salpingo-oophorectomy (RRBSO) than the groups without mutations. However, they were not at increased risk of fractures during the study period. Only 46% of BRCA mutations carriers were screened for bone loss after RRBSO. The rate of bisphosphonates use was also low.

Efficacy and safety of sterilisation procedures to reduce the risk of epithelial ovarian cancer: a systematic review comparing salpingectomy with tubal ligation

PURPOSE

The objective of this systematic review is to evaluate current literature comparing salpingectomy for sterilisation with tubal ligation, regarding the effectiveness and safety, and assess the certainty of evidence.

MATERIALS AND METHODS

PubMed, Cochrane, and Embase databases were searched. Randomised (RCT) and observational studies were included. Articles were quality assessed and data extracted by two independent authors. Certainty of evidence was assessed using GRADE.

RESULTS

Of 2020 articles, 17 were included. No study investigated the risk of EOC. No difference in anti-Müllerian hormone was reported in one RCT at caesarean section (CS). Two cohort studies evaluated ovarian function with surrogate measures and found no difference at caesarean section. Complications did not differ but were inconsistently reported. Laparoscopic tubal ligation was 7 min faster (95% CI 3.8-10.5). Operative time at caesarean section was dependent on the use of surgical devices. Certainty of evidence was low or very low for all estimates, indicating knowledge gaps. Reliable safety data on salpingectomy for sterilisation is lacking, and there is no effectiveness data. Presently, women cannot be properly counselled regarding salpingectomy for sterilisation.

Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States

BACKGROUND

Opportunistic salpingectomy is now recommended at the time of routine gynecologic surgery to reduce the risk of future ovarian cancer, and performance of opportunistic salpingectomy has increased markedly at the time of benign hysterectomy. Salpingectomy has also been suggested to be feasible at the time of cesarean delivery in women desiring sterilization; however, uptake has not been previously studied on a national level.

OBJECTIVE

This study aimed to examine recent population trends in the utilization and characteristics of salpingectomy at the time of cesarean delivery in the United States.

STUDY DESIGN

This is a population-based retrospective observational study querying the National Inpatient Sample between October 2015 and December 2018. The primary outcome measure was the temporal trend of bilateral salpingectomy at cesarean delivery, assessed with linear segmented regression with log transformation utilizing 3-month time increments. The secondary outcome measures included patient characteristics associated with bilateral salpingectomy, assessed with a multinomial regression model, and surgical outcome (hemorrhage, blood transfusion, hysterectomy, and oophorectomy) at the time of bilateral salpingectomy vs bilateral tubal ligation, assessed with generalized estimating equation in a propensity score-matched model.

RESULTS

There were 3,813,823 women at the age of 15 to 49 years who had cesarean deliveries included, of whom 397,260 (10.4%) had bilateral salpingectomy and 203,400 (5.3%) had bilateral tubal ligation overall. During the time period studied, performance of bilateral salpingectomy among women undergoing cesarean delivery significantly increased from 4.6% to 13.2% (odds ratio for the fourth quarter of 2018 vs the fourth quarter of 2015, 2.69; 95% confidence interval, 2.63-2.75; Figure panel). In contrast, performance of bilateral tubal ligation among women undergoing cesarean delivery significantly decreased from 11.3% to 2.4% (odds ratio, 0.20; 95% confidence interval, 0.19-0.21). By the third quarter of 2016, the number of women who had bilateral salpingectomy exceeded those who had bilateral tubal ligation at cesarean delivery (8.6% vs 7.3%). Increasing the utilization of bilateral salpingectomy did not vary across age groups; the salpingectomy rate increased from 7.5% to 21.1% among women at the age of ≥35 years and from 3.8% to 10.7% among women at the age of <35 years (both, P<.001). In a propensity score matched model, women in the bilateral salpingectomy group were more likely to have hemorrhage (3.8% vs 3.1%; odds ratio, 1.24; 95% confidence interval, 1.15-1.33), blood product transfusion (2.1% vs 1.8%; odds ratio, 1.16; 95% confidence interval, 1.04-1.30), hysterectomy (0.8% vs 0.4%; odds ratio, 2.28; 95% confidence interval, 1.84-2.82), and oophorectomy (0.3% vs 0.2%; odds ratio, 2.02; 95% confidence interval, 1.47-2.79) than those in the bilateral tubal ligation group. When restricted to the nonhysterectomy cases, the bilateral salpingectomy group had a higher rate of hemorrhage (3.4% vs 3.0%; odds ratio, 1.16; 95% confidence interval, 1.06-1.26) and oophorectomy (0.3% vs 0.1%; odds ratio, 1.75; 95% confidence interval, 1.22-2.50) than the bilateral tubal ligation group.

CONCLUSION

In the United States, the utilization of bilateral salpingectomy at the time of cesarean delivery increased rapidly between 2015 and 2018, replacing tubal ligation as the most common type of sterilization performed with cesarean delivery. The higher surgical morbidity in the bilateral salpingectomy group than the bilateral tubal ligation group observed in this study warrants further investigation.

Survey: acceptability of opportunistic bilateral salpingectomy in Flanders

Background

The VVOG (Flemish Society of Obstetrics and Gynaecology) published a consensus statement promoting opportunistic bilateral salpingectomy (OBS).

Objectives

The aim of the study was to obtain insight into the current opinion and general practice of Flemish gynaecologists to counsel and perform OBS.

Materials and Methods

A questionnaire was distributed to Flemish gynaecologists three months after publication of the consensus statement.

Main outcome measures

The drawbacks and incentives to counsel and perform OBS were questioned.

Results

Complete response rate was obtained from 99 gynaecologists (17%) and 37 trainees (19%). The majority of respondents (77%) always counselled for OBS in patients scheduled for hysterectomy without oophorectomy. Eighteen per cent counselled only above a certain age cut off and/or if patient was already menopausal. The most important incentive to counsel in cases of hysterectomy by the abdominal approach and vaginal hysterectomy (VH) was the opportunity to prevent ovarian cancer. The yet-undetermined risk of premature ovarian failure was mentioned as the most important barrier in counselling women for OBS in those undergoing hysterectomy by the abdominal approach. For VH, the respondents saw the risk of complications and increased surgical time as the most important barriers. Sixty-one percent of gynaecologists preferred to perform bilateral salpingectomy as sterilisation method.

Conclusions

Our study suggests that the concept of OBS is already well known in Flanders. There is a positive attitude towards the routine implementation of OBS, although some barriers and doubts about an age cut-off still exist in practice.

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.

Postpartum Salpingectomy Compared With Standard Tubal Ligation After Vaginal Delivery

OBJECTIVE

To compare operative outcomes of postpartum salpingectomy and tubal ligation after vaginal delivery.

METHODS

This retrospective cohort study identified patients who underwent tubal sterilization between January 1, 2009, and December 31, 2019, at a large academic hospital, using the electronic medical record. All patients who delivered vaginally and underwent tubal sterilization during their delivery admissions were included. The primary outcome was total operative time. Secondary outcomes included estimated blood loss, perioperative complications, and readmission within 6 weeks postpartum. Patients who underwent bilateral tubal ligation were compared with those who underwent bilateral salpingectomy using Pearson's χ2 test, Fisher exact, and Student's t test.

RESULTS

A total of 317 eligible patients were identified. One hundred and six (94%) salpingectomies were completed using a bipolar electrocautery device. Operative time was 3 minutes shorter in the salpingectomy group, 30 minutes (interquartile range 24-38) compared with 33.5 (26-42) minutes, P=.032. Patients who underwent salpingectomy were more likely to have estimated blood loss of 5 mL or less (our institutional shorthand for minimal blood loss) than women who underwent bilateral tubal ligation (78 [69%] vs 112 [55%], P=.015). There were no significant differences in perioperative complications between the groups.

CONCLUSION

When using electrocautery, bilateral salpingectomy can be completed in the immediate postpartum period after vaginal delivery with equivalent operative times to bilateral tubal ligation.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

Risk of cardiovascular disease among women carrying BRCA mutations after risk-reducing bilateral salpingo-oophorectomy: A population-based study

OBJECTIVE

Examine the risk of cardiovascular disease (CVD) following risk reducing bilateral salpingo-oophorectomy (RRBSO) among women with BRCA mutations.

METHODS

In this retrospective population-based study in British Columbia, Canada, between 1996 and 2017, we compared the risk of CVD among women with known BRCA mutations who underwent RRBSO before the age of 50 (n = 360) with two groups of age-matched women without known BRCA mutations: 1) women who underwent bilateral oophorectomy (BO) for benign conditions (n = 3600); and, 2) women with intact ovaries who had hysterectomy or salpingectomy (n = 3600). Our primary outcome was CVD (a composite (any of) myocardial infarction, heart failure, and/or cerebrovascular disease). Secondary outcomes included a diagnostic code for predisposing conditions (hypertension, dyslipidemia, and/or diabetes mellitus), and use of cardioprotective medications (statins and/or beta-blockers).

RESULTS

We report no significant increased risk for CVD between women with BRCA mutations and women who underwent BO (aHR = 1.08, 95%CI: 0.72-1.62), but women with BRCA mutations were less likely to be diagnosed with predisposing conditions (aHR = 0.69, 95%CI: 0.55-0.85). Compared to women without BRCA mutations with intact ovaries who underwent hysterectomy or salpingectomy, women with BRCA mutations had significantly increased risk for CVD (aHR = 1.82, 95%CI: 1.18-2.79) and were less likely to be diagnosed with predisposing conditions (aHR = 0.78, 95%CI: 0.62-0.97) and to fill cardioprotective medications (aHR = 0.88, 95%CI: 0.64-1.22).

CONCLUSION

Our results suggest an opportunity for improved prevention of CVD in women with BRCA mutations after prophylactic oophorectomy. Despite the observed lower prevalence of predisposing conditions for CVD and lesser use of cardioprotective medications, this population did not have a lower rate of CVD.

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve

OBJECTIVE

This study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS).

STUDY DESIGN

We prospectively enrolled women >35 weeks' gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count.

RESULTS

We enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36-1.21} {CS only} vs 0.49 {0.32-2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58-3.13} vs 1.45 {1.04-2.25}, p = 0.79]; and 6 months [1.74 {0.93-4.45} vs 2.60 {1.41-5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count.

CONCLUSION

BS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery.

IMPLICATION

While our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.