Prophylactic oophorectomy: a continuing controversy

Influence of prophylactic oophorectomy on mood and sexual function in women of menopausal transition or postmenopausal period

AIM

To evaluate the impact of prophylactic oophorectomy on mood and sexual function in women at menopausal transition or postmenopausal period.

METHODS

Patients who underwent operations due to benign diseases of uterus and ovaries were included and were stratified into two groups, namely Group A with 256 patients undergoing hysterectomy and prophylactic oophorectomy and Group B with 337 patients undergoing simple hysterectomy. Follow-ups included demographic data, Self-Rating Zung Depression Scale (ZDS), Self-Rating Zung Anxiety Scale (ZAS), and Female Sexual Function of Index (FSFI).

RESULTS

Five hundred and ninety-three patients were successfully followed. 69.27 % of patients at menopausal transition period chose ovary conservation whilst 79.22 % of postmenopausal women chose oophorectomy due to fear of potential cancer and economy issue. Ovarian cancer was not found in this cohort. Incidence of distress was higher in Group A (P = 0.001). No difference was obtained in ZAS scores between the two groups (P = 0.110). Incidence of anxiety was higher in Group A (P = 0.010). Percentage of patients scoring above 20 in FSFI was significantly higher in Group B (P = 0.003). Oophorectomy and marital status were independent factors for depression (P = 0.009 and <0.001, respectively).

CONCLUSION

Adverse influence on mental and sexual status was severer in women undergoing prophylactic oophorectomy at menopausal transition or postmenopausal period. Comprehensive evaluation may contribute to better ovary conservation strategy for women with benign morbidities.

Malignancies following bilateral salpingo-oophorectomy (BSO)

AIMS

Prophylactic bilateral salpingo-oophorectomy (BSO) is an effective risk reducing measure in ovarian cancer susceptible women. Yet, a small subset of women develop primary peritoneal carcinomatosis (PPC) after BSO. The rates of PPC following non-risk reducing BSO have sparingly been reported.

METHODS

Women who underwent BSO for non-cancer reasons from 1/1/1984 to 12/31/2000 were crossed with the list of cancer diagnoses reported to the Israel National Cancer Registry until 12/31/2001.

RESULTS

Overall, 4128 women at a mean age of 58+/-12 years were analyzed. After a mean of 7.2+/-4 years following BSO, 147 women (3.6%) were diagnosed with cancer: breast cancer in 50 women 62+/-50 months after BSO, and one patient developed PPC, whereas the expected was 0.15 cases. The Standardized Incidence Ratio (SIR) of developing breast cancer was statistically significant lower than expected (SIR 0.71, 95% C.I. 0.44-0.78).

CONCLUSION

The rate of post-oophorectomy PPC in average risk population is low, and BSO appears to lower the rate of breast cancer in average risk women.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Estrogens in BRCA1/2 Mutation Carriers

Persons undergoing genetic testing for an inherited predisposition to cancer often raise questions about recommendations for follow-up care. Missing from current guidelines is consideration of the role of estrogens for BRCA1/BRCA2 mutation carriers. Potential implications of hormones for risk of cancer and effectiveness of risk-reduction strategies need to be considered in the design of comprehensive guidelines for high-risk women. Patients who are mutation carriers may ask questions about the use of oral contraceptives, hormone replacement, and utility of current screening modalities. Controversy exists, even when considering these issues for the general population, but become more imperative when considering young, unaffected women who carry an inherited genetic mutation making decisions that may have long-term health consequences. Many patients have considered estrogen ablation via prophylactic surgeries as risk-reduction interventions. This article reviews data regarding these issues, makes recommendations based on available information, and offers future perspectives for those identified at high risk for cancer because of genetic predisposition. Although questions remain regarding the potential implications of hormones for risk of cancer and effectiveness of risk-reduction strategies, all information should be considered when educating and caring for such patients.

Adequacy of oophorectomy at the time of gynecologic surgery

OBJECTIVES

To determine the incidence of incomplete ovarian removal during gynecologic surgery and correlate the risk of inadequate removal with the procedure chosen.

METHODS

This is a prospective observational study. Ovaries received during a 4-month period in the participating institutions were independently histologically evaluated. Gross inspection of the ovarian capsule, infundibulopelvic ligament, hilum and utero-ovarian ligament was assessed. Grossly close margins were confirmed histopathologically. Any margin with histologically confirmed ovarian tissue at the margin was interpreted as incompletely removed. Details of each surgical procedure were recorded for comparison.

RESULTS

Ovaries (n=174) from 94 patients were collected and 155 were evaluable. The overall incidence of incomplete ovarian removal was 6.5%. Of the 125 ovaries removed abdominally, 23 were laparoscopically assisted and 7 were vaginal; inadequate removal was documented in 5%, 9% and 29%, respectively (P=0.04). There was no relationship of inadequate resection by underlying pathologic diagnosis (P=0.25) or by institution (4.6% university hospital vs. 8.8% community hospital; P=0.29).

CONCLUSIONS

Incomplete ovarian removal occurs and is related to surgical approach. A larger study is warranted to evaluate the role of pelvic pathology or surgeon experience as a risk for incomplete oophorectomy.

Tomatoes, Pap smears, and tea? Adopting behaviors that may prevent reproductive cancers and improve health

Women who adopt healthy lifestyles and practice preventive healthy behaviors can reduce the risks of some cancers and other diseases, such as heart disease and sexually transmitted infections. Risk factors associated with the most common gynecologic cancers and breast cancer are identified, diagnostic and screening alternatives are described, and preventive health practices and information to include when counseling women about making healthy choices are suggested.

Should women at increased risk for breast and ovarian cancer be randomized to prophylactic surgery? An ethical and empirical assessment

More information is needed about the relative effectiveness of prophylactic surgery, chemoprevention, and surveillance in reducing breast and ovarian cancer risk in women with an inherited susceptibility mutation. We assessed practical and ethical barriers to conducting randomized clinical trials (RCTs) to compare preventive interventions for breast and ovarian cancer. Eighty-seven at-risk women who attended an education and counseling session about BRCA1/2 testing were asked about their willingness to participate in hypothetical research studies for breast and ovarian cancer risk reduction. In addition, 247 Maryland physicians from five specialties completed a mail survey including a question about their likelihood of recommending RCT participation to an at-risk woman. Nineteen percent of at-risk women reported willingness to participate in a hypothetical RCT for breast cancer risk reduction and 17% for ovarian cancer risk reduction. Women with children and women likely to have a prophylactic mastectomy if found to have a susceptibility mutation were significantly more willing to participate in an RCT. A majority of women would be willing to participate in nonrandomized trials or registries. Fifty-two percent of physicians responded that they would be likely to recommend RCT participation to a woman carrying a breast cancer susceptibility mutation. Oncologists were the most likely to recommend an RCT. Although the results of nonrandomized trials may be difficult to interpret because of such issues as selection bias. Greater feasibility combined with fewer ethical concerns make nonrandomized trials a more viable alternative to randomized trials for evaluation of preventive interventions for breast and ovarian cancer when prophylactic surgery is one of the treatments being evaluated.