Ovarian Conservation at the Time of Hysterectomy for Benign Disease

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.

Comparative evaluation of reproductive organ-preserving versus standard radical cystectomy in female: a meta-analysis and systematic review of perioperative, oncological, and functional outcomes

BACKGROUND

To evaluate the perioperative, oncological, and functional outcomes of reproductive organ-preserving radical cystectomy (ROPRC) compared to standard radical cystectomy (SRC) in the treatment of female bladder cancer.

METHODS

A systematic search was conducted in November 2023 across several scientific databases. We executed a systematic review and cumulative meta-analysis of the primary outcomes of interest, adhering to the PRISMA and AMSTAR guidelines. The study was registered in PROSPERO (CRD42024501522).

RESULTS

The meta-analysis included 10 studies with a total of 2015 participants. ROPRC showed a significant reduction in operative time and postoperative fasting period compared to SRC (MD - 45.69, 95% CI - 78.91 ~ - 12.47, p = 0.007, and MD - 0.69, 95% CI - 1.25 ~ - 0.13, p = 0.02, respectively). Functional outcomes, both daytime continence rate (OR 4.94, 95% CI 1.53 ~ 15.91, p = 0.008) and nighttime continence rate (OR 5.91, 95% CI 1.94 ~ 18.01, p = 0.002), and sexual function measured by the Female Sexual Function Index (MD 5.72, 95% CI 0.19 ~ 11.26, p = 0.04), were significantly improved in the ROPRC group. There were no significant differences between ROPRC and SRC in terms of estimated blood loss, length of hospital stay, overall postoperative complications, minor complications or major complications. Oncologically, both procedures showed comparable outcomes with no significant differences in positive surgical margins, tumor recurrence rates, overall survival, cancer-specific survival, recurrence-free survival, or progression-free survival.

CONCLUSIONS

ROPRC is a viable and effective alternative to SRC in female bladder cancer patients, offering enhanced functional outcomes and similar oncological safety. These findings suggest that ROPRC can improve the quality of life in female bladder cancer patients without compromising the efficacy of cancer treatment.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery

OBJECTIVE

To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses.

METHODS

EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended).

RESULTS

The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI95% 0.96-0.98) and was of 92.0 % (484/526) for categorizing lesions with a negative predictive value of 98.1 % (415/423, CI95% 0.96-0.99). Theoretical management using the score would have spared surgery in 229 patients (87.1 %, 229/263) with benign lesions and malignancy would have been missed in 6 borderline and 2 invasive cases. In patients with a presumed benign mass using O-RADS MRI score, recommending surgery for lesions >= 100 mm would miss only 4/77 (4.8 %) malignant adnexal tumors instead of 8 (50 % decrease).

CONCLUSION

The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

Take it or leave it: oophorectomy at the time of benign hysterectomy

PURPOSE OF REVIEW

Previous modeling data suggest ovarian conservation up to age 65 for women without adnexal disease and at average risk of ovarian cancer because of an increase in mortality associated with ovarian removal. Recent modeling data challenges this practice. This review of recent literature will update providers regarding consideration for oophorectomy at time of benign hysterectomy.

RECENT FINDINGS

Oophorectomy at time of hysterectomy for women less than 50 years with estrogen supplementation and greater than 50 years without estrogen supplementation is not associated with increased mortality.

SUMMARY

Although not associated with increased mortality, the decision to remove the ovaries at time of hysterectomy in women older than 50 years is nuanced and requires careful shared decision-making, considering unique patient factors.

Assessment of Quality of Life after Hysterectomy using European Quality of Life Five Dimension Scale (EQ5D)

In several regions throughout the globe, caesarean sections constitute the most common nonobstetric surgery, followed by hysterectomy, which is the surgical excision of the uterus. While it is not the only solution for reproductive organ issues, it is the most effective technique to treat many illnesses over the long term. The uterus is a very critical reproductive organ for all age groups as this is not only essential for giving birth but also for hormonal-related physiology in women's life. The quality of life is impacted by a number of hysterectomy-related effects on females. Physical, psychological, environmental, and social relations are some of these impacts. All EuroQol five-dimensions (EQ5D) subscales significantly improved, as per the research 's findings. Preoperative psychosocial status, perioperative pain, indication of hysterectomy, complications occur during surgery, and mode of hysterectomy postoperative infection had been discovered as determinants of quality of life outcome following hysterectomy. In most of the subjects we noticed small, however, noticable improvements in all component of EQ5D Scale. The strengths of EQ5D questionnaire lie in its simplicity and moreover it is available in several languages.

Machine learning combined with radiomics and deep learning features extracted from CT images: a novel AI model to distinguish benign from malignant ovarian tumors

BACKGROUND

To develop an artificial intelligence (AI) model with radiomics and deep learning (DL) features extracted from CT images to distinguish benign from malignant ovarian tumors.

METHODS

We enrolled 149 patients with pathologically confirmed ovarian tumors. A total of 185 tumors were included and divided into training and testing sets in a 7:3 ratio. All tumors were manually segmented from preoperative contrast-enhanced CT images. CT image features were extracted using radiomics and DL. Five models with different combinations of feature sets were built. Benign and malignant tumors were classified using machine learning (ML) classifiers. The model performance was compared with five radiologists on the testing set.

RESULTS

 Among the five models, the best performing model is the ensemble model with a combination of radiomics, DL, and clinical feature sets. The model achieved an accuracy of 82%, specificity of 89% and sensitivity of 68%. Compared with junior radiologists averaged results, the model had a higher accuracy (82% vs 66%) and specificity (89% vs 65%) with comparable sensitivity (68% vs 67%). With the assistance of the model, the junior radiologists achieved a higher average accuracy (81% vs 66%), specificity (80% vs 65%), and sensitivity (82% vs 67%), approaching to the performance of senior radiologists.

CONCLUSIONS

 We developed a CT-based AI model that can differentiate benign and malignant ovarian tumors with high accuracy and specificity. This model significantly improved the performance of less-experienced radiologists in ovarian tumor assessment, and may potentially guide gynecologists to provide better therapeutic strategies for these patients.

Long-Term Health Consequences After Ovarian Removal at Benign Hysterectomy : A Nationwide Cohort Study

BACKGROUND

More evidence is needed to substantiate current recommendations about removing ovaries during hysterectomy for benign conditions.

OBJECTIVE

To compare long-term outcomes in women with and without bilateral salpingo-oophorectomy (BSO) during hysterectomy for benign conditions.

DESIGN

Emulated target trial using data from a population-based cohort.

SETTING

Women in Denmark aged 20 years or older during 1977 to 2017.

PARTICIPANTS

142 985 women with hysterectomy for a benign condition, 22 974 with BSO and 120 011 without.

INTERVENTION

Benign hysterectomy with or without BSO.

MEASUREMENTS

The primary outcomes were overall hospitalization for cardiovascular disease (CVD), overall cancer incidence, and all-cause mortality through December 2018.

RESULTS

Compared with women without BSO, women with BSO who were younger than 45 years at surgery had a higher 10-year cumulative risk for hospitalization for CVD (risk difference [RD], 1.19 percentage points [95% CI, 0.09 to 2.43 percentage points]). Women with BSO had a higher 10-year cumulative risk for cancer for ages 45 to 54 years (RD, 0.73 percentage point [CI, 0.05 to 1.38 percentage points]), 55 to 64 years (RD, 1.92 percentage points [CI, 0.69 to 3.25 percentage points]), and 65 years or older (RD, 2.54 percentage points [CI, 0.91 to 4.25 percentage points]). Women with BSO had higher 10-year mortality in all age groups, although the differences were statistically significant only for ages 45 to 54 years (RD, 0.79 percentage point [CI, 0.27 to 1.30 percentage points]). The mortality at 20 years was inconsistent with that at 10 years in women aged 65 years or older.

LIMITATION

Age was a proxy for menopausal status.

CONCLUSION

The authors find that these results support current recommendations for conserving ovaries in premenopausal women without a high risk for ovarian cancer and suggest a cautious approach in postmenopausal women.

PRIMARY FUNDING SOURCE

The Danish Cancer Society's Scientific Committee and the Mermaid Project.

Prevalence, socio-demographic determinants, and self-reported reasons for hysterectomy and choice of hospitalization in India

BACKGROUND

There is limited evidence of hysterectomy in India because of a lack of data in large-scale, nationally representative health surveys. In 2015-16, the fourth National Family Health Survey (NFHS-4)-a cross-sectional survey-collected for the first-time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. The current study evaluates the prevalence, determinants, and choice of hospitalization (Public vs. Private) for conducting hysterectomy in India among women aged 15-49 years in 29 states and seven union territories (UTs) based on the new large-scale population-based nationally representative dataset (NFHS 5).

METHODS

Cross-tabulations and percentage distributions were utilized to analyse the prevalence of hysterectomy and the choice of hospitalization (public vs. private) across different socioeconomic backgrounds and reasons for undergoing hysterectomy. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy.

RESULTS

In India as a whole, 3.3% of women aged 15-49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs. The southern region stands out for the considerably higher prevalence of hysterectomy; particularly in the states of Andhra Pradesh (8.7%) and Telangana (8.2%), the prevalence was very high followed by Bihar (6%) and Gujrat (4%). On the other hand, the North-eastern region had the lowest prevalence of hysterectomy (1.2%). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector (69.6%) in India. But the scenario was quite different in north-eastern region as in this region more hysterectomies were performed in public health facilities (73%) rather than private health facilities (26.7%). Age, place of residence, religion, caste, level of education, geographic region, wealth quintiles, parity, age at first cohabitation of women were found to be the socio-demographic determinants statistically associated with hysterectomy in India. The likelihood of hysterectomy was higher among women living in rural areas (AOR: 1.3, CI: 1.23-1.35), in the richest wealth quintile (AOR 2.6; CI 2.37-2.76) and in the southern region (AOR 1.6; CI 1.47-1.66). The reasons frequently reported for hysterectomy were excessive menstrual bleeding/pain, followed by fibroids/cysts.

CONCLUSION

This study has attempted to analyse hysterectomy prevalence and its socio-economic determinants using the latest fifth round of NFHS data of all the states and covering 21 states and union territories of India, which gives wider coverage of hysterectomy and more recent with accurate data. More research is needed therefore to unravel the complex dynamics of hysterectomy in India (and elsewhere) which could be used to help women make more informed choices and in turn advance their reproductive health and rights.

Utilizations and characteristics of ovarian conservation at hysterectomy for cervical carcinoma in situ

OBJECTIVE

To examine the trends and characteristics of ovarian conservation at time of hysterectomy in cervical carcinoma in situ.

METHODS

This is a retrospective cohort study examining the Healthcare Cost and Utilization Project's National Inpatient Sample, January 2016 to December 2019. The study population included 6605 patients aged less than 65 years with cervical carcinoma in situ who underwent hysterectomy. Exposure allocation was the adnexal procedure status (ovarian conservation vs. oophorectomy). Main outcome measures were temporal trends of ovarian conservation over time and per patient age. A classification-tree was constructed to examine utilization patterns of ovarian conservation.

RESULTS

Ovarian conservation was performed in 57.2% of patients. Ovarian conservation rates were unchanged over time (P-trend = 0.219). Ovarian conservation rates remained stable until age 40 years, ranging from 88.0% to 78.6% (P-trend = 0.236), after which time the rate sharply decreased from 78.6% to 19.1% (P-trend <0.001). In a multivariable analysis, younger age, fewer comorbidities, higher household income, vaginal hysterectomy, and surgery at small bed capacity non-rural hospitals were associated with ovarian conservation (all, P < 0.05). There were 17 utilization patterns of ovarian conservation for which the rate ranged from 17.2% to 94.4% (absolute rate difference 77.2%, P < 0.001).

CONCLUSION

Decrease in the utilization of ovarian conservation at hysterectomy for cervical carcinoma in situ occurred at age 40 years, which is earlier than expected.

Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease

Cardiovascular disease (CVD), the leading cause of death among US adults, is more prevalent in menopausal females compared with age-matched males. Vasomotor symptoms of menopause (VMS; hot flashes/flushes and night sweats) are common among females undergoing menopausal transition and have been associated with elevated blood pressure (BP) and increased CVD risk. Autonomic dysregulation of BP has been posited as a contributing factor to the elevated CVD risk in menopausal females with VMS. This review includes 1) a brief overview of the relationship between VMS and CVD, 2) mechanisms of hot flushes and their potential impact on short- and long-term BP regulation, and 3) how the disruption of autonomic function associated with VMS might provide a mechanistic pathway to CVD development. Finally, this review will highlight knowledge gaps and future directions toward better understanding of hot flush physiology and VMS contributions to CVD.

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.

Is Adnexectomy Mandatory at the Time of Hysterectomy for Uterine Sarcomas? A Systematic Review and Meta-Analysis

Background and Objectives: Uterine sarcomas represents only 3% of all the female genital tract ones. The tumoral stage is the most significant prognostic factor. The role of the bilateral salpingo-oophorectomy (BSO) in the surgical management of FIGO stage IA and IB appears still controversial. This review aims to investigate the impact of bilateral adnexectomy in the treatment of uterine sarcoma. Methods: Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in February 2022. We applied no language or geographical restrictions, but we considered only English studies. We included the studies containing data about Recurrence Rate (RR), Disease-free Survival (DFS), and Overall Survival (OS). We used comparative studies for meta-analysis. Results: Seventeen studies fulfilled the inclusion criteria; 2 retrospective observational studies, and 15 retrospective comparative studies, And 14 out of the 15 comparative studies were enrolled in meta-analysis. A total of 3743 patients were analyzed concerning the use of adnexectomy with hysterectomy in patients with uterine sarcoma and compared with those who did not. Meta-analysis highlighted a non-significant worsening of the OS in the BSO group compared to the OP group and showed that adnexectomy does not improve the DFS (BSO OR 1.23 (95% CI 0.81–1.85) p = 0.34; I2 = 24% p = 0.22). Conclusions: Most studies selected for our review showed that adnexectomy does not significantly affect the RR, OS, and PFS in treating FIGO stage I uterine sarcomas. Therefore, even if there is a unanimous consensus about bilateral adnexectomy in menopausal patients, preservation of ovarian tissue may be considered in premenopausal women. Nonetheless, there are not enough cases in the literature to recommend this procedure.

A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited

OBJECTIVE

To perform an updated Markov modeling to assess the optimal age for bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy for benign indication.

METHODS

We performed a literature review that assessed hazard ratios (HRs) for mortality by disease, age, hysterectomy with or without BSO, and estrogen therapy use. Base mortality rates were derived from national vital statistics data. A Markov model from reported HRs predicted the proportion of the population staying alive to age 80 years by 1-year and 5-year age groups at time of surgery, from age 45 to 55 years. Those younger than age 50 years were modeled as either taking postoperative estrogen or not; those 50 and older were modeled as not receiving estrogen. Computations were performed with R 3.5.1, using Bayesian integration for HR uncertainty.

RESULTS

Performing salpingo-oophorectomy before age 50 years for those not taking estrogen yields a lower survival proportion to age 80 years than hysterectomy alone before age 50 years (52.8% [Bayesian CI 40.7-59.7] vs 63.5% [Bayesian CI 62.2-64.9]). At or after age 50 years, there were similar proportions of those living to age 80 years with hysterectomy alone (66.4%, Bayesian CI 65.0-67.6) compared with concurrent salpingo-oophorectomy (66.9%, Bayesian CI 64.4-69.0). Importantly, those taking estrogen when salpingo-oophorectomy was performed before age 50 years had similar proportions of cardiovascular disease, stroke, and people living to age 80 years as those undergoing hysterectomy alone or those undergoing hysterectomy and salpingo-oophorectomy at age 50 years and older.

CONCLUSION

This updated Markov model argues for the consideration of concurrent salpingo-oophorectomy for patients who are undergoing hysterectomy at age 50 and older and suggests that initiating estrogen in those who need salpingo-oophorectomy before age 50 years mitigates increased mortality risk.

Time Trends in Unilateral and Bilateral Oophorectomy in a Geographically Defined American Population

OBJECTIVE

To evaluate trends in the incidence of premenopausal unilateral and bilateral oophorectomy between 1950 and 2018.

METHODS

The Rochester Epidemiology Project medical records-linkage system was used to identify all women aged 18-49 years who were residents of Olmsted County, Minnesota, and underwent unilateral or bilateral oophorectomy before spontaneous menopause between January 1, 1950, and December 31, 2018. Population denominators were derived from the U.S. Decennial Censuses for the years 1950-2010, and intercensal year population denominators were linearly interpolated. For 2011-2018, the annual population denominators were obtained from the U.S. Census projections. Where appropriate, overall incidence rates were age-adjusted to the total U.S. female population from the 2010 Census.

RESULTS

There were 5,154 oophorectomies in Olmsted County across the 69-year period between 1950 and 2018, and 2.9% showed malignant disease on pathology. A total of 2,092 (40.6%) women underwent unilateral oophorectomy, and 3,062 (59.4%) women underwent bilateral oophorectomy. More than half (n=1,750, 57.2%) of the bilateral oophorectomies occurred between 1990 and 2009. Until 1975-1979, the incidence of unilateral oophorectomy was mostly higher than bilateral oophorectomy. From 1980-1984 until 2000-2004, the incidence of bilateral oophorectomy more than doubled and the incidence of unilateral oophorectomy declined. After 2005, both procedures declined and converged to a similar incidence in 2015-2018. The decline in premenopausal bilateral oophorectomy over the past 14 years (2005-2018) was most pronounced for women who underwent oophorectomy concurrently with hysterectomy or did not have any ovarian indication.

CONCLUSION

The incidence rates of unilateral and bilateral oophorectomy have varied greatly across the 69-year period of this study. In the past 14 years, the incidence of premenopausal unilateral and bilateral oophorectomy has decreased. These trends reflect the effects of the initial 2005-2006 publications and the subsequent expanding body of evidence against the practice of oophorectomy for noncancer indications.

Substantial variability in ovarian conservation at hysterectomy for endometrial hyperplasia

BACKGROUND

Although ovarian conservation at hysterectomy for benign gynecologic disease has demonstrated mortality benefit in young patients and this benefit may be sustained up to age 65 years, there is a scarcity of data regarding ovarian conservation in those with a diagnosis of endometrial hyperplasia, a premalignant uterine condition.

OBJECTIVE

This study aimed to examine patient, hospital, treatment, and histology characteristics related to ovarian conservation at the time of inpatient hysterectomy for endometrial hyperplasia.

STUDY DESIGN

The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine patients aged ≤65 years with endometrial hyperplasia who had inpatient hysterectomy from January 2016 to December 2019. The exclusion criteria included concurrent gynecologic malignancy, adnexal pathology, and lymphadenectomy. Cases were grouped by adnexal surgery status (ovarian conservation or oophorectomy). A multivariable binary logistic regression model was used to identify independent characteristics for ovarian conservation. A classification tree was constructed with recursive partitioning analysis to examine utilization patterns of ovarian conservation.

RESULTS

Overall, 3105 patients (31.1%) underwent ovarian conservation at hysterectomy among 9975 patients. The utilization of ovarian conservation decreased gradually until age 45 years and then markedly decreased by age 52 years (63.3%-15.3%; P<.001). In a multivariable analysis, younger age, non-White, urban nonteaching centers, and vaginal hysterectomy were associated with increased utilization of ovarian conservation, whereas endometrial hyperplasia with atypia, obesity, comorbidity, large bed capacity centers, and Midwest and South regions were associated with decreased utilization of ovarian conservation (all, P<.05). A classification tree identified 17 utilization patterns for ovarian conservation, ranging from 7.8% to 100.0% (absolute rate difference, 92.2%).

CONCLUSION

The utilization of ovarian conservation at the time of inpatient hysterectomy in patients undergoing surgical management for endometrial hyperplasia started decreasing in their mid-40s and seemed to occur earlier than in benign hysterectomy. There was substantial variability in ovarian conservation at the time of hysterectomy for endometrial hyperplasia based on patient, hospital, surgical, and histology factors, suggesting the possible benefit of clinical practice guidelines for ovarian conservation in this population.

Oophorectomy for ovarian torsion - should this be abandoned?

BACKGROUND

Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration.

AIMS

We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases.

MATERIALS AND METHODS

Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy.

RESULTS

Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia.

CONCLUSION

The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.

Effect of risk-reducing salpingo-oophorectomy on sex steroid hormone serum levels among postmenopausal women: an NRG Oncology/Gynecologic Oncology Group study

BACKGROUND

Risk-reducing salpingo-oophorectomy is an effective ovarian cancer risk reduction strategy. However, bilateral oophorectomy has also been associated with increased long-term nonneoplastic sequelae, effects suggested to be mediated through reductions in systemic sex steroid hormone levels. Currently, it is unclear whether the postmenopausal ovary contributes to the systemic hormonal milieu or whether postmenopausal ovarian volume or other factors, such as body mass index and age, affect systemic hormone levels.

OBJECTIVE

We examined the impact of oophorectomy on sex steroid hormone levels in postmenopausal women. Furthermore, we explored how well ovarian volume measured by transvaginal ultrasound correlated with direct ovarian measures obtained during surgical pathology evaluation and investigated the association between hormone levels and ovarian volumes.

STUDY DESIGN

Postmenopausal women who underwent risk-reducing salpingo-oophorectomy (180 cases) or ovarian cancer screening (38 controls) enrolled in an international, prospective study of risk-reducing salpingo-oophorectomy and risk of ovarian cancer algorithm-based screening among women at increased risk of ovarian cancer (Gynecologic Oncology Group-0199) were included in this analysis. Controls were frequency matched to the cases on age at menopause, age at study entry, and time interval between blood draws. Ovarian volume was calculated using measurements obtained from transvaginal ultrasound in both cases and controls and measurements recorded in surgical pathology reports from cases. Serum hormone levels of testosterone, androstenedione, androstenediol, dihydrotestosterone, androsterone, dehydroepiandrosterone, estrone, estradiol, and sex hormone-binding globulin were measured at baseline and follow-up. Spearman correlation coefficients were used to compare ovarian volumes as measured on transvaginal ultrasound and pathology examinations. Correlations between ovarian volumes by transvaginal ultrasound and measured hormone levels were examined using linear regression models. All models were adjusted for age. Paired t tests were performed to evaluate individual differences in hormone levels before and after risk-reducing salpingo-oophorectomy.

RESULTS

Ovarian volumes measured by transvaginal ultrasound were only moderately correlated with those reported on pathology reports (Spearman rho [ρ]=0.42). The median time interval between risk-reducing salpingo-oophorectomy and follow-up for the cases was 13.3 months (range, 6.0-19.3), and the median time interval between baseline and follow-up for the controls was 12.7 months (range, 8.7-13.4). Sex steroid levels decreased with age but were not correlated with transvaginal ultrasound ovarian volume, body mass index, or time since menopause. Estradiol levels were significantly lower after risk-reducing salpingo-oophorectomy (percentage change, -61.9 post-risk-reducing salpingo-oophorectomy vs +15.2 in controls; P=.02), but no significant differences were seen for the other hormones.

CONCLUSION

Ovarian volumes measured by transvaginal ultrasound were moderately correlated with volumes directly measured on pathology specimens and were not correlated with sex steroid hormone levels in postmenopausal women. Estradiol was the only hormone that declined significantly after risk-reducing salpingo-oophorectomy. Thus, it remains unclear whether the limited post-risk-reducing salpingo-oophorectomy changes in sex steroid hormones among postmenopausal women impact long-term adverse outcomes.

Ovarian cancer incidence and death in average-risk women undergoing bilateral salpingo-oophorectomy at benign hysterectomy

BACKGROUND

Opportunistic bilateral salpingo-oophorectomy is often offered to patients undergoing benign hysterectomy to prevent ovarian cancer, but the magnitude of risk reduction obtained with bilateral salpingo-oophorectomy in this population remains unclear and must be weighed against potential risks of ovarian hormone deficiency.

OBJECTIVE

This study aimed to quantify the relative and absolute risk reduction in ovarian cancer incidence and death associated with bilateral salpingo-oophorectomy at the time of benign hysterectomy.

STUDY DESIGN

We performed a population-based cohort study of all adult women (≥20 years) undergoing benign hysterectomy from 1996 to 2010 in Ontario, Canada. Patients with ovarian pathology, previous breast or gynecologic cancer, or evidence of genetic susceptibility to malignancy were excluded. Inverse probability of treatment-weighted Fine-Gray subdistribution hazard models were used to quantify the effect of bilateral salpingo-oophorectomy on ovarian cancer incidence and death while accounting for competing risks and adjusting for demographic characteristics, gynecologic conditions, and comorbidities. Analyses were performed in all women and specifically in women of postmenopausal age (≥50 years) at the time of hysterectomy.

RESULTS

We identified 195,282 patients (bilateral salpingo-oophorectomy, 24%; ovarian conservation, 76%) with a median age of 45 years (interquartile range, 40-51 years). Over a median follow-up of 16 years (interquartile range, 12-20 years), 548 patients developed ovarian cancer (0.3%), and 16,170 patients (8.3%) died from any cause. Bilateral salpingo-oophorectomy was associated with decreased ovarian cancer incidence (hazard ratio, 0.23; 95% confidence interval, 0.14-0.38; P<.001) and decreased ovarian cancer death (hazard ratio, 0.30; 95% confidence interval, 0.16-0.57; P<.001). At 20 years follow-up, the weighted cumulative incidences of ovarian cancer were 0.08% and 0.46% with bilateral salpingo-oophorectomy and ovarian conservation, respectively, yielding an absolute risk reduction of 0.38% (95% confidence interval, 0.32-0.45; number needed to treat, 260). After restricting to women aged ≥50 years at hysterectomy, the absolute risk reduction was 0.62% (95% confidence interval, 0.47-0.77; number needed to treat, 161).

CONCLUSION

Bilateral salpingo-oophorectomy resulted in a significant absolute reduction in ovarian cancer among women undergoing benign hysterectomy. Population-average risk estimates derived in this study should be balanced against other potential implications of bilateral salpingo-oophorectomy to inform practice guidelines, patient decision-making, and surgical management.

A Stepwise Strategy to Minimally Invasive Salpingo-Oophorectomy in the Post-Hysterectomy Patient

Post-hysterectomy salpingo-oophorectomy can be surgically complex. Up to 9% of women who chose ovarian preservation at the time of hysterectomy require future adnexal surgery. Some of the common indications for post-hysterectomy salpingo-oophorectomy are persistent adnexal masses or masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. This video presents a 5-step strategy to facilitate a post-hysterectomy bilateral salpingo-oophorectomy to include pelvic and abdominal exploration, restoring normal anatomy, identification of the ureter, isolation, coagulation and transection of the infundibulopelvic ligament, and, lastly, hemostasis with re-evaluation of ureter. This stepwise procedure was highlighted in a patient with a prior total abdominal hysterectomy and a complex adnexal mass. We utilize these techniques on the side without anatomic abnormality and then safely apply this same 5-step strategy to remove a more challenging adnexal mass on the opposite side. We describe a 5-step surgical strategy to ensure safe, efficient, and reproducible salpingo-oophorectomy in the post-hysterectomy patient using a minimally invasive approach. Although this surgery can be challenging to perform in post-hysterectomy patients given anatomical variance and adhesive disease, by following these 5 simple principles we aim to standardize and simplify this potentially difficult procedure.

Association of bilateral salpingo-oophorectomy with all cause and cause specific mortality: population based cohort study

OBJECTIVES

To determine if bilateral salpingo-oophorectomy, compared with ovarian conservation, is associated with all cause or cause specific death in women undergoing hysterectomy for non-malignant disease, and to determine how this association varies with age at surgery.

DESIGN

Population based cohort study.

SETTING

Ontario, Canada from 1 January 1996 to 31 December 2015, and follow-up to 31 December 2017.

PARTICIPANTS

200 549 women (aged 30-70 years) undergoing non-malignant hysterectomy, stratified into premenopausal (<45 years), menopausal transition (45-49 years), early menopausal (50-54 years), and late menopausal (≥55 years) groups according to age at surgery; median follow-up was 12 years (interquartile range 7-17).

EXPOSURES

Bilateral salpingo-oophorectomy versus ovarian conservation.

MAIN OUTCOMES MEASURES

The primary outcome was all cause death. Secondary outcomes were non-cancer and cancer death. Within each age group, overlap propensity score weighted survival models were used to examine the association between bilateral salpingo-oophorectomy and mortality outcomes, while adjusting for demographic characteristics, gynaecological conditions, and comorbidities. To account for comparisons in four age groups, P<0.0125 was considered statistically significant.

RESULTS

Bilateral salpingo-oophorectomy was performed in 19%, 41%, 69%, and 81% of women aged <45, 45-49, 50-54, and ≥55 years, respectively. The procedure was associated with increased rates of all cause death in women aged <45 years (hazard ratio 1.31, 95% confidence interval 1.18 to 1.45, P<0.001; number needed to harm 71 at 20 years) and 45-49 years (1.16, 1.04 to 1.30, P=0.007; 152 at 20 years), but not in women aged 50-54 years (0.83, 0.72 to 0.97, P=0.018) or ≥55 years (0.92, 0.82 to 1.03, P=0.16). Findings in women aged <50 years were driven largely by increased non-cancer death. In secondary analyses identifying a possible change in the association between bilateral salpingo-oophorectomy and all cause death with advancing age at surgery, the hazard ratio gradually decreased during the menopausal transition and remained around 1 at all ages thereafter.

CONCLUSION

In this observational study, bilateral salpingo-oophorectomy at non-malignant hysterectomy appeared to be associated with increased all cause mortality in women aged <50 years, but not in those aged ≥50 years. While caution is warranted when considering bilateral salpingo-oophorectomy in premenopausal women without indication, this strategy for ovarian cancer risk reduction does not appear to be detrimental to survival in postmenopausal women.

Safety and Efficacy of Reproductive Organ-Sparing Radical Cystectomy in Women With Variant Histology and Advanced Stage

PURPOSE

Muscle invasive bladder cancer surgical management has been historically a radical cystoprostatectomy in males and an anterior exenteration in females. Uterine, ovarian, and vaginal preservation are utilized, but raise concerns regarding risk to oncologic control, especially in variant histopathology or advanced stage.

MATERIALS AND METHODS

A retrospective single institutional analysis identified radical cystectomies performed in women, including those with variant histology, which were defined as reproductive organ sparing (uterine, vaginal, and ovary sparing) or nonorgan sparing. The Kaplan-Meier method was used for recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in patients with advanced disease.

RESULTS

From 2000 to 2020, 289 women were identified, 188 underwent reproductive organ-sparing cystectomy. No statistical differences were noted for clinical parameters or presence of variant histology for organ-sparing (ROS) and nonorgan-sparing (non-ROS). Positive margin rates did not differ for ROS and non-ROS; 4.3% vs. 7.9%, P = .19, respectively. Median RFS was not statistically significantly different for ROS vs. non-ROS (26.1 vs. 15.3 months) P = .937 hazard ratio (HR) 1.024. CSS was not statistically different for ROS vs. non-ROS (36.3 vs. 28.6 months), P = .755 HR 0.9. OS was not statistically different for ROS vs. non-ROS (25.8 vs. 23.8 months), P = .5 HR = 1.178. Variant histology did not change survival (HR 1.1, P = .643).

CONCLUSION

In this analysis, ROS in women with advanced disease did not increase positive margin rates or decrease RFS, CSS, or OS compared to non-ROS. Variant histology did not decrease survival odds. Based on preoperative assessment and intraoperative findings, ROS in patients with variant histology and advanced disease should be considered.

Premature or early bilateral oophorectomy: a 2021 update

In this invited review, we discuss some unresolved and controversial issues concerning premature (<40 years) or early (40-45 years) bilateral oophorectomy. First, we clarify the terminology. Second, we summarize the long-term harmful consequences of bilateral oophorectomy. Third, we discuss the restrictive indications for bilateral oophorectomy in premenopausal women to prevent ovarian cancer that are justified by the current scientific evidence. Fourth, we explain the importance of estrogen replacement therapy when bilateral oophorectomy is performed. Hormone replacement therapy is indicated after bilateral oophorectomy until the age of expected natural menopause like in premature or early primary ovarian insufficiency. Fifth, we discuss the relationship between adverse childhood experiences, adverse adult experiences, mental health, gynecologic symptoms and bilateral oophorectomy. The acceptance and popularity of bilateral oophorectomy over several decades, and its persistence even in the absence of supporting scientific evidence, suggest that non-medical factors related to sex, gender, reproduction, cultural beliefs and socioeconomic structure are involved. We discuss some of these non-medical factors and the need for more research in this area.

Tubectomy of Pregnant and Non-pregnant Female Balinese Macaques (Macaca Fascicularis) With Post-operative Monitoring

Worldwide, primates, and humans increasingly share habitats and often enter in conflict when primates thrive in human-dominated environments, calling for special management measures. Reproductive control is increasingly used to manage population growth but very few monitoring data are available. Therefore, the efficiency and implications of such programs require a careful examination. In the context of a contraception program in wild female long-tailed macaques in Ubud, Bali, conducted over four successive campaigns between 2017 and 2019, including 140 females (i.e., 41.9% of the reproductive females of the population in 2019), modifications of an endoscopic tubectomy procedure, a permanent sterilization method, clinical evaluation of this method, and the post-operative monitoring results of the neutered females after release are described. This surgical approach was applicable for pregnant females: 28.6% of the treated females were pregnant at the time of the surgery. The procedure used a single lateral port to reach and cauterize both oviducts in non-pregnant as well as in early to mid-term pregnant females. Pregnant females nearer to term required a second lateral port to access both oviducts masked by the size of the gravid uterus. Moreover, bipolar thermocauterization was utilized successfully without resection to realize the tubectomy. The average duration of the laparoscopic surgery was 14 min for non-pregnant females and 22 min for pregnant females. Animals were released 3 h 22 min in average following their capture. This short holding time, recommended for free-ranging primates, was made possible by the minimal invasiveness of the sterilization approach. A laparoscopic post-operative evaluation conducted on two patients during the following campaign confirmed that the oviducts were definitely disrupted and no longer patent. Moreover, no new pregnancies in sterilized females were recorded during the 3-year observation period. The survival rate of the treated females 6 months after sterilization was high (96.3%) with no major post-operative complications clinically recorded. Among females that were pregnant during surgery, 81.1% were confirmed to experience term delivery. This study demonstrates the safety and efficiency of endoscopic tubectomy, even for pregnant females, as a mean of wild macaques' population control.

[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.

Does laparoscopic hysterectomy + bilateral salpingectomy decrease the ovarian reserve more than total abdominal hysterectomy? A cohort study, measuring anti-Müllerian hormone before and after surgery

BACKGROUND

Decreased ovarian function and reserve is one of the complications of hysterectomy. In this study, we aimed to compare anti-müllerian hormone (AMH) levels between total abdominal hysterectomy (TAH), and total laparoscopic hysterectomy (TLH).

METHODS

In this prospective cohort study, serum levels of AMH were compared between the groups undergoing TAH + bilateral salpingectiomy and TLH, in 66 patients (33 in each group) who referred to the hospitals of Shiraz University of Medical Sciences for hysterectomy during one years of work. The collected information included age, weight, gravidity, parity, regularity of menstrual cycle, uterine weight, blood loss during surgery, and serum levels of AMH before and 6 months after surgery, compared between groups.

RESULTS

Most patients (88% in TAH and 73% in TLH group) aged 40-50 years. Mean age, weight, parity of patients was similar in both groups, while blood loss was significantly less in TLH group (P < 0.01). Median (IQR) of pre-surgical AMH values were 0.40 (0.55) ng/ml in the TLH group and 0.92 (1.23) ng/ml in the TAH group (P = 0.12) that decreased to 0.29 (0.44) ng/ml in the TLH group and 0.15 (0.31) ng/ml in the TAH group (P = 0.02). Also Median (IQR) of the difference between pre and post-surgical AMH values were 0.12 (0.31) and 0.58 (1.17) in TLH and TAH group, respectively (P = 0.003).

CONCLUSION

The serum levels of AMH decreased significantly after both methods of hysterectomy (laparoscopy and laparotomy), while this decrease was greater in TAH group that shows.

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.

Changes in abdominal subcutaneous adipose tissue phenotype following menopause is associated with increased visceral fat mass

Menopause is associated with a redistribution of adipose tissue towards central adiposity, known to cause insulin resistance. In this cross-sectional study of 33 women between 45 and 60 years, we assessed adipose tissue inflammation and morphology in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) across menopause and related this to menopausal differences in adipose tissue distribution and insulin resistance. We collected paired SAT and VAT biopsies from all women and combined this with anthropometric measurements and estimated whole-body insulin sensitivity. We found that menopause was associated with changes in adipose tissue phenotype related to metabolic dysfunction. In SAT, postmenopausal women showed adipocyte hypertrophy, increased inflammation, hypoxia and fibrosis. The postmenopausal changes in SAT was associated with increased visceral fat accumulation. In VAT, menopause was associated with adipocyte hypertrophy, immune cell infiltration and fibrosis. The postmenopausal changes in VAT phenotype was associated with decreased insulin sensitivity. Based on these findings we suggest, that menopause is associated with changes in adipose tissue phenotype related to metabolic dysfunction in both SAT and VAT. Whereas increased SAT inflammation in the context of menopause is associated with VAT accumulation, VAT morphology is related to insulin resistance.

The rapid adoption of opportunistic salpingectomy at the time of hysterectomy for benign gynecologic disease in the United States

BACKGROUND

Mounting evidence for the role of distal fallopian tubes in the pathogenesis of epithelial ovarian cancer has led to opportunistic salpingectomy being increasingly performed at the time of benign gynecologic surgery. Opportunistic salpingectomy has now been recommended as best practice in the United States to reduce future risk of ovarian cancer even in low-risk women. Preliminary analyses have suggested that performance of opportunistic salpingectomy is increasing.

OBJECTIVE

To examine trends in opportunistic salpingectomy in women undergoing benign hysterectomy and to determine how the publication of the tubal hypothesis in 2010 may have contributed to these trends.

STUDY DESIGN

This is a population-based, retrospective, observational study examining the National Inpatient Sample between January 2001 and September 2015. Women younger than 50 years who underwent inpatient hysterectomy for benign gynecologic disease were grouped as hysterectomy alone vs hysterectomy with opportunistic salpingectomy. All women had ovarian conservation, and those with adnexal pathology were excluded. Linear segmented regression with log transformation was used to assess temporal trends. An interrupted time-series analysis was then used to assess the impact of the 2010 publication of the tubal hypothesis on opportunistic salpingectomy trends. A regression-tree model was constructed to examine patterns in the use of opportunistic salpingectomy. A binary logistic regression model was then fitted to identify independent characteristics associated with opportunistic salpingectomy. Sensitivity analysis was performed in women aged 50-65 years to further assess surgical trends in a wider age group.

RESULTS

There were 98,061 (9.0%) women who underwent hysterectomy with opportunistic salpingectomy and 997,237 (91.0%) women who underwent hysterectomy alone without opportunistic salpingectomy. The rate at which opportunistic salpingectomy was being performed gradually increased from 2.4% to 5.7% between 2001 and 2010 (2.4-fold increase; P<.001), predicting a 7.0% rate of opportunistic salpingectomy in 2015. However, in 2010, the rate of opportunistic salpingectomy began to increase substantially and reached 58.4% by 2015 (10.2-fold increase; P<.001). In multivariable analysis, the largest change in the performance of opportunistic salpingectomy occurred after 2010 (adjusted odds ratio, 5.42; 95% confidence interval, 5.34-5.51; P<.001). In a regression-tree model, women who had a hysterectomy at urban teaching hospitals in the Midwest after 2013 had the highest chance of undergoing opportunistic salpingectomy during benign hysterectomy (76.4%). In the sensitivity analysis of women aged 50-65 years, a similar exponential increase in opportunistic salpingectomy was observed from 5.8% in 2010 to 55.8% in 2015 (9.8-fold increase; P<.001).

CONCLUSION

Our study suggests that clinicians in the United States rapidly adopted opportunistic salpingectomy at the time of benign hysterectomy following the publication of data implicating the distal fallopian tubes in ovarian cancer pathogenesis in 2010. By 2015, nearly 60% of women had undergone opportunistic salpingectomy at benign hysterectomy.

Evaluation of a convolutional neural network for ovarian tumor differentiation based on magnetic resonance imaging

OBJECTIVES

There currently lacks a noninvasive and accurate method to distinguish benign and malignant ovarian lesion prior to treatment. This study developed a deep learning algorithm that distinguishes benign from malignant ovarian lesion by applying a convolutional neural network on routine MR imaging.

METHODS

Five hundred forty-five lesions (379 benign and 166 malignant) from 451 patients from a single institution were divided into training, validation, and testing set in a 7:2:1 ratio. Model performance was compared with four junior and three senior radiologists on the test set.

RESULTS

Compared with junior radiologists averaged, the final ensemble model combining MR imaging and clinical variables had a higher test accuracy (0.87 vs 0.64, p < 0.001) and specificity (0.92 vs 0.64, p < 0.001) with comparable sensitivity (0.75 vs 0.63, p = 0.407). Against the senior radiologists averaged, the final ensemble model also had a higher test accuracy (0.87 vs 0.74, p = 0.033) and specificity (0.92 vs 0.70, p < 0.001) with comparable sensitivity (0.75 vs 0.83, p = 0.557). Assisted by the model's probabilities, the junior radiologists achieved a higher average test accuracy (0.77 vs 0.64, Δ = 0.13, p < 0.001) and specificity (0.81 vs 0.64, Δ = 0.17, p < 0.001) with unchanged sensitivity (0.69 vs 0.63, Δ = 0.06, p = 0.302). With the AI probabilities, the junior radiologists had higher specificity (0.81 vs 0.70, Δ = 0.11, p = 0.005) but similar accuracy (0.77 vs 0.74, Δ = 0.03, p = 0.409) and sensitivity (0.69 vs 0.83, Δ = -0.146, p = 0.097) when compared with the senior radiologists.

CONCLUSIONS

These results demonstrate that artificial intelligence based on deep learning can assist radiologists in assessing the nature of ovarian lesions and improve their performance.

KEY POINTS

• Artificial Intelligence based on deep learning can assess the nature of ovarian lesions on routine MRI with higher accuracy and specificity than radiologists. • Assisted by the deep learning model's probabilities, junior radiologists achieved better performance that matched those of senior radiologists.

Gynecologic Considerations for the Urologic Surgeon

While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery. An understanding of basic tests, such as a transvaginal sonogram, can help urologists provide comprehensive care.

Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series

BACKGROUND

As transmasculine persons utilize androgen gender affirming hormone therapy as a part of transition, guidance has been lacking on the effects of the therapy on the ovaries, especially for those who may desire retention.

AIM

To describe the ovarian histopathology of transmasculine persons on testosterone therapy following oophorectomy at the time of hysterectomy performed for gender affirmation.

METHODS

This was a multicenter case series study of transmasculine patients on testosterone therapy who underwent hysterectomy with oophorectomy for gender affirmation between January 2015 and December 2017 at 5 tertiary care referral centers. Patients were identified by their current procedural and International Classification of Diseases codes.

OUTCOMES

Pre-, perioperative, and pathologic data were obtained from the electronic medical records and ovarian tissue descriptions from pathology reports were grouped into the following classifications: (i) simple/follicular cysts; (ii) polycystic ovaries; (iii) complex cysts; (iv) endometriomas; (v) other masses; (vi) atrophy; and (vii) normal.

RESULTS

85 patients were included in the study. At the time of oophorectomy, the mean age and body mass index of the cohort were 30.4 ± 8.4 years and 30.2 ± 7.3 kg/m², respectively, and the average interval from the initiation of testosterone to oophorectomy was 36 0.3 ± 37.9 months. On examination of ovarian histopathology, 49.4% (42) of specimens were found to have follicular/simple cysts, 5.9% (5) were polycystic, and 38.8% (33) had normal pathology. For those specimens with volume documented (n = 41), the median volume was 9.6 (range 1.5-82.5) cm³. There was no association between the duration of testosterone therapy or body mass index and the presence of cysts in the ovaries.

CLINICAL IMPLICATIONS

The results of this study reported benign histopathology in ovaries of a large cohort of transmasculine persons on testosterone which should be included when counseling patients on ovarian retention, as transmasculine patients may choose to retain their ovaries while on testosterone for a variety of reasons (including no desire to undergo surgery, desire for backup sex steroids, and potential use for future fertility).

STRENGTHS & LIMITATIONS

This is a large multicenter study seeking to address the uncertainty in present counseling surrounding ovarian conservation in transmasculine persons on testosterone therapy. Its limitations included its retrospective nature and inability to address ovarian function after testosterone discontinuance.

CONCLUSION

In this cohort of transmasculine patients on testosterone therapy undergoing hysterectomy with oophorectomy for gender affirmation, ovarian histopathology was benign in all the specimens. Grimstad FW, Fowler KG, New EP, et al. Ovarian Histopathology in Transmasculine Persons on Testosterone: A Multicenter Case Series. J Sex Med 2020;17:1807-1818.

Hysterectomy and Oophorectomy in Reproductive Age: A Cross-Sectional Study from a Tertiary Care Hospital

Introduction Hysterectomy is a common surgical procedure in women, and oophorectomy may also be performed with the hysterectomy. The objective of this study was to identify clinical indications and pathological findings in hysterectomies, performed for gynecological causes, in women of reproductive age (15-49 years) and to determine if oophorectomy or ovarian conservation was performed with the hysterectomy as well as the pathological findings in the ovaries. Methods This cross-sectional study was conducted in the department of Pathology at Dow Medical College in Karachi, Pakistan, from September 2017 to December 2018. Data were recorded from the pathology reports of hysterectomy specimens received in the department. Data of hysterectomies performed for gynecological causes in women of reproductive age group were selected and analyzed, using Microsoft Excel (Microsoft, Redmond, Washington) and SPSS version 20 (IBM Corp., Armonk, New York). Data of women more than 49 years and obstetric hysterectomies were excluded. Results Three hundred sixty-one hysterectomies were received; 157 of which were hysterectomies performed in women of reproductive age for gynecological reasons. The mean age of the women was 40.37 (± 5.47) years. Abnormal uterine bleeding was the most frequent clinical indication for hysterectomy in 81 (51.59%) women, followed by uterine prolapse in 29 (18.47%) and leiomyoma in 22 (14.01%). Common pathologies in the endometrium were endometritis in 14 (8.92%) and endometrial polyp in nine (5.73%). In the myometrium, leiomyoma was reported in 52 (33.12%) cases, adenomyosis in 37 (23.57%), and both leiomyoma and adenomyosis in 37 (23.57%) women. Uterine prolapse was histologically identified in 38 (24.20%) women. Oophorectomy was performed on 107 (68.15%) women, and out of these, 83 (77.59%) women's ovaries showed either normal histology or functional cysts. Ovarian pathologies reported were endometriosis, serous cystadenomas and oophoritis in five patients each (4.81%), ovarian serous carcinoma in three (2.88%), and mucinous carcinoma in one (0.96%) patient. Conclusion Abnormal uterine bleeding was the most common clinical indication for hysterectomy in women of reproductive age. The common pathologies in the hysterectomies were endometritis, endometrial polyp, leiomyoma, adenomyosis, and uterine prolapse. Most of the ovaries removed with the hysterectomy did not show any significant pathology, therefore, further studies in this direction are recommended for confirmation of this finding. Ovarian conservation may be considered in women undergoing hysterectomy for abnormal uterine bleeding or other uterine causes and with no radiological or surgical indication for oophorectomy.

The role of pharmacotherapy in the treatment of endometriosis across the lifespan

INTRODUCTION

Endometriosis is estimated to affect 10% of reproductive-aged women. The gold standard for treatment is surgery; however, surgery carries a significant morbidity and cost burden. There is an ongoing need for safe, effective medical therapies for endometriosis patients, both in conjunction with and independent of surgical interventions. Most conventional therapies for endometriosis work by a similar mechanism, and efficacy is variable. In recent years, there has been increased interest in the development and testing of novel pharmacotherapies for endometriosis.

AREAS COVERED

This review discusses both conventional and emerging treatments for endometriosis. The authors present the application of these drugs in different presentations of endometriosis across the lifespan and discuss how emerging therapies might fit into future medical management of endometriosis. Conventional therapies include nonsteroidal anti-inflammatory drugs, combined oral contraceptives, progestins, GnRH agonists/antagonists, and aromatase inhibitors. Emerging therapies are focused on disease-specific targets such as endothelial growth factor receptors.

EXPERT OPINION

The field of endometriosis therapy is moving toward modifying the immune and inflammatory milieu surrounding endometrial implants. If these drugs show efficacy in clinical trials, combining them with current medical treatment is expected to result in a profound impact on symptom and disease burden for patients who suffer from endometriosis worldwide.

Adnexectomy at the time of vaginal hysterectomy for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Preoperative counseling about salpingectomy with pelvic surgery is recommended by the American College of Obstetrics and Gynecology for ovarian cancer risk reduction. Our objective was to determine recent practice patterns and patient factors associated with salpingectomy with vaginal hysterectomy (VH) for pelvic organ prolapse (POP) in the USA. We hypothesize that salpingectomy might have become more common in recent years.

METHODS

We queried the 2014-2016 National Surgical Quality Improvement Program database for women with a postoperative diagnosis of POP who underwent VH with any combination of pelvic reconstructive procedures. CPT codes do not differentiate salpingectomy from salpingo-oophorectomy, so subjects were stratified by whether concurrent adnexectomy was performed. Chi-squared and multivariate logistic regression analyses were used to evaluate characteristics associated with adnexectomy. Propensity score matching was utilized when evaluating postoperative complication rates.

RESULTS

Of 5,344 women who underwent VH, 2019 (37.8%) had adnexectomy. Adnexectomy rate increased from 34.4% in 2014 to 46.8% in 2016 (p < 0.001). Adnexectomy rates of fellowship-trained urogynecologists and general gynecologists were similar (36.0% vs 38.8%, p = 0.197). On logistic regression analysis, patients more likely to undergo adnexectomy were < 65 years old (OR 0.844, CI 0.75-0.95, p = 0.004), had BMI <30 (OR 0.76, CI 0.68-0.86, p < 0.001), and were non-smokers (OR 0.78, CI 0.64-0.95, p = 0.016). Mean operative time was 17 min longer with adnexectomy (145 vs 128 min, p < 0.001). There were no differences in postoperative complications or reoperation rates between groups.

CONCLUSIONS

Adnexectomy during VH for POP is safe and increasingly utilized by gynecology surgeons in the USA.

Impact of prior hysterectomy on surgical outcomes for laparoscopic adnexal surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Uterus at a price: Disability insurance and hysterectomy

Taiwanese Labor, Government Employee, and Farmer Insurance programs provide 5 to 6 months of salary to enrollees who undergo hysterectomies or oophorectomies before their 45th birthday. These programs create incentives for more and earlier treatments, referred to as inducement and timing effects. Using National Health Insurance data between 1997 and 2011, we estimate these effects on surgery hazards by difference-in-difference and bunching-smoothing polynomial methods. For Government Employee and Labor Insurance, inducement is 11-12% of all hysterectomies, and timing 20% of inducement. For oophorectomies, both effects are insignificant. Enrollees' behaviors are consistent with rational choices. Each surgery qualifies an enrollee for the same benefit, but oophorectomy has more adverse health consequences than hysterectomy. Induced hysterectomies increase benefit payments and surgical costs, at about the cost of a mammogram and 5 pap smears per enrollee.

The effects of hysterectomy with bilateral salpingectomy on ovarian reserve

OBJECTIVE

To determine whether ovarian reserve is compromised after hysterectomy with bilateral salpingectomy.

METHODS

A prospective longitudinal study was conducted among 84 women who underwent hysterectomy with bilateral salpingectomy at a tertiary medical center in Beijing, China, between August 2, 2015, and January 15, 2017. Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured to assess ovarian function before undergoing the procedure (baseline) and at weeks 1 and 6 after surgery (postoperative period).

RESULTS

The median age was 41.61 ± 0.62 years. Age negatively correlated with the serum AMH level at baseline (P<0.001), as well as with preoperative-to-postoperative changes in the concentration of this hormone (P<0.001). Serum AMH levels were lower in the postoperative period versus the preoperative period (P<0.001). By contrast, serum FSH levels were higher in the postoperative period than in the preoperative period (P<0.001). Moreover, no correlation was found with body mass index.

CONCLUSIONS

Hysterectomy with bilateral salpingectomy compromised ovarian reserve, with the damage being most severe among younger patients.

Hysterectomy for the Management of Menstrual Hygiene in Women With Intellectual Disability. A Systematic Review Focusing on Standards and Ethical Considerations for Developing Countries

Background: Menstruation poses particular challenges for women with intellectual disability (ID). In low-and middle-income countries, where these women do not have access to facilities and resources for adequate menstrual care, hysterectomy could be considered as an ethically acceptable procedure. We conducted the first systematic review to identify what constitutes best practice for menstrual hygiene in women with ID and explored the perspectives of actors involved in the hysterectomy decision.

Methods: Theory-informed mixed-method thematic systematic review with theory development.

Results: Eleven ethical guidelines and 17 studies were included. Respect for autonomy and the patient's best interest were the criteria to determine what constitutes best practice. The actors' values and attitudes expressed some dimensions of existing inequities. In low-and middle-income countries, the main concern of parents was the difficulty to train their daughters about menstrual hygiene. Parents (mothers in particular) also expressed the feeling of being excessively burdened, and complained about the limitations of their support networks. Doctors perceived hysterectomy as a safe procedure and a solution for women with ID, whose menstrual hygiene is problematic. In general, the more severe or profound the level of ID, the more likely the interested parties advocated for a hysterectomy. The women with ID perceived their menstruation as a negative experience. Hence, the three parties supported hysterectomy for menstrual hygiene. Parents and doctors considered informed consent or assent (from the women with ID) as necessary and achievable.

Conclusion: The international ethical guidelines suggest that non-therapeutic hysterectomy in women with ID should not and ought not to be recommended as routine and appropriate method to cope with menstrual hygiene even if it is technically safe. Although hysterectomy to cope with menstrual hygiene is still a live issue in high-, middle-, and low-income countries, in high income countries it is performed with authorization from the Court; whilst in low-and middle-income countries there is not an active involvement of the State, or financial or training support for women with ID and their carers. Hence, in low-and middle-income countries there is an urgent need to develop and enact policies and statutes in this area of public health and clinical practice.

Moving Toward Individualized Medicine for Uterine Leiomyomas

Uterine leiomyomas are common and life-altering for many women. Despite a wide range of symptoms, varying characteristics of the uterus and the leiomyomas themselves, and many alternatives, hysterectomy accounts for almost three fourths of all surgical therapy, yet there is increasing evidence for a variety of procedural therapies for symptomatic leiomyomas and a new generation of medical therapies under development. With increasing evidence of long-term risk from hysterectomy and new data regarding leiomyoma biology, individualized medical approaches to leiomyomas are likely in the near future. Key biological attributes that influence this disease process are common driver mutations and the new appreciation of the interaction of smooth muscle cells and fibroblasts. Additionally, the interaction between cell types and steroid hormone responsiveness likely plays a role in pathogenesis that can be leveraged in individualized therapy. However, given the independent clonal nature of leiomyomas within the same uterus, moving in the direction of biopsies for individual leiomyomas to understand the biology is unlikely to be fruitful. Use of advanced imaging will likely continue to evolve not only to accurately predict malignant disease, including sarcomas, but to predict leiomyoma subtypes, response to therapy, or both. We predict the continued evolution of therapy from excisional or interventional therapies to medical therapies and ultimately prediction of at-risk individuals. Ideally, individualized therapies will offer primary prevention for women at high risk of leiomyomas and secondary prevention after initial treatment.