Why when where oophorectomy

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DR. KAWITA BAPAT
INDORE
WHY WHEN
WHERE
OOPHORECTOMY
ONE DAY HYSTERECTOMY

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•  Salpingo-ophorectomy At The Time Of
Hysterectomy Is A Commonly
PracticedYet Controversial Procedure
With Approximately 300 000 Women
Undergoing This Procedure Each Year

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Fear factor
n Oophorectomy may impair bone health

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Fear factor
n  Loss of ovaries may affect mental health and sexuality

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Fear factor
n  CAD risk rises sharply after oophorectomy

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Fear factor
n  Ovarian cancer is a real, but relatively low, risk

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Fear factor
n  Need for reoperation is very low

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Fear factor
n  Ovarian conservation boosts long-term survival

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Fear factor
n  Cognitive function may suffer

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Oophorectomy Before
The Onset Of
Menopause Increased
The Risk Of
•  Parkinsonism
•  Cognitive Impairment
•  Dementia
•  Anxiety
•  Depression

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Oophorectomy causes more
harm than good in many women
undergoing hysterectomy for
benign disease

+Data From The Centers For Disease Control And
Prevention
n  with Hysterectomy
n  approximately 55% will undergo a concomitant salpingooophorectomy
n  Indications for prophylactic salpingooophorectomy at the time of
hysterectomy include
1.  An Overall Reduction In Ovarian Cancer In Patients Of All Ages
2.  Reduction In Breast Cancer Rates In Premenopausal Patients.
n  In addition, although there is a paucity of data, it is estimated that
between 3% to 8% of women undergoing hysterectomy will require a
second surgery for adnexal disease that develops in the future

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n  The Rate Of Salpingo-oophorectomy With Concomitant
Hysterectomy Is Age Dependent.
n  In Younger Women Ages 40 To 44, 50% Have Concurrent
Oophorectomy Compared With 78% Of Women Ages 45 To
64.
n  In Addition To Age,
n  Route Of Hysterectomy Affects Rates Of Salpingo-
oophorectomy,
n  With Vaginal Hysterectomy Having Lower Concomitant
Removal Of The Adnexa Compared With Laparoscopic
Assisted And Abdominal Hysterectomy.

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Route of hysterectomy
n  Jacoby et al study of more than 450 000 women,
n  showed advanced age, geography, and to be the most important
determinants of salpingo-oophorectomy.
n  Notably, salpingooophorectomy was least likely to be
performed with vaginal hysterectomy
n  8-fold more likely to occur in conjunction with laparoscopic
assisted hysterectomy
n  12-fold as likely with abdominal hysterectomy .
n Desire for salpingooophorectomy may thus be
a factor for deciding route for a hysterectomy.

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n  The Discrepancy In The Rate Of Salpingooophorectomy And
Surgical Approach May Be Explained By
n  The Technical Challenges Inherent To Vaginal Surgery,
n  As Well As Heightened Concerns For Intraoperative
Complications Such As Ureteral Injury
n  Intraoperative Bleeding With A Vaginal Approach .

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Fast Track
n  Perform prophylactic oophorectomy only if a preponderance
of the evidence establishes that it benefits the patient

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Fast Track
n  * Estrogen replacement is recommended for women younger
than 45 years who opt for oophorectomy

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n  An Increased Risk Of Death From Coronary Artery Disease
(CAD), Lung Cancer, All Cancers (Except Ovarian),
n  • An Increased Risk Of Osteoporosis And Hip Fracture
n  • When Performed Before The Onset Of Menopause, An
Increased Risk Of Parkinsonism, Cognitive Impairment,
Dementia, Anxiety, And Depression.
n  Benefits Include A Reduced Risk Of Ovarian Cancer,
Particularly Among Women Who
n  Conservation Is An Option

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1.
n  The most common and lethal subtypes of ovarian cancer are
thought to originate from fallopian tube epithelia or
endometrial cells that travel through the fallopian tube and
implant as endometriosis.

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2.
n  Women at an increased hereditary risk of breast and ovarian
cancer should undergo RRSO when childbearing is complete
and before 40 years of age.
n  The maximum survival benefit is observed in women
undergoing surgery at age 30, whereas the minimal survival
benefit is observed in women undergoing surgery after age
50 years old.

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2.
n  BRCA1 mutation carriers might have a greater magnitude of
benefit than BRCA2 mutation carriers.
n  Histopathologic research suggests that women unwilling to
undergo RRSO by 40 years of age benefit from prophylactic
salpingectomy with delayed oophorectomy.

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3.
n  Hormone therapy after RRSO until the natural age of
menopause
n  maintains the protective benefit on breast cancer risk
n  while alleviating the cardiovascular disease and all-cause
mortality risk observed after premature surgical menopause.
n  Estrogen-only HT is associated with less VTE, stroke, and
breast cancer risk than regimens with systemic
progestogens.

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4.
n  Opportunistic salpingectomy at the time of surgery for
benign gynecologic disease and laparoscopic sterilization
might decrease the risk of ovarian cancer by as much as
65%
n  Although strong clinical data are lacking.

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5.
n  Bilateral tubal ligation decreases the risk of endometrioid
and clear cell EOC.

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6.
n  Lynch syndrome carries an increased risk of uterine and
ovarian cancer that varies widely by mutation type.
n  Risk-reducing surgery (hysterectomy and BSO), annual
cancer screening, and endometrial cancer symptom
education with an annual examination are all reasonable
management strategies from a survival perspective.
n  Decision analyses predict that prophylactic surgery between
the ages of 30 and 40 years delivers the greatest net health
benefits and is most cost-effective.

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7.
n  Cowden syndrome carries a high-risk of uterine cancer. Risk-
reducing hysterectomy before 50 years of age should be
discussed with patients as a management option although it
is not

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n  Conservation vs oophorectomy: A guide to decision-
making

Hysterectomy is planned
Does patient have
personal or family
history of breast or
ovarian cancer?
Oophorectomy is
often advised
Is BRCA mutation
present?
Does patient have
a personal or
family history of
heart disease,
osteoporosis,
or cancer (other
than breast and
ovarian cancer)?
Conservation
is advised*
Consider
oophorectomy based
on history, patient
preference
Conservation is an option
Is hysterectomy indicated to treat malignant disease?
Is patient younger
than 50 years?
NO
NO YES
YES
NO
NO YES
YES
NO
YES

+Women at Population Risk Undergoing Surgery for Benign Disease
n  Opportunistic Bilateral Salpingectomy
n  Opportunistic bilateral salpingectomy (OBS) at the time of
gynecologic surgery for benign disease and sterilization is
an attractive option in women at average risk for ovarian
cancer.
n  Histopathologic research has shown biologic plausibility, and
clinical data, although limited, consistently suggest a
protective effect.

+Women at Population Risk Undergoing Surgery for Benign Disease
n  Clinical Data Evaluating the Effect of Bilateral Salpingectomy
on Ovarian Cancer Prevention
n  Falconer et al performed a large population-based cohort
study using Swedish registries to evaluate the effect of
benign gynecologic surgery on the development of ovarian
cancer
n  Patients were considered exposed if they underwent
hysterectomy, oophorectomy, salpingectomy, or sterilization.

+Risk of Ovarian Cancer Associated with Salpingectomy and
Tubal Ligation
n  Hysterectomy: HR = 0.79 (0.70–0.88)
n  BS = bilateral salpingectomy;
n  BSO = bilateral salpingo-oophorectomy;
n  BTL = bilateral tubal ligation;
n  CI = confidence interval; HR = adjusted hazard ratio;
n  NR = not reported;
n  OC = oral contraceptive;
n  OR = adjusted odds ratio;
n  PID = pelvic inflammatory disease;
n  US = unilateral salpingectomy.

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Safety and Feasibility
n  The body of evidence suggests that OBS at the time of
hysterectomy or sterilization is safe and feasible.
n  When compared with women conserving their fallopian
tubes at the time of gynecologic surgery for benign disease,
those receiving OBS experience similar perioperative
complication and readmission rates]; surgical time is slightly
increased [but cost analyses favor OBS

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Prophylactic Salpingo-
oophorectomy
n  Familial Cancer Syndromes:
n  Breast-ovarian Cancer Syndrome (BRCA1, BRCA2)
n  Hereditary Nonpolyposis Colorectal Cancer Syndrome
(HNPCC) Is A Associated
n  With A 13% Lifetime Risk Of Ovarian Cancer And 60%
Lifetime Risk Of Endometrial
n  Cancer
n  Site-specific Ovarian Cancer Syndrome

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Fast Track
n  How this evidence should inform your practice

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Fast Track
n  The resultant loss of hormone production in premenopausal
women is obvious, but “postmenopausal ovaries continue to
produce significant amounts of testosterone and
androstenedione, which are converted to estrogen
peripherally.”

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Fast Track
n  Salpingo-ophorectomy at the time of hysterectomy is a
commonly practiced yet controversial procedure

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Fast Track
n  This loss of estrogen production translates into increased
cardiovascular risk, so the prophylactic removal of the
ovaries to prevent ovarian cancer has to be weighed against
heart disease, stroke, and death from cardiovascular events.

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1.n .Women at an increased hereditary risk of
breast and ovarian cancer should undergo
RRSO when childbearing is complete and
before 40 years of age.

+
2.
n  The maximum survival benefit is observed in women
undergoing surgery at age 30, whereas the minimal survival
benefit is observed in women undergoing surgery after age
50 years old.
n  BRCA1 mutation carriers might have a greater magnitude of
benefit than BRCA2 mutation carriers.
n  Histopathologic research suggests that women unwilling to
undergo RRSO by 40 years of age benefit from prophylactic
salpingectomy with delayed oophorectomy.

+
3.n Hormone therapy after RRSO until the natural age
of menopause maintains the protective benefit on
breast cancer risk while alleviating the
cardiovascular disease and all-cause mortality risk
observed after premature surgical menopause.
n  Estrogen-only HT is associated with less VTE,
stroke, and breast cancer risk than regimens with
systemic progestogens.

+
4.
n Opportunistic salpingectomy at the time of
surgery for benign gynecologic disease
and laparoscopic sterilization might
decrease the risk of ovarian cancer by as
much as 65% although strong clinical data
are lacking.

+
5.
n Bilateral tubal ligation decreases the
risk of endometrioid and clear cell
EOC.

+
6.n  Lynch syndrome carries an increased risk of uterine and
ovarian cancer that varies widely by mutation type.
n  Risk-reducing surgery (hysterectomy and BSO), annual
cancer screening, and endometrial cancer symptom
education with an annual examination are all reasonable
management strategies from a survival perspective.
n  Decision analyses predict that prophylactic surgery between
the ages of 30 and 40 years delivers the greatest net health
benefits and is most cost-effective.

+
7.
n Cowden syndrome carries a
high-risk of uterine cancer. Risk-
reducing hysterectomy before 50
years of age should be discussed
with patients as a management
option although it is not

+
Bilateral Salpingo-Oophorectomy
n  The “opportunistic” removal of ovaries and fallopian tubes at
the time of surgery for benign disease is a reasonable option
for ovarian cancer prevention in postmenopausal women.
n  It might be preferable to ovarian conservation in patients
over 65 years old
n  The health risks of BSO in premenopausal women at an
average risk of ovarian and breast cancer is generally too
high to be considered routinely.

+
Bilateral Salpingo-Oophorectomy
n  If pursued, HT after removal attenuates risks
n  BSO in premenopausal women at the time of hysterectomy
for benign disease decreases the risk of ovarian cancer from
1.3% to 0.03%
n  This does come at significant cost because the abrupt loss of
estrogen affects all organ systems and results in an increased
risk of cardiovascular disease, osteoporosis, urogenital
disease, and all-cause mortality.
n  The negative health effects are most evident in women who
undergo oophorectomy before age 40 . If also obese, all-
cause mortality more than doubles in this population (HR =
2.23; 95% CI, 1.25–3.98)
n 

+Opportunistic Bilateral Salpingectomy
n  Opportunistic bilateral salpingectomy (OBS) at the time of
gynecologic surgery for benign disease and sterilization is
an attractive option in women at average risk for ovarian
cancer.
n  Histopathologic research has shown biologic plausibility, and
clinical data, although limited, consistently suggest a
protective effect.

+
n The body of evidence suggests that
OBS at the time of hysterectomy or
sterilization is safe and feasible.
n When compared with women
conserving their fallopian tubes at the
time of gynecologic surgery for
benign disease, those receiving OBS
experience similar perioperative
complication and readmission rates

+
n surgical time is
slightly increased
n but cost analyses
favor OBS

+
n  A decision analysis constructed using National Surgical
Quality Improvement Program data predicted a small
increase in major complications with OBS at the time of
vaginal hysterectomy than with hysterectomy alone (7.95%
vs 7.68%) but still favored OBS, stating that “complications
are minimally increased, but the trade-off with cancer
prevention is highly favorable”
n  Women who do retain their fallopian tubes are twice as likely
to return to the operating room for tubal pathology (HR =
2.13; 95% CI, 1.88–2.42)
n  Furthermore, OBS does not appear to significantly impact
ovarian reserve or perfusion as measured by serum markers,
the response to controlled ovarian hyperstimulation, and
ovarian stromal blood flow

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Society Recommendations on
Risk-reducing Bilateral
Salpingectomy

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n  ACOG = The American College of Obstetricians and
Gynecologists;
n  BS = bilateral salpingectomy;
n  NCCN = National Comprehensive Cancer Network;
n  PSDO = prophylactic salpingectomy with delayed oophorectomy;
n  RRSO = risk-reducing salpingo-oophorectomy;
n  SGO = Society of Gynecologic Oncologists;
n  SOGC = Society of Gynecologic Oncology of Canada;
n  US = unilateral salpingectomy.

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ACOG
n  Not recommended
n  BS at the time of hysterectomy appears safe.
n  Surgeon should discuss potential benefits of concomitant
bilateral salpingectomy with patients before hysterectomy
for benign disease.
n  Surgeons can communicate with patients that BS is an
effective means of contraception.
n  Complete salpingectomy up to the uterotubal junction is
preferable to fimbriectomy.
n  The approach to hysterectomy or sterilization “should not be
influenced by the theoretical benefit of salpingectomy.”

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SGO
n  Women with BRCA mutations who decline RRSO “should be
counseled regarding risk-reducing salpingectomy when
childbearing is complete followed by oophorectomy in the
future, although the safety of this approach has not been
studied.”
n  In women at population risk of ovarian cancer,“risk-reducing
salpingectomy should also be discussed and considered with
patients at the time of abdominal or pelvic surgery,
hysterectomy, or in lieu of tubal ligation.”

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NCCN
n  “Salpingectomy alone is not the standard of care
n  for risk reduction although clinical trials are ongoing.
n  The concern for risk-reducing salpingectomy alone is that
women are still at risk for developing ovarian cancer.
n  In addition, in premenopausal women, oophorectomy likely
reduces the risk of developing breast cancer but the
magnitude is uncertain and may be gene-specific.”
n  “Despite some evidence regarding the safety and feasibility
of this procedure, more data are needed regarding its
efficacy in reducing the risk for ovarian cancer.”

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SOGC
n When considering permanent
contraception, physicians should discuss
with patients the possible additional
protective benefit of BS
n BS should be performed at the time of
hysterectomy for benign disease

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Prevalence of Practice
n  Over the past decade, the practice of OBS at the time of
gynecologic surgery for benign disease has markedly
increased, but it is still practiced by a minority of surgeons.
n  In the United States from 2008 to 2013, OBS at the time of
hysterectomy increased 3-fold to 7.7%
n  In Europe, 26% of gynecologists perform OBS at the time of
abdominal and laparoscopic hysterectomy, whereas only 5%
perform OBS at the time of vaginal hysterectomy.
n  An even smaller proportion perform salpingectomy for
sterilization procedures.
n  The ACOG and the SGO support the practice of OBS,
whereas the NCCN does not

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n  Perform prophylactic oophorectomy only if a preponderance of
the evidence establishes that it benefits the patient
n  Manipulate the patient or convince yourself

Why when where oophorectomy

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