Oophorectomy Or Salpingectomy— Which Makes More Sense?

Oophorectomy or salpingectomy— which makes more sense?

During hysterectomy for benign indications, many surgeons routinely remove the ovaries to prevent cancer. Here’s what we know about this practice.

William H. Parker, MD

CASE Patient opts for hysterectomy, asks than age 45 to prevent the subsequent devel- about oophorectomy opment of ovarian cancer (FIGURES 1 and 2). Your 46-year-old patient reports increasingly The 2002 Women’s Health Initiative re- severe dysmenorrhea at her annual visit, and a port suggested that exogenous hormone use pelvic examination reveals an enlarged uterus. was associated with a slight increase in the You order pelvic magnetic resonance imaging, risk of breast cancer.2 After its publication, which shows extensive adenomyosis. the rate of oophorectomy at the time of hys- After you counsel the patient about terectomy declined slightly, likely reflect- IN THIS her options, she elects to undergo lapa- ARTICLE ing women’s desire to preserve their own roscopic supracervical hysterectomy and source of estrogen.3 For women younger Algorithm: Should asks whether she should have her ovaries than age 50, further slight declines in the rate the ovaries removed at the time of surgery. She has no of oophorectomy were seen from 2002 to be removed? family history of ovarian or breast cancer. 2010. However, in the United States, almost page 54 What would you recommend for this 300,000 women still undergo “prophylactic” woman, based on her situation and current bilateral salpingo-oophorectomy every year.4 medical research? The lifetime risk of ovarian cancer Ovarian cancer does among women with a BRCA 1 mutation not come from the prophylactic procedure should be is 36% to 46%, and it is 10% to 27% among ovary considered only if 1) there is a rea- women with a BRCA 2 mutation. Annual page 56 A sonable expectation that it will ben- screening for ovarian cancer using trans- efit the patient and 2) there is evidence that, vaginal ultrasound and CA 125 has not The case for without it, the individual will be at high risk been effective even among this group of salpingectomy for disease.1 Bilateral oophorectomy at the women and is not recommended.5 There is page 56 time of hysterectomy for benign disease of- universal agreement that women with these ten has been recommended for women older mutations should strongly consider oophorectomy once they have completed child- Dr. Parker is Director of Minimally bearing.6 Genetic counseling and testing Invasive Gynecologic Surgery for these genetic mutations now are readily at University of California at Los Angeles Medical Center in available. Santa Monica, California, and In the general population of US women, a past President of AAGL. the lifetime risk of ovarian cancer is 1.4%. The risk varies between populations, however. For The author reports no financial relationships white women with 3 or more term pregnan- relevant to this article. cies and 4 or more years of oral contraceptive

50 OBG Management | March 2014 | Vol. 26 No. 3 obgmanagement.com FIGURE 1 When hysterectomy is planned, a number of variables influence whether concomitant oophorectomy or salpingectomy is advisable, including the likelihood of malignancy, the woman’s personal and family history of cancer, any BRCA mutations, and her desire for childbearing. Overall, the evidence suggests use, the lifetime risk is only 3 women in every higher risk of dying from CHD (hazard ratio that removing 7 1,000 (0.3%). [HR], 1.23), colorectal cancer (HR, 1.49), lung healthy ovaries cancer (HR, 1.29), and all causes (HR, 1.13) at hysterectomy than did women who had hysterectomy and does not meet Know the full range of risks ovarian conservation.9 During the 28 years, requirements associated with oophorectomy 44 of 13,302 women (0.9%) died of ovarian for prophylactic After menopause and throughout a woman’s cancer. At no age was there a survival ad- intervention life, the ovaries continue to produce andro- vantage in the oophorectomy group. A Mayo gens, which are converted to estrone. Many Clinic study found similar results.10 studies suggest that endogenous estrogen is Additional studies of the Mayo popula- beneficial to the heart, bones, and brain. tion found higher risks of anxiety, depression, A 2009 study from the Nurses’ Health dementia or cognitive impairment, and Par- Study (NHS) database found that, among kinsonism in women who had their ovaries women who underwent hysterectomy with removed.11 Also, about 90% of premenopausal oophorectomy, there were more cases of cor- women experience vasomotor symptoms fol- onary heart disease (CHD), stroke, and lung lowing oophorectomy; many women also ex- cancer, compared with women who had hys- perience mood changes, a decline in feelings terectomy with ovarian conservation.8 of well-being, lower sexual desire, sleep dis- A subsequent NHS report focused on turbances, and headaches. long-term mortality and found that, after Overall, the evidence suggests that the 28 years of follow-up, women who had a hys- removal of healthy ovaries does not meet the terectomy and bilateral oophorectomy had a requirements for a prophylactic intervention. CONTINUED ON PAGE 54 ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT

obgmanagement.com Vol. 26 No. 3 | March 2014 | OBG Management 51 oophorectomy or salpingectomy? CONTINUED FROM PAGE 51

FIGURE 2 Should the ovaries be removed at hysterectomy?

Hysterectomy is planned

Is hysterectomy indicated to treat malignant disease?

No Yes

Does patient have a personal Bilateral salpingo- or family history of breast or oophorectomy ovarian cancer? is often advised

No Yes Is a BRCA mutation present? Yes

No Is childbearing completed?

Recommend bilateral Ovarian and tubal Yes No salpingectomy, but defer to conservation patient preference In women with a BRCA mutation, bilateral salpingo- Consider bilateral salpingectomy with ovarian oophorectomy often preservation is advised

Exogenous estrogen is not statins 1 year after their first prescription.12 a practical strategy after Even these figures are overstated because oophorectomy they do not include women who never see a In the NHS studies, women who underwent doctor, those who see a doctor but don’t get hysterectomy and bilateral oophorectomy a prescription, and those who never fill their before age 50 but did not use subsequent es- first prescription. trogen therapy had a higher risk of all-cause Clearly, oophorectomy followed by ini- mortality than women who did use estrogen tiation of estrogen and statins for women (HR, 1.41).9 An early response to this find- younger than 50 is unlikely to be effective. ing was to advocate oophorectomy followed by the initiation of menopausal hormone therapy and statins to ward off any nega- The likelihood of future adnexal tive cardiovascular effects. However, data surgery is low indicate that only 17% of women continue Only about 6.2% of women who undergo to take estrogen 5 years after the initial pre- hysterectomy with ovarian conservation scription, and only 18% of women still take require reoperation over the succeeding

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54 OBG Management | March 2014 | Vol. 26 No. 3 obgmanagement.com oophorectomy or salpingectomy? CONTINUED FROM PAGE 54

20 years. The risk for age-matched women hormone and follicle-stimulating hormone without hysterectomy is 4.8%, so the abso- at baseline (prior to salpingectomy) and lute difference is only 1.4% over 20 years.13 3 months following surgery.16 Therefore, Although asymptomatic ovarian cysts bilateral salpingectomy may be a reason- are rather prevalent (6.6%) in postmeno- able choice for women who have completed pausal women, they do not undergo trans- childbearing and who are considering pelvic formation to cancer and usually resolve surgery. As the Society of Gynecologic On- spontaneously.14 Therefore, the majority of cologists stated in recent guidelines: “For these cysts do not need to be removed. women at average risk of ovarian cancer, sal- The suggestion that oophorectomy can pingectomy should be discussed and con- avert the need for future adnexal surgery ap- sidered prior to abdominal or pelvic surgery, pears to be unfounded. hysterectomy, or in lieu of tubal ligation.”17

CASE Resolved Ovarian cancer does not come After you review the risks and benefits of pro- from the ovary phylactic oophorectomy versus prophylactic Seventy percent of epithelial ovarian can- salpingectomy, the patient chooses the latter cers are of the serous high-grade and clini- option and undergoes a successful surgery. cally aggressive type. The ovary contains no epithelial cells.15 Almost all high-grade cancers are associated with p53 mutations. Bottom line: In women with an Cancer precursor lesions called serous tub- average risk of ovarian cancer, al intraepithelial cancer (STIC) have been salpingectomy is preferred found in the fallopian tubes of both BRCA- Reasonable evidence now suggests that positive and BRCA-negative women, but no oophorectomy is associated with higher risks corresponding precursor lesions have ever of CHD, colorectal and lung cancers, and The suggestion been found in the ovary. Moreover, STIC pre- overall mortality. Almost all high-grade se- that oophorectomy cursor lesions have p53 mutations matching rous cancers arise from the fallopian tubes, can avert the need those found in high-grade serous “ovarian” not the ovaries. Therefore, for women at av- for future adnexal cancers, but no similar p53 mutations have erage risk for ovarian cancer who have com- surgery appears to been found in low-grade, more indolent and pleted childbearing, salpingectomy should be unfounded treatable cancers found inside the ovary (ie, be considered at the time of pelvic surgery. Stage 1). Therefore, the deadly form of ovar- After decades of failure to achieve early ian cancer is, in fact, tubal cancer. diagnosis or curative treatment of “ovarian” cancer, we finally may have a way to reduce the incidence of this deadly disease. The case for salpingectomy Because convincing evidence points to the References 1. Hodges F, Svoboda J, Van Howe RS. Prophylactic tubal origin of ovarian cancer, some experts interventions on children: balancing human rights with have proposed salpingectomy for prophylax- public health. J Med Ethics. 2002;28(1):10–16. 2. Writing Group for the Women’s Health Initiative is. Salpingectomy should remove the source Investigators. Risks and benefits of estrogen plus progestin of aggressive cancers and preserve func- in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. tioning ovaries. However, some wondered JAMA. 2002;288(3):321–333. whether salpingectomy would compromise 3. Perera HK, Ananth CV, Richards CA, et al. Variation in ovarian conservation in women undergoing hysterectomy collateral circulation to the ovaries and pre- for benign indications. Obstet Gynecol. 2013;121(4):717–726. dispose women to early ovarian failure. 4. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient A recent study of 79 women found simi- hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198:34.e1–e7. lar antral follicle counts and mean ovarian 5. Evans GR, Gaarenstroom KN, Stirling D, et al. Screening for diameters (as measured sonographically) familial ovarian cancer: poor survival of BRCA1/2 related cancers. J Med Genet. 2009;46(9):593–597. and similar serum levels of anti-Müllerian 6. Kauff ND, Domchek SM, Friebel TM, et al. Risk-reducing

56 OBG Management | March 2014 | Vol. 26 No. 3 obgmanagement.com salpingo-oophorectomy for the prevention of BRCA1- 12. Sprague BL, Trentham-Dietz A, Cronin KA. A sustained and BRCA2-associated breast and gynecologic cancer: A decline in postmenopausal hormone use: Results from the multicenter, prospective study. J Clin Oncol. 2008;26(8):1331– national health and nutrition examination survey, 1999– 1337. 2010. Obstet Gynecol. 2012;120(3):595–603. 7. Hartge P, Whittemore AS, Itnyre J, McGowan L, Cramer 13. Casiano ER, Trabuco EC, Bharucha AE, et al. Risk of D. Rates and risks of ovarian cancer in subgroups of white oophorectomy after hysterectomy. Obstet Gynecol. women in the United States. The Collaborative Ovarian 2013;121(5):1069–1074. Cancer Group. Obstet Gynecol. 1994;84(5):760–764. 14. Pavlik EJ, Ueland FR, Miller RW, et al. Frequency and 8. Parker W, Broder M, Chang E, et al. Ovarian conservation at the disposition of ovarian abnormalities followed with serial time of hysterectomy and long-term health outcomes in the transvaginal ultrasonography. Obstet Gynecol. 2013;122 Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027–1037. (2 Pt 1):210–217. 9. Parker WH, Feskanich D, Broder MS, et al. Long-term 15. Kurman RJ, Shih IM. The origin and pathogenesis of mortality associated with oophorectomy compared with epithelial ovarian cancer: A proposed unifying theory. Am J ovarian conservation in the Nurses’ Health Study. Obstet Surg Pathol. 2010;34(3):433–443. Gynecol. 2013;121(4):709–716. 16. Morelli M, Venturella R, Mocciaro R, et al. Prophylactic 10. Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, salpingectomy in premenopausal low-risk women for Melton LJ III. Survival patterns after oophorectomy in ovarian cancer: primum non nocere. Gynecol Oncol. premenopausal women: A population-based cohort study. 2013;129(6):448–451. Lancet Oncol. 2006;7(10):821–828. 17. SGO Clinical Practice Statement: Salpingectomy for Ovarian 11. Rocca W, Bower J, Maraganore D, et al. Increased risk Cancer Prevention. Society of Gynecologic Oncology. of cognitive impairment or dementia in women who November 2013. https://www.sgo.org/clinical-practice underwent oophorectomy before menopause. Neurology. /guidelines/sgo-clinical-practice-statement-salpingectomy 2007;69(11):1074–1083. -for-ovarian-cancer-prevention. Accessed February 10, 2014.

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Karl Storz Shionogi Inc. Bipolar Resectoscopes...... P 7 Osphena...... C2, PP 1–2

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