Management of Adnexa at the time of Benign Hysterectomy: Review of literature

Management of Adnexa at the time of Benign
Hysterectomy: Review of literature







Hysterectomy is the most common surgery performed worldwide
in Gynecology and the most common indication for it is benign gynecologic
diseases[1, 2].
Physician and patient’s shared decision making regarding adnexal management
during benign hysterectomy is crucial. Concomitant adnexal surgery is performed
to prophylactically reduce the risk of ovarian cancer and includes oophorectomy
and salpingectomy. Ovarian cancer is a challenging health problem with the
absence of effective screening method and 238,700 new cases and 151,900 deaths,
worldwide [3].Nevertheless,
concurrent oophorectomy during benign hysterectomy remains a difficult decision
due to other potential health risks that result as a consequence of surgically
induced menopause. Parker et al concluded that compared with ovarian
conservation, bilateral oophorectomy at the time of hysterectomy for benign
disease is associated with a decreased risk of breast and ovarian cancer but an
increased risk of all-cause mortality, fatal and nonfatal coronary heart
disease, and lung cancer[4].
Recent studies revealed Serous intraepithelial carcinoma, a pre-neoplastic
alteration at fimbriated end of fallopian tube to be the precursor of most
common ovarian cancer subtype[5].
Hence there is an increased trend towards performing bilateral salpingectomy, a
type of concomitant adnexal surgery with benign hysterectomy among gynecologic
surgeons in United State[6].



Oophorectomy V/S ovarian preservation:


Concurrent oophorectomy is performed in 43.7% of
women undergoing hysterectomy for benign indications[6].
Factors affecting this decision include peri-menopausal age, surgical route of
hysterectomy, family history of the patient. Karp et al found that the highest
likelihood of concomitant oophorectomy was in women in the age group of 46- 50 yrs.
[OR,1.78;95% CI, 1.53-2.07]. It is also more likely in women undergoing laparoscopic
or abdominal hysterectomy as opposed to vaginal hysterectomy or with family
history of cancer, endometrial hyperplasia, endometriosis and cervical
dysplasia [7].
Similar study showed a rate of 53.6% for ovarian conservation and indicated younger
age had the strongest association with ovarian conservation, while oophorectomy
was more likely with abdominal hysterectomy. Stratified by age, the rate of
ovarian conservation was 74.3% for those younger than 40 years of age; 62.7%
for those 40–44 years of age; 40.8% for those 45–49 years of age; 25.2% for
those 50–54 years of age; 25.5% for those 55–59 years of age; and 31.0% for
those 60–64 years of age [8].


The major drawback of concomitant oophorectomy with
hysterectomy is surgically induced menopause. This was observed by the Nurses’
health study with a large prospective cohort of 30,000 women and long follow up
of 28 yrs. The study concluded that increased survival was not associated with
oophorectomy in any age group or analysis. In fact, concurrent oophorectomy was
associated with increased risk of all cause mortality [HRs:1.12 (95%
CI-1.03–1.21)] [9].
secondary analysis of women who never used estrogen therapy was done and it showed
oophorectomy was associated with an increased risk for incident stroke and lung
cancer (HR 2.09, 95% 1.01– 4.33), and oophorectomy before age 50 years was associated
with an increased risk of fatal plus nonfatal coronary heart disease (HR 1.98,
95% CI 1.18 –3.32), stroke (HR 2.19, 95% CI 1.16 – 4.14), and deaths from all
causes (HR 1.40, 95% CI 1.01–1.96) [4].
Additionally, it was demonstrated that oophorectomy increased the risks of
cardiovascular disease in women who never smoked and never used estrogen
therapy in comparison to women with known risk factors for cardio vascular
disorders. Oophorectomy before age of 50 years was associated with a 200%
increase in mortality  [9]. Mytton et
al conducted a similar study and compared women undergoing bilateral ovarian
removal versus no or unilateral removal and concluded that patients who had at
least one ovary conserved had a significantly lower rate of all-cause mortality
than patients who had both ovaries removed [10].


Pre-menopausal oophorectomy has also shown deleterious effect
on cognition, sexual function and bone mineral density. There is increased risk
of global cognitive decline, dementia, Alzheimer’s disease in patients with
surgical menopause and this risk is not increased with post-menopausal
oophorectomy or natural menopause [11]. Similar
results were observed in a study that showed that the risk of death associated
with neurological or mental disease was increased in women who underwent
bilateral oophorectomy at age <45 years [12]. A study on bone loss and fracture interestingly showed a statistically significant increase in fracture rate in women who underwent BSO after natural menopause [13].   All these deleterious effects of oophorectomy before menopause are caused due to abrupt reduction in endogenous estrogen and was traditionally overcome by hormone replacement therapy (HRT). However, a study conducted to learn about HRT compliance revealed that 3% of women discontinued HT by 2 years, 20% by 5 years, and 67% by 10 years [14]. A similar study observed a discontinuation rate of 42% at an average of 5.2 years of follow-up [15]     Advantages of prophylactic oophorectomy include prevention of development of ovarian cancer and decreased risk of subsequent surgery for ovarian pathology. There is also evidence suggesting decreased breast cancer in women who have undergone oophorectomy. However, it should be noted that only 34 of 13,035 women (0.3%) who had ovarian preservation at time of hysterectomy later died of ovarian cancer [4]. Nurses’ health study also found that with oophorectomy there is paradoxical increased risk of death from all cancer that exceeds the risk of dying from ovarian cancer (low incidence) and breast cancer (high long-term survival rate) [4]. There is also mixed data related to association of colorectal cancer with oophorectomy[9, 16-18].    Potential risk of re-operation in women with ovarian conservation at time of hysterectomy has been studied and found to be 2.8- 9.2% [19-22]. These risks should be weighed against the potential adverse effects of oophorectomy. Casiano et al studied risk of subsequent oophorectomy after hysterectomy and concluded that the incidence of oophorectomy after hysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentage points higher than the incidence of oophorectomy in women with intact reproductive organs. Hence, women can be reassured that the odds are low that they will require subsequent oophorectomy.   There is also evidence to prove safety of ovarian conservation in premenopausal women with endometrial cancer. Wright et al concluded that ovarian conservation does not adversely affect survival for women with early-stage endometrial cancer and despite the oncologic safety of ovarian conservation, the majority of young women with endometrial cancer still undergo oophorectomy at the time of surgery [23].                                                 Salpingectomy pros and cons     BRCA     Opinion of professional societies     Current trends     Conclusion                                                                         REFERENCES     1.         Hammer, A., et al., Global epidemiology of hysterectomy: possible impact on gynecological cancer rates. Am J Obstet Gynecol, 2015. 213(1): p. 23-9. 2.         Wright, J.D., et al., Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol, 2013. 122(2 Pt 1): p. 233-41. 3.         Torre, L.A., et al., Global cancer statistics, 2012. CA Cancer J Clin, 2015. 65(2): p. 87-108. 4.         Parker, W.H., et al., Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses' health study. Obstet Gynecol, 2009. 113(5): p. 1027-37. 5.         Dietl, J., Revisiting the pathogenesis of ovarian cancer: the central role of the fallopian tube. Arch Gynecol Obstet, 2014. 289(2): p. 241-6. 6.         Mikhail, E., et al., National trends of adnexal surgeries at the time of hysterectomy for benign indication, United States, 1998-2011. Am J Obstet Gynecol, 2015. 213(5): p. 713 e1-13. 7.         Karp, N.E., et al., Removal of normal ovaries in women under age 51 at the time of hysterectomy. Am J Obstet Gynecol, 2015. 213(5): p. 716 e1-6. 8.         Perera, H.K., et al., Variation in ovarian conservation in women undergoing hysterectomy for benign indications. Obstet Gynecol, 2013. 121(4): p. 717-26. 9.         Parker, W.H., et al., Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol, 2013. 121(4): p. 709-16. 10.       Mytton, J., et al., Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage. BMJ, 2017. 356: p. j372. 11.       Adelman, M.R. and H.T. Sharp, Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol, 2017. 12.       Rivera, C.M., et al., Increased mortality for neurological and mental diseases following early bilateral oophorectomy. Neuroepidemiology, 2009. 33(1): p. 32-40. 13.       Melton, L.J., 3rd, et al., Fracture risk after bilateral oophorectomy in elderly women. J Bone Miner Res, 2003. 18(5): p. 900-5. 14.       Read, M.D., et al., Compliance with estrogen hormone replacement therapy after oophorectomy: a prospective study. Menopause Int, 2010. 16(2): p. 60-4. 15.       Rossouw, J.E., et al., Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA, 2002. 288(3): p. 321-33. 16.       Jacoby, V.L., et al., Oophorectomy vs ovarian conservation with hysterectomy: cardiovascular disease, hip fracture, and cancer in the Women's Health Initiative Observational Study. Arch Intern Med, 2011. 171(8): p. 760-8. 17.       Gaudet, M.M., et al., Oophorectomy and hysterectomy and cancer incidence in the Cancer Prevention Study-II Nutrition Cohort. Obstet Gynecol, 2014. 123(6): p. 1247-55. 18.       Luo, G., et al., Risk of colorectal cancer with hysterectomy and oophorectomy: A systematic review and meta-analysis. Int J Surg, 2016. 34: p. 88-95. 19.       Holub, Z., et al., Does hysterectomy without salpingo-oophorectomy influence the reoperation rate for adnexal pathology? A retrospective study. Clin Exp Obstet Gynecol, 2000. 27(2): p. 109-12. 20.       Baloglu, A., et al., Development of secondary ovarian lesions after hysterectomy without oophorectomy versus unilateral oophorectomy for benign conditions: a retrospective analysis of patients during a nine-year period of observation. Clin Exp Obstet Gynecol, 2010. 37(4): p. 299-302. 21.       Plockinger, B. and H. Kolbl, Development of ovarian pathology after hysterectomy without oophorectomy. J Am Coll Surg, 1994. 178(6): p. 581-5. 22.       Casiano, E.R., et al., Risk of oophorectomy after hysterectomy. Obstet Gynecol, 2013. 121(5): p. 1069-74. 23.       Wright, J.D., et al., Utilization and Outcomes of Ovarian Conservation in Premenopausal Women With Endometrial Cancer. Obstet Gynecol, 2016. 127(1): p. 101-8.