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

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

 

Abstract:

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Introduction:

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].
A
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