Management of Adnexa at the time of BenignHysterectomy: Review of literature Abstract: Introduction:Hysterectomy is the most common surgery performed worldwidein Gynecology and the most common indication for it is benign gynecologicdiseases[1, 2].Physician and patient’s shared decision making regarding adnexal managementduring benign hysterectomy is crucial. Concomitant adnexal surgery is performedto prophylactically reduce the risk of ovarian cancer and includes oophorectomyand salpingectomy. Ovarian cancer is a challenging health problem with theabsence of effective screening method and 238,700 new cases and 151,900 deaths,worldwide .Nevertheless,concurrent oophorectomy during benign hysterectomy remains a difficult decisiondue to other potential health risks that result as a consequence of surgicallyinduced menopause.
Parker et al concluded that compared with ovarianconservation, bilateral oophorectomy at the time of hysterectomy for benigndisease is associated with a decreased risk of breast and ovarian cancer but anincreased risk of all-cause mortality, fatal and nonfatal coronary heartdisease, and lung cancer.Recent studies revealed Serous intraepithelial carcinoma, a pre-neoplasticalteration at fimbriated end of fallopian tube to be the precursor of mostcommon ovarian cancer subtype.Hence there is an increased trend towards performing bilateral salpingectomy, atype of concomitant adnexal surgery with benign hysterectomy among gynecologicsurgeons in United State. Oophorectomy V/S ovarian preservation: Concurrent oophorectomy is performed in 43.7% ofwomen undergoing hysterectomy for benign indications.
Factors affecting this decision include peri-menopausal age, surgical route ofhysterectomy, family history of the patient. Karp et al found that the highestlikelihood 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 laparoscopicor abdominal hysterectomy as opposed to vaginal hysterectomy or with familyhistory of cancer, endometrial hyperplasia, endometriosis and cervicaldysplasia .Similar study showed a rate of 53.
6% for ovarian conservation and indicated youngerage had the strongest association with ovarian conservation, while oophorectomywas more likely with abdominal hysterectomy. Stratified by age, the rate ofovarian 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% forthose 50–54 years of age; 25.5% for those 55–59 years of age; and 31.0% forthose 60–64 years of age . The major drawback of concomitant oophorectomy withhysterectomy is surgically induced menopause.
This was observed by the Nurses’health study with a large prospective cohort of 30,000 women and long follow upof 28 yrs. The study concluded that increased survival was not associated withoophorectomy in any age group or analysis. In fact, concurrent oophorectomy wasassociated with increased risk of all cause mortality [HRs:1.12 (95%CI-1.
03–1.21)] .Asecondary analysis of women who never used estrogen therapy was done and it showedoophorectomy was associated with an increased risk for incident stroke and lungcancer (HR 2.
09, 95% 1.01– 4.33), and oophorectomy before age 50 years was associatedwith 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 allcauses (HR 1.
40, 95% CI 1.01–1.96) .Additionally, it was demonstrated that oophorectomy increased the risks ofcardiovascular disease in women who never smoked and never used estrogentherapy in comparison to women with known risk factors for cardio vasculardisorders. Oophorectomy before age of 50 years was associated with a 200%increase in mortality .
Mytton etal conducted a similar study and compared women undergoing bilateral ovarianremoval versus no or unilateral removal and concluded that patients who had atleast one ovary conserved had a significantly lower rate of all-cause mortalitythan patients who had both ovaries removed . Pre-menopausal oophorectomy has also shown deleterious effecton cognition, sexual function and bone mineral density. There is increased riskof global cognitive decline, dementia, Alzheimer’s disease in patients withsurgical menopause and this risk is not increased with post-menopausaloophorectomy or natural menopause . Similarresults were observed in a study that showed that the risk of death associatedwith neurological or mental disease was increased in women who underwentbilateral oophorectomy at age <45 years . A study onbone loss and fracture interestingly showed a statistically significantincrease in fracture rate in women who underwent BSO after natural menopause .
All these deleterious effects of oophorectomy beforemenopause are caused due to abrupt reduction in endogenous estrogen and wastraditionally overcome by hormone replacement therapy (HRT). However, a studyconducted to learn about HRT compliance revealed that 3% of women discontinuedHT by 2 years, 20% by 5 years, and 67% by 10 years . A similarstudy observed a discontinuation rate of 42% at an average of 5.2 years offollow-up  Advantages of prophylactic oophorectomy include preventionof development of ovarian cancer and decreased risk of subsequent surgery forovarian pathology. There is also evidence suggesting decreased breast cancer inwomen who have undergone oophorectomy.
However, it should be noted that only 34of 13,035 women (0.3%) who had ovarian preservation at time of hysterectomylater died of ovarian cancer .Nurses’ health study also found that with oophorectomy there is paradoxicalincreased risk of death from all cancer that exceeds the risk of dying fromovarian cancer (low incidence) and breast cancer (high long-term survival rate).There is also mixed data related to association of colorectal cancer withoophorectomy[9, 16-18]. Potential risk ofre-operation in women with ovarian conservation at time of hysterectomy hasbeen studied and found to be 2.8- 9.2% [19-22].These risks should be weighed against the potential adverse effects ofoophorectomy.
Casiano et al studied risk of subsequent oophorectomy afterhysterectomy and concluded that the incidence of oophorectomy afterhysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentagepoints higher than the incidence of oophorectomy in women with intactreproductive organs. Hence, women can be reassured that the odds are low thatthey will require subsequent oophorectomy. There is also evidence to prove safety of ovarianconservation in premenopausal women with endometrial cancer.
Wright et al concludedthat ovarian conservation does not adversely affect survival for women with early-stageendometrial cancer and despite the oncologic safety of ovarian conservation,the majority of young women with endometrial cancer still undergo oophorectomyat the time of surgery . Salpingectomypros 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 theperformance 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.
H., et al., Ovarian conservation at thetime 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 ofovarian cancer: the central role of the fallopian tube. Arch GynecolObstet, 2014. 289(2): p.
241-6.6. Mikhail,E., et al., National trends of adnexalsurgeries 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 ovariesin 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 ovarianconservation in women undergoing hysterectomy for benign indications.Obstet Gynecol, 2013. 121(4): p.717-26.9. Parker,W.
H., et al., Long-term mortalityassociated 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 tissueversus conserving ovarian tissue at time of hysterectomy in premenopausalpatients with benign disease: study using routine data and data linkage.BMJ, 2017. 356: p. j372.
11. Adelman,M.R. and H.T. Sharp, Ovarian conservationvs removal at the time of benign hysterectomy.
Am J Obstet Gynecol, 2017.12. Rivera,C.M.
, et al., Increased mortality forneurological and mental diseases following early bilateral oophorectomy.Neuroepidemiology, 2009. 33(1): p.32-40.13. Melton,L.J.
, 3rd, et al., Fracture risk afterbilateral oophorectomy in elderly women. J Bone Miner Res, 2003. 18(5): p. 900-5.
14. Read,M.D., et al., Compliance with estrogenhormone replacement therapy after oophorectomy: a prospective study.Menopause Int, 2010. 16(2): p.
60-4.15. Rossouw,J.E., et al., Risks and benefits ofestrogen plus progestin in healthy postmenopausal women: principal results Fromthe Women’s Health Initiative randomized controlled trial. JAMA, 2002. 288(3): p.
, et al., Oophorectomy vs ovarianconservation with hysterectomy: cardiovascular disease, hip fracture, andcancer in the Women’s Health Initiative Observational Study. Arch InternMed, 2011. 171(8): p. 760-8.17. Gaudet,M.
M., et al., Oophorectomy andhysterectomy and cancer incidence in the Cancer Prevention Study-II NutritionCohort. Obstet Gynecol, 2014.
123(6):p. 1247-55.18. Luo,G.
, et al., Risk of colorectal cancerwith hysterectomy and oophorectomy: A systematic review and meta-analysis.Int J Surg, 2016.
34: p. 88-95.19. Holub,Z., et al.
, Does hysterectomy withoutsalpingo-oophorectomy influence the reoperation rate for adnexal pathology? Aretrospective study. Clin Exp Obstet Gynecol, 2000. 27(2): p.
, et al., Development of secondaryovarian lesions after hysterectomy without oophorectomy versus unilateraloophorectomy for benign conditions: a retrospective analysis of patients duringa nine-year period of observation. Clin Exp Obstet Gynecol, 2010. 37(4): p.
299-302.21. Plockinger,B. and H. Kolbl, Development of ovarianpathology after hysterectomy without oophorectomy. J Am Coll Surg, 1994. 178(6): p.
581-5.22. Casiano,E.R., et al., Risk of oophorectomy afterhysterectomy.
Obstet Gynecol, 2013. 121(5):p. 1069-74.23. Wright,J.D., et al., Utilization and Outcomes ofOvarian Conservation in Premenopausal Women With Endometrial Cancer.
ObstetGynecol, 2016. 127(1): p. 101-8.