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

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 [3].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[4].Recent studies revealed Serous intraepithelial carcinoma, a pre-neoplasticalteration at fimbriated end of fallopian tube to be the precursor of mostcommon ovarian cancer subtype[5].Hence there is an increased trend towards performing bilateral salpingectomy, atype of concomitant adnexal surgery with benign hysterectomy among gynecologicsurgeons in United State[6].  Oophorectomy V/S ovarian preservation: Concurrent oophorectomy is performed in 43.7% ofwomen undergoing hysterectomy for benign indications[6].

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 [7].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 [8]. 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)] [9].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) [4].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  [9].

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 [10]. 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 [11]. 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 [12]. A study onbone loss and fracture interestingly showed a statistically significantincrease in fracture rate in women who underwent BSO after natural menopause [13].

 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 [14]. A similarstudy observed a discontinuation rate of 42% at an average of 5.2 years offollow-up [15]  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 [4].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)[4].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 [23].                        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.

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