aboubakr elnashar

1. Elective
Oophorectomy
or ovarian conservation
at the time of
Hysterectomy?
Prof. Aboubakr
Elnashar
Benha university
hospital, EgyptABOUBAKR ELNASHAR

2. 1. INTRODUCTION
1. Change in clinical practice
Hysterectomy for benign disease
What to do with the?
Fallopian tubes
Ovaries
Cervix.
Over the past 15 years:
dramatic change
United States
3.6% annual decline in
bilateral salpingooophorectomy
ABOUBAKR ELNASHAR

3. A growing understanding of
1. Risks of elective oophorectomy
2. Benefits of elective oophorectomy
≤51y: ovarian cancer: 2/1000
(Jacoby et al, 2014)
3. Benefits of elective salpingectomy
In the setting of benign disease
decision to retain or remove
tubes and ovaries
should be based upon the long term health
effects.
ABOUBAKR ELNASHAR

4. 2. Terminology
Elective salpingo-oophorectomy
Removal of the ovaries and fallopian tubes
in a woman who has no known indication for this
procedure e.g.
ovarian pathology
hereditary ovarian cancer syndrome
Ovaries and tubes are typically removed, rather than
the ovaries alone.
ABOUBAKR ELNASHAR

5. Risk-reducing salpingooophorectomy
Removal of the tubes and ovaries
In a woman at high risk of
ovarian or breast cancer
(due to a known gene mutation).
ABOUBAKR ELNASHAR

6.  Risk factors for ovarian cancer
 Majority: no known risk factors
 Most significant: genetic predisposition
 Epithelial ovarian cancer:
 10% are familial
 3 familial syndromes
1. Familial breast-ovarian cancer syndrome AND
2. Site-specific ovarian cancer
 associated with mutations of the BRCA1 suppressor
gene
 account for 90% of familial ovarian cancers
3. Cancer family syndrome (Lynch type II)
(Rollins, 2000)

7.  Breast and ovarian cancer
 5-10% have genetic predisposition:
• BRCA 1
• BRCA 2
• Mismatch repair genes (Lynch type 1 and 2) endometrial,
colorectal and ovarian cancer.
ABOUBAKR ELNASHAR

8. Additional Risk Factors for ovarian cancer
• Age
– ≥50 y: 80% of all cases
• Reproductive history
– early menarche
– nulliparity
– age >30y at 1st child-
bearing
– late menopause
• Fertility drugs
– Prolonged use of CC
especially without
achieving pregnancy
• Personal history of breast
cancer
• HRT> 5 years
– 30% increased risk
• Talcum powder
– use talc powder on
genital area
(American Cancer Society, 2001)
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9. 4. Indications for oophorectomy
Women who undergo hysterectomy for benign indications may
also have an indication for concurrent oophorectomy.
Oophorectomy in this context is not elective.
1. Ovarian pathology
e.g. ovarian neoplasms.
2. Endometriosis
{The risk of reoperation for endometriosis-related
concerns appears to be lower if the ovaries are
removed at the time of hysterectomy}
ABOUBAKR ELNASHAR

10. 3. Tubo-ovarian abscess
{the risk of reoperation is higher if one or both ovaries
are conserved}
4. Pelvic adhesions/pelvic pain
 Residual ovary syndrome:
posthysterectomy pelvic pain
0.9 to 3.4%
1. Preoperative pelvic pain and adhesions are risk
factors for this syndrome.
2. Subsequent oophorectomy may be required to
manage such symptoms.
ABOUBAKR ELNASHAR

11. 2. BENEFITS OF ELECTIVE OOPHORECTOMY
Breast cancer
The most common women's malignancy,
Ovarian cancer
The most fatal gynecological malignancy
1.Ovarian cancer risk reduction
Oophorectomy performed for ovarian cancer risk
reduction should include removal of the fallopian
tubes
ABOUBAKR ELNASHAR

12. 1. Women who are
At high risk of ovarian cancer: BSO is an important
risk reduction strategy
ABOUBAKR ELNASHAR
Risk of ovarian cancer
1.4%General population
13-46%BRCA1 or BRCA2 gene mutations
3-14%Lynch syndrome (hereditary
nonpolyposis colorectal cancer
syndrome):
Salpingo-oophorectomy in these women is considered
risk-reducing and not elective.

13. Alternatives to BSO for ovarian cancer risk reduction
1.Remove the fallopian tubes:
reduce the risk of ovarian cancer, but
not to the same extent as BSO.
2.Tubal ligation:
34% reduction in ovarian cancer risk
3.Hysterectomy alone:
34% reduction in the risk of ovarian cancer
ABOUBAKR ELNASHAR

14. 2. Breast cancer risk reduction in women
1. 45 years old or younger
{reduced exposure to estrogen from
premenopausal ovary}.
2. At high risk of breast cancer.
ABOUBAKR ELNASHAR

15. 3. Avoiding the need for subsequent oophorectomy
Reoperation for ovarian pathology, termed residual
ovary syndrome
4% of women who retained one or both ovaries
after hysterectomy
more common in women who underwent
hysterectomy at a young age
ABOUBAKR ELNASHAR

16. 3. RISKS OF ELECTIVE OOPHORECTOMY
1.Added surgical risk —
 uncommon
Circulatory/bleeding complications
Organ injury
GIT complications
 The risk of such complications increased if
1. adhesions or other intraabdominal pathology
2. vaginal hysterectomy
ABOUBAKR ELNASHAR

17. 2. Long-term health risks
may be serious
Greater for women
1. younger at the time of oophorectomy
2. did not take estrogen therapy
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18. a.All-cause mortality
 Increased
 at younger age
 who do not take estrogen therapy.
Mechanism:
hypoestrogenism may be an important factor.
ABOUBAKR ELNASHAR

19. b. Cardiovascular disease and stroke —
Increased
at a younger age(≤50y)
Mechanism:
early menopause
surgical menopause.
estrogen therapy may mitigate adverse
cardiovascular effects
ABOUBAKR ELNASHAR

20. c. Cognitive function and neurologic disease —
 increased if oophorectomy prior to menopause
{Estrogen therapy may be neuroprotective in these
women}.
(Mayo Clinic Cohort Study of Oophorectomy and Aging , 2006].
ABOUBAKR ELNASHAR

21. d. Depression and anxiety —
Increased if early bilateral oophorectomy
The median time from oophorectomy to the onset of
symptoms of depression or anxiety:
14 years
shorter-term studies:
Inconsistent results
ABOUBAKR ELNASHAR

22. f. Sexual dysfunction —
Increased if
bilateral oophorectomy in premenopausal women
not treated with hormones.
{an abrupt decrease in androgen output}.
ABOUBAKR ELNASHAR

23. g. Osteoporosis —
Increased in oophorectomy
in postmenopausal
fractures of the hip, spine, or distal forearm
In premenopausal
distal forearm and vertebral fractures, but not
hip fracture
(Mayo Clinic study)
ABOUBAKR ELNASHAR

24. 4. CLINICAL DECISION-MAKING
Depend on
1. Genetic risk factors for cancer
2. Risks and
3. Benefits
ABOUBAKR ELNASHAR

25. ACOG (2008)
Ovarian conservation at time of hysterectomy in
1. Premenopausal women
2. Not at an increased genetic risk of ovarian
cancer
3. Absence of ovarian pathology
4. Absence of familial cancer syndrome
5. Discussion regarding removal of the fallopian
tubes
ABOUBAKR ELNASHAR

26. Oophorectomy at time of hysterectomy
1. Postmenopausal
2. Condition that may benefit from oophorectomy
1. Endometriosis
2. PID
3. Chronic pelvic pain
3. Women who place a higher priority on ovarian
cancer prevention than on other long-term health
risks
4. 51 years old or older.
ABOUBAKR ELNASHAR

27. Matthews, 2016

28. 5. ESTROGEN THERAPY AFTER OOPHORECTOMY
Women experiencing premature or early menopause due to bilateral
oophorectomy at the time of hysterectomy are different from women who reach
menopause at the median age of 51 years
Data regarding the use of hormone therapy in naturally menopausal
women should not be extrapolated to women who have surgical
menopause at the time of hysterectomy
Estrogen therapy:
Several of the serious long-term health
consequences of bilateral oophorectomy can be
ameliorated by taking estrogen therapy
until at least age 50 to 51 years
ABOUBAKR ELNASHAR

29. Estrogen therapy alone
1. Progestogen for endometrial protection is not
needed
2. under 60 years of age:
risks of estrogen and progesterone is greater than
estrogen alone
(Women's Health Initiative)
ABOUBAKR ELNASHAR

30. ABOUBAKR ELNASHAR
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