Prophylactic bilateral-salpingo-oophorectomy

It is a question that commonly arises when women undergo hysterectomy for benign gynaecological diseases such as:

• Uterine fibroids
• Endometriosis
• Adenomyosis
• Pelvic organ prolapse
• Abnormal bleeding
• Pelvic infection
• Ovarian cysts
• Pre-invasive diseases of uterus and cervix

Pro- BSO may also be performed to reduce the actual or perceived increased risk of ovarian cancer (risk-reducing RR-BSO).  This is because:

• Ovarian cancer typically present at an advanced stage, where the survival rate is less than 20%. In comparison, the survival rate for early stage cancer is 90% or better.
• Symptoms are often vague and resemble other common medical conditions
• Despite being relatively uncommon with estimated lifetime risk of 1 in 78 women by the age of 85, ovarian cancer is both the most prevalent and lethal form of gynaecological carcinoma
• At present there are no proven effective routine screening tests for women at high risk and at average risk for ovarian cancer

Risk factors for ovarian cancer include:

• Low parity
• Infertility
• Never taking oral contraceptive pill
• Age > 50
• BRCA1 and BRCA2 carriers carry 15 to 60% lifetime risk of ovarian cancer and high risk of breast cancer
• Family history of either ovarian or breast cancer- especially multiple affected members at early age

Potential benefits of Pro-BSO include:

• Reduction of risk of disease recurrence such as severe endometriosis
• Reduction of risk of repeat surgery for pain or ovarian cyst formation due to retained or entrapped ovaries, infection, endometriosis or adhesions
• Reduction of risk of ovarian malignancy in post-menopausal women
• Reduction of risk of ovarian malignancy in women with strong family history of either ovarian or breast cancer or with BRCA1 and BRCA2 genes in whom the risk of BRCA-related gynaecologic cancer may be reduced by 96%.
• Endocrine treatment of breast cancer where advised by breast specialists

Elective BSO is protective against the development of ovarian cancer at any age and reduces breast cancer incidence when performed before menopause.

However, elective BSO in women at average risk of ovarian cancer does not lead to an overall health advantage in premenopausal women, and perhaps in postmenopausal women < 65.

Potential risks / side-effects  of prophylactic BSO at time of hysterectomy for benign disease

Short term

• More abrupt, severe vasomotor symptoms – hot flushes
• Sleep disturbance
• Reduced libido and sexual dysfunction

Long term

• Increased risk of coronary heart disease (CHD) and increased morbidity and mortality due to osteoporosis related fractures – one study suggests increased mortality if BSO before 65 years age
• Increased risk of depressive and anxiety symptoms
• Increased risk of cognitive dysfunction including dementia

Factors for consideration when considering Pro-BSO and RR-BSO

• Indications for hysterectomy
• Individual’s risk (real or perceived) of ovarian cancer
• Personal risk factors for CHD, osteoporosis, depression
• Personal view and absolute or relative contra-indication to HRT

Management of surgical menopause

• In pre-menopausal women, epidemiological evidence suggest that replacement low-dose oestrogen until age 50 years maybe beneficial in reducing some of the long-term health effects after BSO
• Limited information is available to document the safety of HRT in women at high risk undergoing risk-reducing BSO.
• General measures include regular exercise, focusing on cardiovascular fitness and bone health, healthy diet
• Vitamin D supplement 800-2000 IU + 1200 to 1500 mg Calcium
• Baseline bone density study, then every 2 -3 years

References

• 1. RANZCOG clinical guideline no. 25
• 2. Prophylactic and risk-reducing bilateral salpingo-oophorectomy – recommendations based on Risk of ovarian cancer. Berek J et al. Obstet & Gynecol 2010;116:733-43.
• 3. ACOG Practice Bulletin no.89.: Elective and risk-reducing salpingo-oophorectomy. Obstet & Gynecol 2008; 111: 231.
• 4. Elective oophorectomy in the gynaecological patient: when is it desirable? Parker W et al. Curr Opin Obstet Gynecol 2007.