AT SGS 2015

ORLANDO (FRONTLINE MEDICAL NEWS)At the time of benign hysterectomy, 44% of premenopausal women underwent bilateral oophorectomy or salpingo-oophorectomy although approximately half of these procedures were performed in women with histologically normal ovaries, according to data presented at the annual scientific meeting of the Society of Gynecologic Surgeons.

This rate of normal ovary removal appears high in the context of American College of Obstetricians and Gynecologists practice recommendations, said Dr. Natalie Karp, a fellow in obstetrics and gynecology at the University of Michigan, Ann Arbor. Referring to ACOG Practice Bulletin 89 entitled “Elective and Risk-Reducing Salpingo-oophorectomy”( Obstet. Gynecol. 2008;111:231-41 ), the recommendation is to preserve ovaries in the absence of pathology or genetically established cancer risk.

In this study, the focus was on bilateral oophorectomies performed in women 50 years of age or younger undergoing a benign hysterectomy. In the 52 Michigan hospitals participating in a statewide surgical quality collaborative, 6,789 procedures were available for analysis. Of the 44% with oophorectomy, 21% had a benign pathology, 0.2% had cancer, and the remaining 23% had no pathology.

Of the 23% with no pathology, some were likely to have requested oophorectomy because of concern for cancer, but only 3.8% of all subjects had “family history of breast, ovary, or other malignancy involving gynecologic organs” listed as an indication. Whether others requested oophorectomy out of concern for cancer even without a family history is unknown, but it is likely that the proportion of patients having normal ovaries removed is still substantial.

“If we apply these findings nationally, at least 22,000 women annually have their ovaries removed without a compelling indication,” reported Dr. Karp, who based this “broad estimate” on premenopausal women undergoing hysterectomy for indications not typically associated with pathology affecting the ovaries, such as cervical dysplasia or fibroids. The rate would climb higher if any indication for hysterectomy was included.

In a multivariate logistic regression analysis, removal of normal ovaries was more likely in women closer to menopause (ages 46-50) than younger women, in those who underwent abdominal relative to vaginal hysterectomy, in those with other pathology such as endometriosis or cervical dysplasia relative to no pathology, and in those with a family history of cancer, Dr. Karp said at the meeting jointly sponsored by the American College of Surgeons.

In those with normal ovaries and no genetic predisposition for ovarian cancer, it is important to consider both risks and benefits of oophorectomy, according to Dr. Karp. In addition to an increased potential for complications from an extra surgical procedure, removal of the ovaries may increase cardiovascular risk, accelerate bone loss, and adversely affect sexual function.

“We must ensure that we are counseling our patients effectively and documenting the decisions that they make,” Dr. Karp advised. It is not known what proportion of premenopausal women with normal ovaries in this analysis opted for oophorectomy because of a family history of ovarian cancer, but it is likely to be a minority.

These data are timely because of a potential “Angelina Jolie effect,” suggested the SGS-invited discussant Dr. Eman Elkadry, a Boston ob.gyn. who specializes in female pelvic medicine and reconstructive surgery. Referring both to the recent New York Times editorial by filmmaker Angelina Jolie Pitt (March 24, 2015) and to the many news reports that surrounded her decision to undergo prophylactic salpingo-oophorectomy, Dr. Elkadry suggested that there may be an accelerated trend toward prophylactic oophorectomy.

“The decision to remove ovaries is very complex,” cautioned Dr. Elkadry, who agreed that clinicians need to be prepared to explain both risks and benefits to patients who may be influenced by a variety of factors unrelated to objective evidence or detailed risk analysis.

Based on the large sample size and the fact that both academic and community hospitals were included in the mix of institutions contributing data to this analysis, Dr. Elkadry said that the substantial rate of prophylactic oophorectomy identified in Michigan “is probably generalizable” across the country. She also said that the data are consistent with other reports in the literature that “many ovaries are being removed that are completely normal.”

Dr. Natalie Karp reported no relevant financial disclosures.