ArticleLiterature Review

Ovarian Conservation at the Time of Hysterectomy for Benign Disease

Authors:
  • Partnership for Health Analytic Research
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Abstract

Objective: Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease. The optimal age for this recommendation in women at average risk for ovarian cancer has not been determined. Methods: Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease, hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to estimate the optimal strategy for maximizing survival for women at average risk of ovarian cancer. For each 5-year age group from 40 to 80 years, 4 strategies were compared: ovarian conservation or oophorectomy, and use of estrogen therapy or nonuse. Outcomes, as proportion of women alive at age 80 years, were measured. Sensitivity analyses were performed, varying both relative and absolute risk estimates across the range of reported values. Results: Ovarian conservation until age 65 benefits long-term survival for women undergoing hysterectomy for benign disease. Women with oophorectomy before age 55 have 8.58% excess mortality by age 80, and those with oophorectomy before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease. Conclusion: Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease.

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... Germline mutations in BRCA 1 or 2 genes increase breast, ovarian, and overall cancer risks considerably and are associated with diagnosis at a young age (2,3). Bilateral oophorectomy performed before natural menopause reduces the risk of cancer substantially (4-9) but may impair cognition (10) and increase the risk of cardiovascular disease (8,11) and all-cause mortality (8,11,12). An immediate side effect of bilateral oophorectomy in premenopausal women is the induction of surgical menopause, often associated with vasomotor symptoms and reduced quality of life (13), which can be avoided through the use of hormone therapy (HT) (14). ...
... Germline mutations in BRCA 1 or 2 genes increase breast, ovarian, and overall cancer risks considerably and are associated with diagnosis at a young age (2,3). Bilateral oophorectomy performed before natural menopause reduces the risk of cancer substantially (4-9) but may impair cognition (10) and increase the risk of cardiovascular disease (8,11) and all-cause mortality (8,11,12). An immediate side effect of bilateral oophorectomy in premenopausal women is the induction of surgical menopause, often associated with vasomotor symptoms and reduced quality of life (13), which can be avoided through the use of hormone therapy (HT) (14). ...
... The effect of bilateral oophorectomy and subsequent use of HT on morbidity and mortality has been debated (8,11,12,37). We found that prophylactic oophorectomy at age 45 years or younger was associated with an increased risk of both lowenergy fractures and infections. ...
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Background: Current international guidelines recommend systemic hormone therapy (HT) to oophorectomized women until the age of natural menopause. Despite an inherited predisposition to estrogen-dependent malignancies, the guidelines also apply to women oophorectomized because of a family history of cancer. The objective of this study was to investigate the impact of HT on mortality and risk of cancer in women oophorectomized because of a family history of cancer. Methods: A nationwide, population-based cohort was used to study women oophorectomized because of a family history of cancer (n = 2002). Comparison cohorts included women from the background population individually matched on age (n = 18 018). Oophorectomized women were subdivided into three groups: oophorectomized at 1) age 45 years or younger not using HT, 2) age 45 years or younger using HT, 3) older than age 45 years, and their respective population comparison cohorts. Results: Women oophorectomized at age 45 years or younger using HT had increased overall mortality (mortality rate ratio [MRR] = 3.45, 95% confidence interval [CI] = 1.53 to 7.79), mortality because of cancer (MRR = 5.67, 95% CI = 1.86 to 17.34), and risk of overall cancer (incidence rate ratio [IRR] = 3.68, 95% CI = 1.93 - 6.98), primarily reflected in an increased risk of breast cancer (IRR = 4.88, 95% CI = 2.19 - 10.68). Women oophorectomized at age 45 years or younger not using HT and women oophorectomized at older than age 45 years did not have increased mortality, mortality because of cancer, or risk of overall cancer, but they had increased risk of breast cancer (IRR = 2.64, 95% CI = 1.14 to 6.13, and IRR = 1.72, 95% CI = 1.14 to 2.59, respectively). Conclusions: Use of HT in women oophorectomized at age 45 years or younger with a family history of cancer is associated with increased mortality and risk of overall cancer and breast cancer. Our study warrants further investigation to establish the impact of HT on mortality and cancer risk in oophorectomized women with a family history of cancer.
... In 2000, the number of elderly women (≥ 60 years old) in the world was around 366 million and it is expected to increase threefold by 2050 [2]. In addition, the number of women estimated to have bilateral prophylactic ovariectomy is approximately 300,000 per year [3]. Estrogen is known as a steroid hormone which has neuroprotective functions in the brain [4]. ...
... The data were analyzed using one-way ANOVA and post hoc LSD tests. *p < 0.001 vs. Sham groups a df=(3,16); F = 23.4; p = 0.0001, b df=(3,16); F = 22.5; p = 0.0001, c df=(3,16); F = 22.8; p = 0.0001. ...
... *p < 0.001 vs. Sham groups a df=(3,16); F = 23.4; p = 0.0001, b df=(3,16); F = 22.5; p = 0.0001, c df=(3,16); F = 22.8; p = 0.0001. df, degree of freedom; F F-ratio, Sham Sham-operated group, OVX ovariectomy group, OVX + MIIE ovariectomy with MIIE group, OVX + HIIE ovariectomy with HIIE group ...
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Objectives The aim of the present study was to investigate the effects of moderate- or high-intensity intermittent exercise (MIIE/HIIE) on the oxidative status of the prefrontal cortex and cerebellum, locomotor activities, as well as working memory performances of rats. Materials and Methods Twenty female rats were divided into four groups: (1) sham-operated (Sham), (2) ovariectomy (OVX), (3) OVX + MIIE, and (4) OVX + HIIE groups. The OVX + MIIE and OVX + HIIE groups exercised on a rat treadmill for 7 weeks. The assessment on the working memory performances and locomotor activities were conducted on the last day of the exercise period. Levels of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPX) enzyme activities, as well as levels of hydrogen peroxidase (H2O2), and malondialdehyde (MDA) in the prefrontal cortex and cerebellum were determined using a spectrophotometer. Results Ovariectomy depressed the working memory, locomotor activities, the levels of SOD, CAT, and GPX enzyme activities, and elevated the levels of H2O2, and MDA in the prefrontal cortex and cerebellum. Conclusion MIIE and HIIE exert their neuroprotective effects by reducing oxidative stress in the brain of ovariectomized rats. HIIE has more potent effects than MIIE in suppressing the levels of oxidants in the prefrontal cortex and cerebellum by increasing the levels of SOD and CAT activities more than MIIE.
... 20,21 The data on low-risk women is controversial. The risk of breast cancer mortality is decreased by 18% if oophorectomy is performed prior to 50 years of age, but it is increased by 19% if ovarian removal occurs between the ages of 50 and 60. [22][23][24] As we will discuss below, the overall all-cause mortality (due to cardiovascular disease, stroke, osteoporosis, and colorectal and lung cancer) is greater than the risk reduction in ovarian and breast cancer-specific mortality following oophorectomy, and prophylactic ovarian removal should be avoided in low-risk women. At present, the only population that has been shown to benefit from prophylactic oophorectomy are high-risk patients with genetic predisposition to gynecologic malignancies and breast cancer and women with advanced premenopausal breast cancer (in whom surgery is intended to augment treatment). ...
... [57][58][59][60]62,63,65 Survival Prophylactic oophorectomy has been consistently associated with increased all-cause mortality. 18,23,24,28,30,31,34 Using a statistical model linking surgical castration with subsequent onset of estrogen-dependent malignancy, coronary artery disease, cerebral vascular accidents, and hip fracture, Parker et al. showed that at no age was there a survival benefit from oophorectomy. As the age of oophorectomy increased, the estimated risk of dying following ovarian removal approached, but was always greater than the mortality risk predicted following ovarian conservation. ...
... There is a decreasing trend of bilateral salpingooophorectomy all over the world which was mainly done in order to decrease risk of ovarian cancer and the age limit was 45 year. 15,16 But the current scientific evidence suggest that elective oophorectomy is not advisable in majority of the women, as it may lead to higher risk of death from cardiovascular disease and hip fracture and higher incidence of dementia and Parkinson's disease. [16][17][18] In present study, clinico-pathological correlation was only 72.7%, consistent to prior studies. ...
... 15,16 But the current scientific evidence suggest that elective oophorectomy is not advisable in majority of the women, as it may lead to higher risk of death from cardiovascular disease and hip fracture and higher incidence of dementia and Parkinson's disease. [16][17][18] In present study, clinico-pathological correlation was only 72.7%, consistent to prior studies. 4,7,19,20 This suggests that the standard preoperative workup made for routine gynecological surgeries are not sufficient in predicting the cancerous lesions and they need standardized modifications. ...
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Background: Hysterectomy, the surgical removal of uterus, is 2nd most frequently performed major surgical procedures on women,with90% of hysterectomies are performed for benign indications. However, there may be cases in which malignancy or premalignant lesions which are only confirmed on histopathology are defined as occult malignancy.Methods: We conducted a prospective observational study on a cohort of women undergoing various gynaecological surgeries for benign indications in a time period of January 2019 to January 2020 in the Department of obstetrics and gynaecology, Dr. BRAM hospital and Pt. J. N. M. medical college, Raipur (C.G) to find out the prevalence of occult pre malignant and malignant lesions.Results: Of 132 women who underwent surgeries for benign gynecological indications, based on final histopathological report, prevalence of occult premalignant lesion was 11.36% (95% CI 5.7-16.3%) and prevalence of occult malignancy was 2.27% (95% CI 0.2 -4.8%). Prevalence of occult premalignant lesion of corpus uteri and cervix uteri was 2.3 and 9.1% respectively. No occult premalignant lesion of ovary was found. Prevalence of occult malignant lesion of corpus uteri and ovary was 1.5 and 0.75% respectively.Conclusions: We observed that even after complete preoperative workup only 72.7% of the preoperative clinical diagnoses were correlated with their histopathological diagnosis. Thus, while making the diagnosis, risk factors along with standard preoperative approach should be strongly adhered to prevent misdiagnosis and to prevent missing of any pre malignant or malignant findings.
... Women underwent hysterectomy for benign indications are commonly offered elective bilateral salpingo-oophorectomy (BSO) because this approach greatly decreases the risk of ovarian cancer and the need for future ovarian surgery (Asante et al., 2010). However, oophorectomy has potential adverse effects such as cardiovascular disease, osteoporosis, impaired cognitive function, and neurologic disease particularly if performed in women under the age of 45-50 years (Rocca et al., 2006;Parker et al., 2007;Shuster et al., 2008;Parker et al., 2009). In the previous studies, the incidence of subsequent oophorectomy in women with ovarian preservation during hysterectomy varied from 2.8-9.2 % (Plockinger et al., 1994;Dekel et al., 1996;Zalel et al., 1997;ACOG Practice Bulletin, 2008;Casiano et al., 2013) and incidence of ovarian cancer in women with ovarian preservation during hysterectomy varied from 0.07-9.9% ...
... This information may be useful for counseling the patients before operation for gynecologic benign conditions. In addition, women who underwent bilateral salpingooophorectomy (BSO) may possibly suffer from estrogen deficiency conditions such as menopausal symptoms within 2 years after surgery, coronary heart disease, osteoporosis, cognitive dysfunction or neurologic diseases (Rocca et al., 2006;Parker et al., 2007;Shuster et al., 2008;Parker et al., 2009) and may take risk of hormone replacement therapy. ...
Article
This study was undertaken to determine the incidence of subsequent oophorectomy due to ovarian pathology or ovarian cancer in women with prior hysterectomy for benign gynecologic conditions at Chiang Mai University Hospital. Medical records of women who underwent hysterectomy for benign gynecologic diseases and precancerous lesions between January 1, 2004 and December 31, 2013 at Chiang Mai University Hospital were retrospectively reviewed. The incidence and indications of oophorectomy following hysterectomy were analyzed. During the study period, 1,035 women had hysterectomy for benign gynecologic conditions. Of these, 590 women underwent hysterectomy with bilateral salpingo-oophorectomy and 445 hysterectomy with bilateral ovarian preservation or unilateral salpingo-oophorectomy. The median age was 47 years (range, 11-75 years). Ten women (2.45 %) had subsequent oophorectomy for benign ovarian cysts. No case of ovarian cancer was found. The mean time interval between hysterectomy and subsequent oophorectomy was 43.1 months (range, 2-97 months) and the mean follow-up time for this patient cohort was 51 months (range, 1.3-124.9 months). According to our hospital-based data, the incidence of subsequent oophorectomy in women with prior hysterectomy for benign gynecologic conditions is low and all represent benign conditions.
... This issue is of increasing importance as more patients and surgeons elect ovarian conservation at the time of hysterectomy in response to data from large observational studies reporting increased all-cause mortality, cardiovascular disease, osteoporosis and cognitive decline in patients who undergo BSO prior to age 65 [5][6][7][8]. Elective BSO in perimenopausal women age 40-54 years has declined significantly since 2002, the same year that results from the Women's Health Initiative were published [9]. ...
... This data can assist patients and surgeons when considering the risks and benefits of planned adnexal surgery after prior hysterectomy during the informed consent process. This data can also help guide the conversation regarding ovarian conservation versus elective BSO at time of benign hysterectomy in postmenopausal patients, balancing theoretical risks of future adnexal surgery with data showing benefit to ovarian conservation through age 65 [8]. Furthermore, our findings can assist surgeons in preoperative planning for adnexal surgery after prior hysterectomy. ...
Article
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Background Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning. Methods We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher’s exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval. Results Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1–2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1–14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8–14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5–135.0) vs. 78.0 min (IQR 53.0–109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046). Conclusions Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.
... [11] Tartışmalar açısından netlik kazanılmamasına rağmen; Amerika'da yılda yaklaşık 600.000 histerektomi operasyonunun gerçekleştiği ve bu ope-rasyonların yaklaşık olarak yarısında profilaktik amaçla bilateral ooferektominin de yapıldığı tahmin edilmektedir. [12] Tarihsel olarak, salpingo-ooferektomi, over kanseri ve overe bağlı hastalığı olanlarda, tekrar operasyon riskini azaltmak için histerektomi sırasında sıklıkla yapılmıştır. [13][14] Bu uygulama over kanseri riskini azaltmak için, 1965 ve 1999 yılları arasında iki katına çıkmıştır. ...
... [13] Ancak over ya da meme kanseri gelişimi için risk faktörü bulunmayan yaklaşık olarak üç yüz bin kadının, her yıl bu cerrahi işlemi geçirmesi, tıbbi gereklilik sorusunu gündeme getirmektedir. [12,24] Yüksek riskli genetik varyantlar taşımayan çoğu kadın için profilaktik ooferektominin maliyet-fayda dengesi bilinmemektedir. Ayrıca, sağ kalım oranları açısından, hangi yaşta profilaktik bilateral ooferektominin gerekli olduğu tartışmalıdır. ...
Article
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Profilaktik bilateral salpingo-ooferektomi BRCA 1/2 mutasyonlu ka-dınlarda kanser riskinin azaltılması için birçok ülkede yaygın olarak uygulanmaktadır. Tümör supresör genler olan BRCA 1/2 gen mutas-yon taşıyıcılarında, yaşam boyu, meme ve over kanseri yakalanma riski daha yüksektir. BRCA 1/2 gen mutasyonları ile meme ve over kanser-leri arasındaki ilişkinin ortaya konması ile profilaktik bilateral salfingo-ooferektominin over kanserine olduğu kadar meme kanseri için de ko-ruyucu etkisinin mevcut olduğu düşünülmektedir. Genetik mutasyon analiz testlerinin yapılabilirliğinin artması ile risk azaltıcı cerrahinin yararları ve etkileri konusunda birçok tartışma ortaya atılmıştır. Risk azaltıcı stratejinin seçiminde, en uygun yöntemin hangisi olduğuna dair net sınırlar olmadığı için, hasta ve sağlık personeli açısından tar-tışmalı bir konu olmaya devam etmektedir. Seçilecek risk azaltıcı cer-rahinin kanser riskine, sürveyansına ve yaşam kalitesine olan etkileri anahtar kriterlerdir. Profilaktik bilateral salpingo-ooferektomi anlamlı olarak meme kanseri riskini yaklaşık %50 ve over kanseri riskini %80-95 azaltmakta olmasına karşın buna menopoz semptomları, yaşam ka-litesinde bozulma ve hızlanmış kemik kaybı eşlik edebilmektedir. Bu derlemede, düşük ve yüksek riskli over ve meme kanserli olgularda son zamanlarda sık başvurulan bir yöntem olan profilaktik bilateral salpin-go-ooferektomi yapılmasının yarar ve zararlarının tartışılması, hemşire-lerin bu cerrahiye yönelik farkındalıklarının ve bilgi gereksinimlerinin karşılanması amaçlanmıştır. Anahtar kelimeler: BRCA 1 Geni; BRCA 2 Geni; meme kanseri; over kanseri. ABSTRACT Prophylactic bilateral salpingo-oophorectomy has been widely practiced in many countries to reduce the risk of cancers in women with BRCA 1/2 mutations. BRCA1/2 gene mutation carriers with tumor suppressor genes confer a high lifelong risk of breast and ovarian cancers. Prophylactic bilateral salpingo-oophorectomy (PBSO) is considered to have a preventative effect on ovarian cancer as well as breast cancer due to the relationship between BRCA1/2 gene mutations and breast and ovarian cancers. Parallel to defining a strong relationship between BRCA-1/2 mutations and the development of breast/ovarian cancers and increasing the feasibility of genetic mutation analysis test, many controversies about the benefits and effects of risk-reducing surgeries have been raised. The impact of the preferred risk-mitigation strategies on cancer risk, survival, and quality of life are key criteria in this regard. Bilateral prophylactic salpingo-oophorectomy significantly reduces breast cancer risk by approximately 50% and ovarian cancer risk by 80-95% but may be accompanied by menopausal symptoms, impaired quality of life, and accelerated bone loss. Therefore, decisions regarding the timing of bilateral prophylactic salpingo-oophorectomy and the use of post-bilateral prophylactic salpingo-oophorectomy hormone replacement therapy must be carefully considered. This review was conducted to discuss the benefits and disadvantages of PBSO use on low-and high-risk ovarian and breast cancer patients in addition to meeting the information requirements and awareness of nurses for this type of surgery.
... Bilateral salpingo-oophorectomy is practiced in 37-78% of these operations due to prevention of subsequent development of ovarian cancer (Whiteman et al., 2008, Asante et al., 2010, McAlpine et al., 2014. In each year, 14.700 deaths occur because of ovarian cancer, however; 490.000 women die due to cardiovascular diseases, 48.000 women die within 1 year after hip fracture and stroke accounts for approximately 86.900 deaths (Parker et al., 2007, Kung et al., 2008. Endogenous sex steroids undoubtedly have a protective effect of these fatal diseases. ...
Article
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Epithelial ovarian cancer is the gynecologic cancer with the highest mortality in the western world. Distal part of tuba uterine is accused of being the origin of this cancer type. Thus, prophylactic salpingectomy has been suggested by several societies however this procedure can also cause early ovarian ageing. We aimed to elucidate the effect of salpingectomy additional to hysterectomy on ovarian reserve appraising ultrasonographic scanning and AMH. Prospective, randomized analytical study is achieved comparing patients who have underwent solely hysterectomy (N:29) and underwent hysterectomy and prophylactic salpingectomy (N:34). Comparison of AMH values between groups did not differ statistically significant whereas pre-operative and post-operative values of AMH were significantly decreased in both groups. Comparison of ovarian volume and AFC did not differ statistically significant. Ovarian blood flow doppler ultrasonography parameters were (PSV, PI) generally (10/12 parameters) did not differ significantly between groups. Prophylactic salpingectomy during hysterectomy did not cause additional ovarian reserve impairment without any operative and post-operative complications. Patients scheduled hysterectomy for benign reasons, could be informed about retained fallopian tubes and the benefit and harm of prophylactic salpingectomy precisely.
... Up until the menopause it is essential to conserve the ovaries in order to avoid cardiovascular and osteoporosis morbidity and mortality [15]. Certain mathematical models even suggest conserving the ovaries beyond physiological menopause (up until age 65) due to the residual hormonal secretions [16]. Indeed the ovary produces androgens (androstenedione and testosterone) significantly with an aromatization in fat tissue into estrone after the menopause [17]. ...
Article
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Introduction The aim of this study is to assess the prevalence of tubal histopathological abnormalities (serous tubal intraepithelial carcinoma STIC and p53 signatures) and the prevalence of perioperative and postoperative complications related to opportunistic laparoscopic salpingectomy in a low risk population. Materials and Methods In this observational prospective cohort, prophylactic bilateral salpingectomy during benign laparoscopic hysterectomy was systematically performed in 100 consecutive women. Peri- and postoperative complications were registered. Duration of salpingectomy and post-salpingectomy blood loss were also measured. Histopathological and immunohistochemical analysis with anti-p53 antibody were performed on the whole fallopian tubes according to a specific and validated protocol. Results Laparoscopic salpingectomy was always possible without any peri- or postoperative complication attributable to the salpingectomy itself. The mean duration was 428 seconds (354 – 596) and the blood loss was 9 cm3 (2 – 15). Using histopathological and immunohistochemical assessment with anti-p53 antibody on 199 fallopian tubes (99 bilateral salpingectomies and one unilateral salpingectomy because of previous salpingectomy for ectopic pregnancy), there was a prevalence of 5.52% (11/199) of p53 signatures. No STIC were observed and no associated cancer. Conclusions Laparoscopic salpingectomy is both feasible and innocuous during benign hysterectomy. Meticulous histopathologic examination of the tubes may reveal specific abnormalities.
... De esta manera se mantiene la función ovárica y se evitan los efectos negativos de la ooforectomía, 55,56 está indicada en pacientes pre y posmenopáusicas, sobre todo menores de 65 años. 57,58 La salpingo-ooforectomía bilateral ante el riesgo de cáncer de ovario por mutaciones germinales Cuadro 2. Lesiones precursoras del cáncer de ovario de alto grado. Las neoplasias intraepiteliaes en el epitelio de las trompas uterinas exhiben los cambios de p53 que posteriormente influyen en la aparición de varios de los carcinomas de alto grado. ...
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Background: Globally, ovarian cancer is the seventh neoplasm and the eight oncologic cause of death in women, responsible of 150,000 deaths per year, with a 5 year survival under the 45%, mainly represented by high-grade serous carcinomas. Findings such as serous intraepithelial carcinomas and genetic predisposition have become a constant for the vast majority of cases. Objetive: To summarize and review the most recent advances about the carcinogenesis of the ovarian serous tumors, its implications on the pathological diagnosis and the consequences of these new concepts for the clinical and surgical therapies. Materials and methods: We performed a systematic search to select all kinds of languages articles, using the keywords “serous ovarian neoplasms” AND “carcinogenesis” AND “low-grade serous carcinoma” OR “high-grade serous carcinoma”. Two investigators independently extracted characteristics and results to select the articles. Two pathologists independently did the assessment of the preselected articles selecting the most appropriate ones, based on their utility for this review. Results: 66 articles were selected and included in the bibliography for this review. Conclusions: A better understanding of the physiopathology and many other new findings that have been done during the last decade are essential for the treatment of this patients, for the creation and application of strategies for primary prevention and screening for the risk, and the medical and surgical interventions, mainly directed to patients with mutations on BRCA, family history of breast, ovarian or peritoneal cancer, among other conditions. A multidisciplinary and updated approach will affect significantly the long-term survival.
... Women who have undergone bilateral ovariectomy have often lost their reproductive function and the ability to make the oestrogen and progesterone hormones, whereas in natural menopause, the production of hormones, especially low levels of androgens, continues in ovaries (17). The side effects and other risks of ovariectomy include premature death, cardiovascular diseases, cognitive disorders, dementia, Parkinsonism, osteoporosis, and bone fractures (18)(19)(20). ...
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Objective(s) In this study, potential protective effects of Bortezomib (Bort), as a proteasome inhibitor, were investigated on the uterus of ovariectomized rats by histological, morphometric and immunohistochemical methods. Materials and Methods In this study, 18 Sprague dawley strain female rats (12 weeks old, 250-300 g body weight) were used. Animals in the control group (Cont, n=6) were not exposed to any treatment. Ovariectomy was performed on the experimental groups. They (n=12) were divided into ovariectomy (Ovt, n=6) and Bortezomib (Bort, n=6) subgroups. Twelve weeks later, the rats were perfused. Then, uterine tissues were removed and examined by morphometrical, and light and electron microscopy methods. In addition, immunoreactivity of nuclear factor-kappa (NF-κB) was evaluated. Results Morphometric and histopathological evaluations showed that Bort was effective in the uterus and protects the layer structures and the cells. Conclusion In the light of these findings, we suggest that for proteasome inhibitor particularly Bort is thought to be useful through proteasome inhibition and NF-κB pathway.
... 15,16 The benefits of ovarian conservation decrease as age goes high, and there is little benefit if it is done after age 65 years. 17 Given current theories of ovarian carcinogenesis, ovarian conservation and salpingectomy represent a better option than BSO for ovarian cancer risk reduction for most women undergoing other pelvic surgeries for benign disease. It was also proved from studies that the fallopian tubes were the site of origin of many serous ovarian cancers. ...
Article
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Background: The incidence of cancer is increasing day by day. Ovarian cancer ranks as the fifth leading cause of cancer related death among women worldwide. The cure rate of early stage disease is high. The accepted view is that ovarian cancer arises from ovarian surface epithelium. Recent evidence suggested that around sixty percentage of women without a genetic predisposition who developed sporadic ovarian cancer also have early tubal lesion and cancer. The present study aims to find out the histopathology of fallopian tube in neoplastic surface epithelial ovarian tumour.Methods: A descriptive study was conducted among hundred women who had undergone surgery for malignant and benign surface epithelial ovarian tumor from Govt. Medical College, Kottayam for one year from January-December 2017.Results: Fifty percent of the patients had malignant surface epithelial ovarian tumors.Conclusions: The risk factors of malignant surface epithelial ovarian tumors include age above fifty years and post-menopausal women. Whereas oral contraceptive pill use is a protective factor against malignant surface epithelial ovarian tumors. The fimbrial end of fallopian tube is the site of origin of malignancy in high grade ovarian epithelial carcinoma. So, prophylactic bilateral salpingectomy should be encouraged in all patients who have completed family and undergoing hysterectomy. This will reduce the morbidity and mortality due to ovarian carcinoma.
... La conservación ovárica hasta por lo menos la edad de 65 años, beneficia la sobrevida a largo plazo para mujeres con un riesgo promedio de cáncer de ovario cuando se someten a histerectomía por enfermedad benigna (18). La salpigooforectomía profiláctica se relaciona con disminución de la calidad de vida en cuanto a mayor dolor, menos vitalidad, menos vida social, menos capacidad física y menor satisfacción sexual (41). ...
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Objetivo: Evaluar la ooforectomía como medida profiláctica para la disminución del riesgo de cáncer de ovario en mujeres con antecedente de histerectomía y conservación de ovarios, debida a patología benigna, que consultaron desde enero 2000 a diciembre 2006.
... They concluded that conservation of ovaries in women under 65 years with low risk for ovarian cancer provided longterm survival benefit. Hysterectomy is significant only in women with oophorectomy and less important in the case of a patient with conservation of ovaries [31]. ...
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Menopause can occur spontaneously (natural menopause) or it can be surgically induced by oophorectomy. The symptoms and complications related to menopause differ from one patient to another. We aimed to review the similarities and differences between natural and surgically induced menopause by analyzing the available data in literature regarding surgically induced menopause and the current guidelines and recommendations, the advantages of bilateral salpingo-oophorectomy in low and high risk patients, the effects of surgically induced menopause and to analyze the factors involved in decision making.
... A survival benefit of prophylactic oophorectomy is seen among women with genetic predisposition to ovarian cancer [3,4], but for women with no known family history of cancer, health benefits and risks are more uncertain. In Denmark, the tendency over recent decades has been to be increasingly more reluctant towards removing the ovaries-both in pre-and postmenopausal women-after publication of the Women's Health Initiative trial of hormone replacement therapy (HRT) in 2002 [5] and studies on the consequences of oophorectomy [6,7]. Thus, in 2004Thus, in -2008, approximately 15% of Danish women undergoing benign hysterectomy had concomitant elective bilateral oophorectomy [2]. ...
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PurposeLarge-scale population-based registry studies investigating the risk of breast cancer after removal of both ovaries at hysterectomy for benign conditions in women with no known genetic predisposition to cancer are needed. We aimed to perform such a study taking into account the age at surgery status and use of hormone replacement therapy (HRT).Methods Within the female population of Denmark born 1937–1996, we evaluated breast cancer incidence after unilateral or bilateral oophorectomy concomitant with or after benign hysterectomy in comparison with no surgery and with hysterectomy alone using health registry data during 1978–2016. In a subpopulation followed from 1996, the analyses were stratified according to use of HRT.ResultsWe found a reduced risk of breast cancer among women aged < 45 years at bilateral oophorectomy compared with women with hysterectomy alone (HR = 0.78; 95% CI 0.66, 0.92), whereas slightly increased risks were seen in women above 50 years. In the subpopulation, non-users of HRT aged ≥ 50 years at oophorectomy had a HR of 0.74 (95% CI 0.56, 0.98) for breast cancer after bilateral oophorectomy compared with hysterectomy alone.Conclusions Our large-scale study covering four decades provides evidence that bilateral oophorectomy performed at young age in women with benign indications for hysterectomy is associated with a reduction in breast cancer risk. The finding of a negative association at older ages in women not using HRT deserves further attention.
... First, we examined women aged between 50 and 65 years, as these women were excluded from the primary analysis but are known to still benefit from ovarian conservation until the age of 65 years. 31,32 Second, a sensitivity analysis was performed on only those without any evidence of pelvic infection because salpingectomy is frequently performed if there is any evidence of current or prior infection or in the setting of tubo-ovarian abscess. ...
Article
Background Mounting evidence for the role of the distal fallopian tubes in the pathogenesis of epithelial ovarian cancer has led to the increased performance of opportunistic salpingectomy at the time of benign gynecologic surgery. Opportunistic salpingectomy has now been recommended as best practice in the United States to reduce future risk of ovarian cancer even in low-risk women. Preliminary analyses have suggested that performance of opportunistic salpingectomy is increasing. Objective To examine trends in opportunistic salpingectomy in women undergoing benign hysterectomy and to determine how the publication of the tubal hypothesis in 2010 may have contributed to these trends. Methods This is a population-based retrospective observational study examining the National Inpatient Sample between January 2001 and September 2015. Women <50 years of age who underwent inpatient hysterectomy for benign gynecologic disease were grouped as hysterectomy alone versus hysterectomy with opportunistic salpingectomy. All women had ovarian conservation, and those with adnexal pathology were excluded. Linear segmented regression with log-transformation was utilized to assess temporal trends. An interrupted time-series analysis was then used to assess the impact of the 2010 publication of the tubal hypothesis on opportunistic salpingectomy trends. A regression-tree model was constructed to examine patterns in the utilization of opportunistic salpingectomy. A binary logistic regression model was then fitted to identify independent characteristics associated with opportunistic salpingectomy. Sensitivity analysis was performed in women ages 50-65 to further assess surgical trends in a wider age group. Results There were 98,061 (9.0%) women who underwent hysterectomy with opportunistic salpingectomy and 997,237 (91.0%) women who had hysterectomy alone without opportunistic salpingectomy. Performance of opportunistic salpingectomy gradually increased from 2.4% to 5.7% between 2001-2010 (2.4-fold increase, P<0.001), predicting a 7.0% rate of opportunistic salpingectomy in 2015. However, in 2010, the rate of opportunistic salpingectomy began to increase substantially and reached 58.4% by 2015 (10.2-fold increase, P<0.001). In multivariable analysis, the largest change in the performance of opportunistic salpingectomy occurred after 2010 (adjusted-odds ratio 5.42, 95% confidence interval 5.34-5.51, P<0.001). In a regression-tree model, women who had hysterectomy at urban teaching hospitals in the Midwest after 2013 had the highest chance of undergoing opportunistic salpingectomy during benign hysterectomy (76.4%). In the sensitivity analysis of women ages 50-65, a similar exponential increase in opportunistic salpingectomy was seen from 5.8% in 2010 to 55.8% in 2015 (9.8-fold increase, P<0.001). Conclusion Our study suggests that clinicians in the United States rapidly adopted opportunistic salpingectomy at the time of benign hysterectomy following the publication of data implicating the distal fallopian tubes in ovarian cancer pathogenesis in 2010. By 2015, nearly 60% of women had opportunistic salpingectomy at benign hysterectomy.
... Il est é galement dé montré qu'il persiste une sé cré tion ré siduelle significative d'androstè nedione et de testosté rone jusqu'à l'âge de 80 ans ; ces androgè nes pourront être aromatisé s en estrone. La conservation ovarienne aprè s la mé nopause (jusqu'à 65 ans selon certains modè les mathé matiques) serait une des meilleurs options en termes d'espé rance de vie [16,17]. ...
Article
Objectives: Since the recent evidence of a tubal origin of most ovarian cancers, opportunistic salpingectomy could be discussed as a prophylactic strategy in the general population and with hereditary predisposition. We aimed to survey French gynecological surgeons about their current surgical practice of prophylactic salpingectomy. Methods: An anonymous online survey was sent to French obstetrician-gynaecologists and gynecological surgeons. There were 13 questions about their current clinical practice and techniques of salpingectomy during a benign hysterectomy or as a tubal sterilization method, salpingectomy versus salpingo-oophorectomy in the population with genetic risk, salpingectomy in relationship with endometriosis and questions including histopathological considerations. Results: Among the 569 respondents, opportunistic salpingectomy was always performed between 42.48% and 43.44% during laparoscopic, laparoscopic-assisted vaginal or laparotomic hysterectomy and only 12.26% in case of vaginal route. In the genetic population, salpingo-oophorectomy was mainly performed. Tubal sterilization was often practiced by the hysteroscopic route. More than 90% of respondents didn't perform salpingectomy in case of endometriosis. There was not any specific tubal histopathological protocol in 71.54% of cases. Conclusions: Salpingectomy may be a preventing strategy in the low- and high-risk population. The survey's responses show that salpingectomy seems to be a current practice during benign hysterectomy for more than 40% doctors. However, there is not any change with no more salpingectomy in the population with genetic risk, or in case of endometriosis or tubal sterilization.
... 20,21 Bilateral oophorectomy and the induction of early menopause may increase all-cause mortality. 22 However, a review article published in 2014, which evaluated the current evidence, suggested that pain relief is better achieved if the surgery involves the removal of the ovaries. The authors suggested that ovarian preservation carries a six-fold greater risk of recurrent pain than oophorectomy. ...
Article
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Objective: To assess pain symptoms before and after hysterectomy in women with endometriosis. Design: A population-based registry study. Setting: Sweden. Population: Women aged 18-45 years who underwent hysterectomy for endometriosis between 2010 and 2015. Methods: Pain symptoms before hysterectomy and 12 months after surgery were collected from the Swedish National Quality Register for Gynaecological Surgery (GynOp). Pain symptoms were also assessed by follow-up surveys after a median follow-up period of 63 months. Main outcome measures: Pelvic or lower-abdominal pain after hysterectomy. Results: The study included 137 women. The proportion of women experiencing pain of any severity decreased by 28% after hysterectomy (p <0.001). The proportion of women with severe pain symptoms decreased by 76% after hysterectomy (p<0.001). The majority of patients (84%) were satisfied with the surgical result. Presence of severe pain symptoms after the hysterectomy was associated with less satisfaction (p<0.001). Pain symptoms after surgery, patient satisfaction, and the patient's perceived improvement were not significantly different between patients whose ovarian tissue was preserved and patients who underwent bilateral oophorectomy. Conclusions: We observed a significant, long-lasting reduction in pain symptoms after hysterectomy among women with endometriosis. Hysterectomy, with the possibility of ovarian preservation, may be a valuable option for women with endometriosis who suffer from severe pain symptoms. Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
... Laparoscopy has been associated with a substantial rate of disease recurrence (30-50%) within 5 years [16,17] and a repeat surgery rate as high as 55% within 7 years [18]. Previous evidence of hysterectomy outcomes has been inconsistent, leaving physicians and patients to wonder, for instance, whether it is best to preserve the ovaries during the hysterectomy, as some have argued [13,19], or to remove both ovaries along with the uterus [16,18]. As a result, the American Society for Reproductive Medicine has argued that there is a need for further research examining the benefits and costs of the current endometriosis treatment strategies [1]. ...
Article
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Introduction: Hysterectomy and laparoscopy are common surgical procedures used for the treatment of endometriosis. This study compares outcomes for women who received either procedure within the first year post initial surgery. Methods: The study used data from the Truven Health MarketScan claims databases from 2004 to 2013 to identify women aged 18-49 years who received an endometriosis-related laparoscopy or hysterectomy. Patients were excluded if they did not have continuous insurance coverage from 1 year before through 1 year after their endometriosis-related procedure, if they were diagnosed with uterine fibroids prior to or on the date of surgery (i.e., index date), or if they had a hysterectomy prior to the index date. The descriptive analyses examined differences between patients with an endometriosis-related laparoscopy or hysterectomy in regard to medications prescribed, complications, and hospitalizations during the immediate year post procedure. Results: The final sample consisted of 24,915 women who underwent a hysterectomy and 37,308 who underwent a laparoscopy. Results revealed significant differences between the cohorts, with women who received a laparoscopy more likely to be prescribed a GnRH agonist, progestin, danazol, or an opioid analgesic in the immediate year post procedure compared to women who underwent a hysterectomy. In contrast, women who underwent a hysterectomy generally had higher complication rates. Index hospitalization rates and length of stay (LOS) were higher for women who had a hysterectomy, while post-index hospitalization rates and LOS were higher for women who had a laparoscopy. For both cohorts, post-procedure complications were associated with significantly higher hospitalization rates and longer LOS. Conclusion: This study indicated significantly different 1-year post-surgical outcomes for patients who underwent an endometriosis-related hysterectomy relative to a laparoscopy. Furthermore, the endometriosis patients in this analysis had a considerable risk of surgical complications, subsequent surgeries, and hospital admissions, both during and after their initial therapeutic laparoscopy or hysterectomy. Funding: AbbVie.
... Interestingly, in a large prospective cohort study of women undergoing hysterectomy for benign indications (Nurses' Health Study, n = 30,117), women undergoing concomitant prophylactic bilateral salpingooophorectomy experienced a decrease in ovarian cancer specific mortality (4 deaths among women undergoing oophorectomy vs 44 deaths among those women who did not), but an increased risk in overall mortality (HR 1.13) [33••]. Parker et al. estimated that prophylactic salpingo-oophorectomy at the time of hysterectomy was associated with an increased risk of all-cause mortality until age 65, when the risk of mortality from ovarian cancer was similar to the risk of all-cause mortality [38]. Furthermore, they found that there was no age at which performing salpingo-oophorectomy decreased a woman's risk of overall mortality. ...
Article
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Hysterectomy is an important surgical procedure in the care of women with pelvic organ prolapse or lower urinary tract malignancy. Therefore, hysterectomy can be a commonly performed surgical procedure in the urologist’s practice. Obtaining a thorough gynecologic history is necessary prior to performing a hysterectomy and prolapse repair. Specifically, reviewing prior cervical cancer screening, risk factors for uterine malignancy, and the role of prophylactic salpingo-oophorectomy are important steps of the reconstructive surgical planning process. In women with lower urinary tract malignancy, hysterectomy is included in the classic technique of radical cystectomy. However, preliminary research has begun to question whether or not the uterus can be spared in some cases. In the article, we review the literature on hysterectomy as it pertains to the field of urology.
... The total robotic hysterectomy with bilateral salpingo- oophorectomy was proposed to the patient because of the perimenopausal status and the diagnosis of adenomyosis. Even the ovarian conservation until at least age 65 years confers long term survival benefits for those women with average risk for ovarian cancer 3 . GnRH analogue (Enantone ® 3.75 mg) intramuscular injection was prescribed for 3 months, in order to reduce uterine size and minimize pain and bleeding 4 . ...
Article
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Objective: This study aimed to report the feasibility, trouble shooting and surgical technique in the total robotic hysterectomy for the patient with adenomyoma uteri. Methods: A 51 year-old patient was diagnosed with adenomyosis. Total robotic hysterectomy was performed. Results: Total operating time was 350 min, estimated blood loss was 50 ml, and length of hospitalization was 6 days. The pathologic section revealed adenomyosis with myoma uteri. The intraoperative and post-operative complications were unremarkable. The patient was in good conditions at 6th week, 3rd, 6th, 12th and 24th month. Conclusion: Total robotic hysterectomy for benign gynecologic condition, such as adenomyosis, is safe and feasible. However, the sustained high consuming cost must be weighted with the patient’s advantages.
... [5][6][7][8] There is a further risk of developing osteoporosis and coronary artery disease, when oophorectomy is done simultaneously. 9 The prevalence rate of hysterectomy in US is 26.4% and in Australia, it is between 16.9% to 22%. [10][11][12] Recent studies have shown a decline in the number of hysterectomies performed in developed countries because of availability of less-invasive alternative treatment modalities like endometrial ablation, uterine artery embolization etc. 13,14 But in developing countries, there has been a rise in the number of women undergoing hysterectomy for nononcological reasons, since most of them are of the view that uterus is dispensable after childbirth and also because they experience prompt relief from symptoms of heavy menstrual bleeding and backache as seen in fibroid and dysfunctional uterine bleeding. ...
Article
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Background: An increase in the number of women undergoing hysterectomy especially in South India is of great concern. Whenever hysterectomy is performed, it is imperative that clinical diagnosis is accurate. The purpose of current study is to assess whether the histopathological diagnosis after surgery is correlated with the clinical diagnosis. Methods: This is a retrospective study conducted in the department of obstetrics and gynaecology at Indira Gandhi medical college and research institute Puducherry, from January 2018 to December 2018. Patients, who underwent hysterectomy for benign causes, were included in the study. Data was collected from the patients' case records. Whether the histopathological diagnosis was in tandem with the clinical diagnosis, was notedResults: Out of the 234 hysterectomies performed, 46.15% were by abdominal route and 53.84% were by vaginal route. 24.7% were TAH with BSO with mean age of 49.72 years. VH with PFR (46.5%) was the most common surgery done. Out of the 80 cases of fibroid, 66 (28.2%) were confirmed on histopathology. Histopathological diagnosis corroborated the clinical diagnosis in patients with ovarian cyst, fibroid with ovarian cyst and DUB. Adenomyosis was validated in 7 of 9 cases. Endometriosis of ovary was confirmed in 4 (1.7%) cases. In patients with pelvic organ prolapse, histopathology showed atrophic changes.Conclusions: Accurate clinical diagnosis, supported by in-depth preoperative evaluation and a sound clinical knowledge helps to avoid unnecessary hysterectomies. It is imperative to study the histopathology of the operated specimen and confirm the appropriateness of the clinical indication.
... Normally, for many years after menopause ovaries continue to produce androgens which are converted to estrogen peripherally. Negative health consequences after prophylactic oophorectomy include increased risk of death, total cancer mortality, neurologic high blood pressure, high cholesterol, higher incidence of heart disease, stroke, all-cause mortality, premature death, pre-diabetes, and weight gain postoperatively [12][13][14][15][16][17]. Ovarian conservation in premenopausal women may be important especially in patients with a personal or family history of cardiovascular disease or cognitive impairment. ...
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Prophylactic bilateral oophorectomy during hysterectomy for benign conditions in a premenopausal woman with sufficient ovarian reserve is still subject to debate. Women of all age groups should be thoroughly counseled regarding the risks and benefits of ovarian preservation. In women age 40 or older, with a history of familial ovarian cancer, bilateral oophorectomy may result in a significant decrease in the death rate from ovarian cancer. For women at average risk of ovarian cancer, the decision to perform prophylactic bilateral salpingo-oophorectomy should be individualized, because this may cause sudden hormonal imbalance, aggravation of menopausal symptoms, and decrease in libido. Ovarian conservation in young women may be especially important in patients with a personal or strong family history of cardiovascular or neurological disease. Negative effects of ovarian hormone deficiency in these women outweigh the beneficial effects on ovarian cancer. If ovaries would be preserved, it is important to protect the ovarian blood supply as much as possible while performing hysterectomy, because ovaries may be damaged. Ovarian conservation until age 65 may benefit long-term survival and it would be advisable to offer prophylactic oophorectomy only to women older than 65 years, who are undergoing hysterectomy for benign disease.
... [3,4] There is decreased risk of cardiovascular complaints and osteoporotic fractures in women with preserved ovarian function. [5] Menopausal symptoms such as hot flashes, sweating, poor memory, vaginal dryness, and decreased libido often appear during menopausal transition and these symptoms are higher in women undergoing surgical menopause. [6] Menopausal arthralgia is a common problem around the time of menopause. ...
... Another important issue in hysterectomy is redirected towards the ovaries. As most women undergoing hysterectomy are women of premenopausal age (40-44 years) [6], there are multiple risks and benefits to retaining or removing ovaries during hysterectomy [12]; some suggest retaining at least one ovary, because of the benefits of estrogen production [13], while others suggest that bilateral oophorectomy at the time of hysterectomy, due to decreased risk of breast, ovarian, and total cancers in long-term follow-up [14]. Thus, recent guidelines, such as American College of Obstetricians and Gynecologists (ACOG), suggest retaining ovaries in premenopausal women with negative genetic risk of ovarian cancer and oophorectomy for older women [15]. ...
Article
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Background Decreased ovarian function and reserve is one of the complications of hysterectomy. In this study, we aimed to compare anti-müllerian hormone (AMH) levels between total abdominal hysterectomy (TAH), and total laparoscopic hysterectomy (TLH). Methods In this prospective cohort study, serum levels of AMH were compared between the groups undergoing TAH + bilateral salpingectiomy and TLH, in 66 patients (33 in each group) who referred to the hospitals of Shiraz University of Medical Sciences for hysterectomy during one years of work. The collected information included age, weight, gravidity, parity, regularity of menstrual cycle, uterine weight, blood loss during surgery, and serum levels of AMH before and 6 months after surgery, compared between groups. Results Most patients (88% in TAH and 73% in TLH group) aged 40–50 years. Mean age, weight, parity of patients was similar in both groups, while blood loss was significantly less in TLH group (P < 0.01). Median (IQR) of pre-surgical AMH values were 0.40 (0.55) ng/ml in the TLH group and 0.92 (1.23) ng/ml in the TAH group (P = 0.12) that decreased to 0.29 (0.44) ng/ml in the TLH group and 0.15 (0.31) ng/ml in the TAH group (P = 0.02). Also Median (IQR) of the difference between pre and post-surgical AMH values were 0.12 (0.31) and 0.58 (1.17) in TLH and TAH group, respectively (P = 0.003). Conclusion The serum levels of AMH decreased significantly after both methods of hysterectomy (laparoscopy and laparotomy), while this decrease was greater in TAH group that shows.
... Ovarian conservation during abdominal hysterectomy in a premenopausal woman with sufficient ovarian reserve is a subject to be considered, since oophorectomy may cause sudden hormonal imbalance, aggravation of menopausal symptoms and decrease of libido (1) . ...
... Ovariectomized Wistar rat model was used for the present investigations which have been approved by FDA [25]. Removal of the ovaries has also been shown to be associated with increased risk of death from heart disease [26]. ...
Article
Purpose: Osteoporosis is a bone metabolic disorder which is well known to increase bone porosity and is the outcome of various factors like ageing, genetic, nutritional deficiency, decreased calcium uptake, and last but the most important hormonal imbalances. Hormonal imbalance is one of the major factors affecting women worldwide and leading to osteoporosis. Trace elements play a very essential role in number of pathological conditions. Ingestion of zinc in the early stages of bone loss may be more beneficial in mitigating bone loss and also in improving the overall strength of the bone. In the current work, we have intended to extract the information pertaining to the mechanical strength of bone, bone tissue composition and hydroxyapatite crystallite size upon supplementing zinc in the osteopenic condition. Methods: Forty eight wistar female rats in two set of twenty four animals each were assigned to four groups: Control, Zinc, Ovariectomized (OVX) and OVX+Zinc. Duration of the treatment period was of eight weeks. Biochemical estimations were carried out to make comparison between the treatment groups based on bone metabolism markers in serum. Bone mechanical strength of both the bones i.e., femur and tibia, was assessed using texture analyzer. Also, bone matrix analysis using Fourier transformer infrared spectroscopy and X-ray diffraction studies were carried out for all the treatment groups. Results: Estradiol levels decreased and tartarate-resistant acid phosphatase 5b levels increased in the OVX group. Zinc supplemented following ovariectomy regulated these levels. The OVX group showed significantly higher serum alkaline phosphatase levels, which recovered upon zinc supplementation. Further, zinc plays a potential role in preventing bone tissue deterioration by restoring its composition and microstructure in the post-menopausal condition, thereby, maintaining the mechanical strength of the bone. Conclusion: These findings suggested that alterations in the bone tissue material properties following estrogen deficiency can be averted by zinc if administered at early stages of bone loss.
... Other reasons include avoidance of further gynecological surgical interventions related to retained ovaries; reduction of symptoms associated with advanced endometriosis, not responsive to other medical or surgical therapies, and to solve intractable and severe premenstrual syndrome [83]. For women who do not have genetic variants that increase the risk of ovarian cancer, the risk-benefit balance of a preventive surgery remains uncertain and controversial [84]. ...
Chapter
Testosterone production in women across their lifespan, as well as transport, measurement, and metabolism are reviewed. Testosterone directly influences sexuality, mood, body composition, skin and hair, mebonian glands in the eyes, as well as acts on the hematologic and immune system. Bone and cardiovascular system effects are at least in part mediated through aromatization to estrogens. Evaluation and morbidity of testosterone excess syndromes such as polycystic ovary syndrome (PCOS) and androgen secreting tumors are described. Presently, androgen deficient syndrome in women is not acceptable, situations with lower testosterone such as Turner Syndrome, premature ovarian failure, and bilateral oophorectomy carry an increased morbidity and mortality risk. Trials have demonstrated short-term effects of pharmacological, not physiological, levels of testosterone in women. Long-term safety is unknown.
Article
Ante el descubrimiento de una masa anexial, conviene ante todo descartar una urgencia quirúrgica que pueda comprometer la función ovárica. Estas urgencias están dominadas por las torsiones anexiales. En ausencia de urgencia terapéutica, un estudio completo (clínico, pruebas de imagen y biológico) debe permitir estimar el riesgo de malignidad y discutir la indicación operatoria, así como la vía de abordaje quirúrgica. Otros elementos pueden entrar en juego en la indicación terapéutica: la existencia de infertilidad, en particular en caso de endometriosis, y el riesgo de torsión, sobre todo en caso de quistes de gran tamaño. Este artículo revisa de manera práctica los principales problemas que se plantean ante el descubrimiento de un tumor ovárico supuestamente benigno.
Article
The term prophylactic oophorectomy implies that the ovaries are normal at the time of their surgical removal and that it is performed for possible future benefits, such as prevention of ovarian cancer or to avoid eventual gynecological surgical interventions. However, it has been suggested that the production of androgens in the ovaries in perimenopausal women has an important rol in the quality of life and sexual well being. Bilateral oophorectomy has also been related with an increased risk of cardiovascular disease and mortality in women that did not use hormonal replacement therapy. Until more research of better methodological quality becomes available, prophylactic oophorectomy at the time of an elective hysterectomy in ovarian cancer low risk women should be approached with great caution. The poor and limited evidence suggests that the decision to perform or not a prophylactic bilateral oophorectomy at the time of an elective hysterectomy, is mostly opinion-based than evidence-based, and it does not justify the elevated number of prophylactic oophorectomies seen in current clinical practice.
Article
Gynecologists performing hysterectomy for benign disease must universally counsel women about ovarian management. The beneficial effect of elective bilateral salpingo-oophorectomy (BSO) on incident ovarian and breast cancer and elimination of need for subsequent adnexal surgery must be weighed against the risks of ovarian hormone withdrawal. Ovarian conservation rates have increased significantly over the past 15 years. In postmenopausal women, however, BSO can reduce ovarian and breast cancer rates without an adverse impact on coronary heart disease, sexual dysfunction, hip fractures, or cognitive function.
Article
Over the last two decades, the rate of oophorectomy at the time of hysterectomy in the U.S. has consistently been between 40 and 50%. A decline in hormone use has been observed since the release of the principle results of the Women’s Health Initiative. Oophorectomy appears to be associated with an increased risk of coronary heart disease, as well as deleterious effects on overall mortality, cognitive functioning, and sexual functioning. Estrogen deficiency from surgical menopause is associated with bone mineral density loss and increased fracture risk. While hormone therapy may mitigate these effects, at no age does there appear to be a survival benefit associated with oophorectomy. Reduction of ovarian cancer risk may be accomplished with salpingectomy at the time of hysterectomy.
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Endometriosis is considered a chronic condition with a high risk of recurrence following treatment; hence clinicians should be familiar with assessment of these patients. High recurrence rates of 20% after 2 years and up to 50% after 5 years have been reported. Up to one in four after minor surgery and one in five after major conservative surgery with ovarian preservation require additional endometriosis surgery within 5 years following operation. Recurrence appears to be less common after hysterectomy. Recurrence may be due to incomplete treatment or regrowth of the condition; however persistent or recurrent symptoms after surgery have usually a more complex background. Possibilities that the symptoms may not be due to endometriosis, centralisation of pain due to prolonged exposure and side effects of previous surgery/surgeries should be considered. A multidisciplinary approach that would be able to offer surgery, medical treatment and pain management would be necessary for the management of woman with recurrent endometriosis.
Article
Objective: Metabolic syndrome (MetS) is a cluster of risk factors for cardiovascular disease and diabetes. Menopause is associated with an increased risk for MetS. The purpose of this meta-analysis is to better understand the relationship between MetS and menopause. Methods: MEDLINE and EMBASE were searched for all the associated articles on (1) MetS components in postmenopausal women vs. premenopausal women, (2) comparison of MetS incidence between surgical menopause and natural menopause, (3) the effect of hormone therapy (HT) with 17β-estradiol (E2) compared to conjugated equine estrogen (CEE) on MetS components among postmenopausal women. A meta-analysis was applied by Review Manager 5.3 software. Results: All comparable indicators were significantly unfavorably changed in postmenopausal women compared to premenopausal women except for high density lipoprotein cholesterol. Women who underwent surgical menopause suffered a 1.51-fold higher risk for MetS compared to those with natural menopause. HT with E2 provided more benefits for levels of triglyceride and diastolic blood, while CEE showed a better effect on both high and low density lipoprotein cholesterol levels. Conclusions: Menopause nearly adversely affects all components of MetS, and surgical menopause may lead to a higher incidence of MetS compared to natural menopause. HT with various preparations may have different effects on MetS components. These results may clarify the management of menopause-related MetS in clinical practice.
Article
Objective: We studied the long-term risk of depressive and anxiety symptoms in women who underwent bilateral oophorectomy before menopause. Design: We conducted a cohort study among all women residing in Olmsted County, MN, who underwent bilateral oophorectomy before the onset of menopause for a noncancer indication from 1950 through 1987. Each member of the bilateral oophorectomy cohort was matched by age with a referent woman from the same population who had not undergone an oophorectomy. In total, we studied 666 women with bilateral oophorectomy and 673 referent women. Women were followed for a median of 24 years, and depressive and anxiety symptoms were assessed using a structured questionnaire via a direct or proxy telephone interview performed from 2001 through 2006. Results: Women who underwent bilateral oophorectomy before the onset of menopause had an increased risk of depressive symptoms diagnosed by a physician (hazard ratio = 1.54, 95% CI: 1.04-2.26, adjusted for age, education, and type of interview) and of anxiety symptoms (adjusted hazard ratio = 2.29, 95% CI: 1.33-3.95) compared with referent women. The findings remained consistent after excluding depressive or anxiety symptoms that first occurred within 10 years after oophorectomy. The associations were greater with younger age at oophorectomy but did not vary across indications for the oophorectomy. In addition, treatment with estrogen to age 50 years in women who underwent bilateral oophorectomy at younger ages did not modify the risk. Conclusions: Bilateral oophorectomy performed before the onset of menopause is associated with an increased long-term risk of depressive and anxiety symptoms.
Article
Background: Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration. Aims: We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases. Materials and methods: Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy. Results: Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia. Conclusion: The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.
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Ein hohes Lebensalter gilt als größter Risikofaktor für die Entstehung von Krebserkrankungen. In diesem Kapitel erklären wir, wie sich dieses erhöhte Krebsrisiko im Laufe unseres Lebens durch die Ansammlung von genetischen Mutationen und den Einfluss von krebsfördernden Lebensgewohnheiten und Umwelteinflüssen ergibt. Zudem stellen wir einige interessante Methoden vor, durch welche sich im Tierreich und möglicherweise auch im Menschen der gesamte Alterungsprozess inklusive der ungewünschten Begleiterkrankungen verlangsamt lässt.
Article
Objective: To establish the rate of occult ovarian micro-metastases in early stage disease and to provide an eligibility framework for providers to consider ovarian preservation in a patient population with presumed early stage disease. Methods: A retrospective review from January 2005 to December 2010 identified women with presumed early stage endometrial cancer from a single institutional database. Inclusion criteria included: (1) FIGO grade 1 endometrioid endometrial cancer on endometrial biopsy; or (2) the same pathology as (1) on frozen section specimen with less than 50% myometrial biopsy; and (3) no evidence of metastatic disease on preoperative imaging or visible metastatic disease in the peritoneal cavity. Results: Of the 52 patients, 86.5% were diagnosed with stage IA and 11.5% were diagnosed with stage II disease. One patient (1.9%) had microscopic adnexal involvement in a fallopian tube, which upstaged her to stage IIA disease. None of the patients had ovarian involvement. Conclusion: Preservation of the ovaries appears to be a safe and viable option for premenopausal women who are diagnosed with presumed early stage endometrioid endometrial cancer. It is believed that ovarian preservation in this select population will provide them with significant health benefits and improve their quality of life.
Article
Objective: To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy. Methods: Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions. Results: Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χP < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749). Conclusions: Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.
Article
Objectives There currently lacks a noninvasive and accurate method to distinguish benign and malignant ovarian lesion prior to treatment. This study developed a deep learning algorithm that distinguishes benign from malignant ovarian lesion by applying a convolutional neural network on routine MR imaging.Methods Five hundred forty-five lesions (379 benign and 166 malignant) from 451 patients from a single institution were divided into training, validation, and testing set in a 7:2:1 ratio. Model performance was compared with four junior and three senior radiologists on the test set.ResultsCompared with junior radiologists averaged, the final ensemble model combining MR imaging and clinical variables had a higher test accuracy (0.87 vs 0.64, p < 0.001) and specificity (0.92 vs 0.64, p < 0.001) with comparable sensitivity (0.75 vs 0.63, p = 0.407). Against the senior radiologists averaged, the final ensemble model also had a higher test accuracy (0.87 vs 0.74, p = 0.033) and specificity (0.92 vs 0.70, p < 0.001) with comparable sensitivity (0.75 vs 0.83, p = 0.557). Assisted by the model’s probabilities, the junior radiologists achieved a higher average test accuracy (0.77 vs 0.64, Δ = 0.13, p < 0.001) and specificity (0.81 vs 0.64, Δ = 0.17, p < 0.001) with unchanged sensitivity (0.69 vs 0.63, Δ = 0.06, p = 0.302). With the AI probabilities, the junior radiologists had higher specificity (0.81 vs 0.70, Δ = 0.11, p = 0.005) but similar accuracy (0.77 vs 0.74, Δ = 0.03, p = 0.409) and sensitivity (0.69 vs 0.83, Δ = -0.146, p = 0.097) when compared with the senior radiologists.Conclusions These results demonstrate that artificial intelligence based on deep learning can assist radiologists in assessing the nature of ovarian lesions and improve their performance.Key Points • Artificial Intelligence based on deep learning can assess the nature of ovarian lesions on routine MRI with higher accuracy and specificity than radiologists. • Assisted by the deep learning model’s probabilities, junior radiologists achieved better performance that matched those of senior radiologists.
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No two ovaries are alike, and indeed, the same ovary can change its architecture from day to day. This is because ovarian follicles are present in different numbers, positions, and states of maturation throughout reproductive life. All possible developmental states of follicles can be represented at any time, along with follicles that have committed to death (termed follicle atresia). Static histological and whole-mount imaging approaches allow snapshots of what is occurring within ovaries, but our views of dynamic follicle growth and death have been limited to these tools. We present a simple Markov chain model of the complex mouse ovary, called “ŌvSim”. In the model, follicles can exist in one of three Markov states with stationary probabilities, Hold (growth arrest), Grow, and Die. The probability that individual primordial follicles can growth activate daily, the fraction of granulosa cells that survive as follicles grow, and the probability that individual follicles can commit to atresia daily are user definable parameters. When the probability of daily growth activation is stationary at 0.005, the probability of atresia for all follicles is near 0.1, and the probability of granulosa cell survival is modeled around 0.88, ŌvSim simulates the growth and fate of each of the approximately 3000 postpubertal mouse ovarian follicles in a fashion that approximates actual biological measurements (e.g., follicle counts). ŌvSim thus offers a starting platform to simulate mammalian ovaries and to explore factors that might impact follicle development and global organ function. Author Summary ŌvSim is a computer simulation of the dynamic growth of mouse ovarian follicles. The program is offered as the beginning of a research and teaching platform to model asynchronous follicle growth and survival or death.
Article
In 2020, endometrial cancer continues to be the most common gynecologic malignancy in the United States. The majority of endometrial cancer is low-grade, and nearly one out of every eight low-grade endometrial cancer diagnoses occurs in women younger than 50 with early-stage disease. The incidence of early-stage, low-grade endometrial cancer is increasing in particular among women in their 30s. Women with early-stage, low-grade endometrial cancer generally have a favorable prognosis, and hysterectomy-based surgical treatment alone can often be curative. In young women with endometrial cancer, consideration of ovarian conservation is especially relevant to avoid both the short-term and long-term sequelae of surgical menopause including menopausal symptoms, cardiovascular disease, metabolic disease, and osteoporosis. While disadvantages of ovarian conservation include failure to remove ovarian micro-metastasis (0.4-0.8%), gross ovarian metastatic disease (4.2%), or synchronous ovarian cancer (3-5%) at the time of surgery as well as the risk of future potential metachronous ovarian cancer (1.2%), ovarian conservation is not negatively associated with endometrial cancer-related nor all-cause mortality in young women with early-stage, low-grade endometrial cancer. Despite this, utilization of ovarian conservation for young women with early-stage, low-grade endometrial cancer remains modest with only a gradual increase in uptake in the United States. We propose a framework and strategic approach to identify young women with early-stage, low-grade endometrial cancer who may be candidates for ovarian conservation. This evidence-based schema consists of a two-step assessment at both the preoperative and intraoperative stages that can be universally integrated into practice.
Chapter
Vaginoplasty is the most common genital surgery performed for gender affirmation. Annually, there are more than 3000 performed each year. Vaginoplasty is a safe, reliable technique for performing genital transition in transgender female patients. Penile inversion vaginoplasty is the most common technique used today, although there are several other methods of vaginoplasty: penile inversion, visceral interposition, and pelvic peritoneal vaginoplasty. Overall, outcomes are excellent. It is recommended surgeons follow the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. There are no absolute contraindications to vaginoplasty, only relative contraindications that include active smoking and morbid obesity. Important but rare complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in appropriately selected patients by expert surgeons, this is a rewarding operation for both patient and surgeon.
Article
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Menopause is associated with a redistribution of adipose tissue towards central adiposity, known to cause insulin resistance. In this cross-sectional study of 33 women between 45 and 60 years, we assessed adipose tissue inflammation and morphology in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) across menopause and related this to menopausal differences in adipose tissue distribution and insulin resistance. We collected paired SAT and VAT biopsies from all women and combined this with anthropometric measurements and estimated whole-body insulin sensitivity. We found that menopause was associated with changes in adipose tissue phenotype related to metabolic dysfunction. In SAT, postmenopausal women showed adipocyte hypertrophy, increased inflammation, hypoxia and fibrosis. The postmenopausal changes in SAT was associated with increased visceral fat accumulation. In VAT, menopause was associated with adipocyte hypertrophy, immune cell infiltration and fibrosis. The postmenopausal changes in VAT phenotype was associated with decreased insulin sensitivity. Based on these findings we suggest, that menopause is associated with changes in adipose tissue phenotype related to metabolic dysfunction in both SAT and VAT. Whereas increased SAT inflammation in the context of menopause is associated with VAT accumulation, VAT morphology is related to insulin resistance.
Article
Objective: To determine whether ovarian reserve is compromised after hysterectomy with bilateral salpingectomy. Methods: A prospective longitudinal study was conducted among 84 women who underwent hysterectomy with bilateral salpingectomy at a tertiary medical center in Beijing, China, between August 2, 2015, and January 15, 2017. Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured to assess ovarian function before undergoing the procedure (baseline) and at weeks 1 and 6 after surgery (postoperative period). Results: The median age was 41.61 ± 0.62 years. Age negatively correlated with the serum AMH level at baseline (P<0.001), as well as with preoperative-to-postoperative changes in the concentration of this hormone (P<0.001). Serum AMH levels were lower in the postoperative period versus the preoperative period (P<0.001). By contrast, serum FSH levels were higher in the postoperative period than in the preoperative period (P<0.001). Moreover, no correlation was found with body mass index. Conclusions: Hysterectomy with bilateral salpingectomy compromised ovarian reserve, with the damage being most severe among younger patients. This article is protected by copyright. All rights reserved.
Article
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Objective: Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease. The optimal age for this recommendation in women at average risk for ovarian cancer has not been determined. Methods: Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease, hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to estimate the optimal strategy for maximizing survival for women at average risk of ovarian cancer. For each 5-year age group from 40 to 80 years, 4 strategies were compared: ovarian conservation or oophorectomy, and use of estrogen therapy or nonuse. Outcomes, as proportion of women alive at age 80 years, were measured. Sensitivity analyses were performed, varying both relative and absolute risk estimates across the range of reported values. Results: Ovarian conservation until age 65 benefits long-term survival for women undergoing hysterectomy for benign disease. Women with oophorectomy before age 55 have 8.58% excess mortality by age 80, and those with oophorectomy before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease. Conclusion: Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease. (Obstet Gynecol 2005;106:219-26)
Article
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Markov models are useful when a decision problem involves risk that is continuous over time, when the timing of events is important, and when important events may happen more than once. Representing such clinical settings with conventional decision trees is difficult and may require unrealistic simplifying assumptions. Markov models assume that a patient is always in one of a finite number of discrete health states, called Markov states. All events are represented as transitions from one state to another. A Markov model may be evaluated by matrix algebra, as a cohort simulation, or as a Monte Carlo simulation. A newer representation of Markov models, the Markov-cycle tree, uses a tree representation of clinical events and may be evaluated either as a cohort simulation or as a Monte Carlo simulation. The ability of the Markov model to represent repetitive events and the time dependence of both probabilities and utilities allows for more accurate representation of clinical settings that involve these issues.
Article
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To explore potential etiologic differences in the two major types of hip fracture, the authors computed the incidence rates of fractures of the femoral neck and trochanteric region of the proximal femur using a 5% sample of the US Medicare population aged 65–99 years. For the period they examined, July 1, 1986, through June 30, 1990, the rates of both hip fracture types increased with age in all race and sex categories. The proportion of hip fractures that occurred in the trochanteric region rose steeply with age among white women, but not among black women, white men, or black men. Within the United States, a north-to-south gradient in rates of both fracture types was observed among women, while no clear pattern was found for men. These findings raise the possibility of etiologic differences in the two fracture types, and the results provide further evidence of sex and racial differences in the risk of osteoporotic fractures.
Article
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It has been suggested that oestrogen replacement therapy is associated with risk of epithelial ovarian cancer of the endometrioid type. Using data from an Australian population-based case-control study, the relation between unopposed oestrogen replacement therapy and epithelial ovarian cancer, both overall and according to histological type, was examined. A total of 793 eligible incident cases of epithelial ovarian cancer diagnosed from 1990 to 1993 among women living in Queensland, New South Wales and Victoria were identified. These were compared with 855 eligible female controls selected at random from the electoral roll, stratified by age and geographic region. Trained interviewers administered standard questionnaires to obtain detailed reproductive and contraceptive histories, as well as details about hormone replacement therapy and pelvic operations. No clear associations were observed between use of hormone replacement therapy overall and risk of ovarian cancer. Unopposed oestrogen replacement therapy was, however, associated with a significant increase in risk of endometrioid or clear cell epithelial ovarian tumours (odds ratio (OR) 2.56; 95% confidence interval (CI) 1.32-4.94). In addition, the risk associated with oestrogen replacement therapy was much larger in women with an intact genital tract (OR 3.00; 95% CI 1.54-5.85) than in those with a history of either hysterectomy or tubal ligation. Post-menopausal oestrogen replacement therapy may, therefore, be a risk factor associated with endometrioid and clear cell tumours in particular. Additionally, the risk may be increased predominantly in women with an intact genital tract. These associations could reflect a possible role of endometriosis in the development of endometrioid or clear cell ovarian tumours.
Article
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To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Oophorectomy decision consultation at the outpatient or pre-admission clinic. A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised formal and some were surprised at the specificity of the guidance given. A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient's own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients' preferences for inclusion in the decision making process.
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Despite decades of use and considerable research, the role of estrogen alone in preventing chronic diseases in postmenopausal women remains uncertain. To assess the effects on major disease incidence rates of the most commonly used postmenopausal hormone therapy in the United States. A randomized, double-blind, placebo-controlled disease prevention trial (the estrogen-alone component of the Women's Health Initiative [WHI]) conducted in 40 US clinical centers beginning in 1993. Enrolled were 10 739 postmenopausal women, aged 50-79 years, with prior hysterectomy, including 23% of minority race/ethnicity. Women were randomly assigned to receive either 0.625 mg/d of conjugated equine estrogen (CEE) or placebo. The primary outcome was coronary heart disease (CHD) incidence (nonfatal myocardial infarction or CHD death). Invasive breast cancer incidence was the primary safety outcome. A global index of risks and benefits, including these primary outcomes plus stroke, pulmonary embolism (PE), colorectal cancer, hip fracture, and deaths from other causes, was used for summarizing overall effects. In February 2004, after reviewing data through November 30, 2003, the National Institutes of Health (NIH) decided to end the intervention phase of the trial early. Estimated hazard ratios (HRs) (95% confidence intervals [CIs]) for CEE vs placebo for the major clinical outcomes available through February 29, 2004 (average follow-up 6.8 years), were: CHD, 0.91 (0.75-1.12) with 376 cases; breast cancer, 0.77 (0.59-1.01) with 218 cases; stroke, 1.39 (1.10-1.77) with 276 cases; PE, 1.34 (0.87-2.06) with 85 cases; colorectal cancer, 1.08 (0.75-1.55) with 119 cases; and hip fracture, 0.61 (0.41-0.91) with 102 cases. Corresponding results for composite outcomes were: total cardiovascular disease, 1.12 (1.01-1.24); total cancer, 0.93 (0.81-1.07); total fractures, 0.70 (0.63-0.79); total mortality, 1.04 (0.88-1.22), and the global index, 1.01 (0.91-1.12). For the outcomes significantly affected by CEE, there was an absolute excess risk of 12 additional strokes per 10 000 person-years and an absolute risk reduction of 6 fewer hip fractures per 10 000 person-years. The estimated excess risk for all monitored events in the global index was a nonsignificant 2 events per 10 000 person-years. The use of CEE increases the risk of stroke, decreases the risk of hip fracture, and does not affect CHD incidence in postmenopausal women with prior hysterectomy over an average of 6.8 years. A possible reduction in breast cancer risk requires further investigation. The burden of incident disease events was equivalent in the CEE and placebo groups, indicating no overall benefit. Thus, CEE should not be recommended for chronic disease prevention in postmenopausal women.
Article
Whittemore, A. S. (Stanford U. School of Medicine, Dept. of Health Research and Policy, Stanford, CA 94305–5092), M. L. Wu, R. S. Paffenbarger, Jr., D. L. Sarles, J. B. Kampert, S. Grosser, D. L Jung, S. Ballon, and M. Hendrickson. Personal and environmental characteristics related to epithelial ovarian cancer. II. Exposures to talcum powder, tobacco, alcohol, and coffee. Am J Epidemiol 1988;128:1228–40. Vaginal exposures to talc and other particulates may play an etiologic role in epithelial ovarian cancer. Surgical sterilization may protect against ovarian cancer by blocking entry of such particulates into the peritoneal cavity. The authors assessed histories of talcum powder use, tubal sterilization, and hysterectomy with ovarian conservation in 188 women in the San Francisco Bay Area with epithelial ovarian cancers diagnosed in 1983–1985 and in 539 control women. To investigate the roles of blood-borne environmental exposures on ovarian cancer risk, they assessed lifetime consumption of coffee, tobacco, and alcohol in these women. Of the 539 controls, 280 were hospitalized women without overt cancer, and 259 were chosen from the general population by random digit telephone dialing. Ninety-seven (52%) of the cancer patients habitually used talcum powder on the perineum, compared with 247 (46%) of the controls. Adjusted for parity, the relative risk (RR) = 1.40, p = 0.06. There were no statistically significant trends with increasing frequency or duration of talc use, and patients did not differ from controls in use of talc on sanitary pads and/or contraceptive diaphragms. Fewer ovarian cancer patients (7%) than controls (13%) reported prior fallopian tube ligation (RR, adjusted for parity, = 0.56, p = 0.06), and fewer patients (20%) than controls (28%) reported prior hysterectomy (RR = 0.66, p = 0.05). The protective effect of hysterectomy was confined to those who underwent this surgery 10 or more years prior to interview and to those who had not undergone prior tubal sterilization. Consumption of cigarettes and alcohol did not differ between cases and controls. By contrast, 11 (6%) cases never regularly consumed coffee, compared with 31 (11%) hospital controls and 26 (10%) population controls (RR, adjusted for smoking, = 2.2, p = 0.03, for the comparison using all controls). Overall, ovarian cancer risk among women who had drunk coffee for more than 40 years was 3.4 times that of women who had never regularly consumed coffee (p < 0.01). However, the data exhibited no clear trends in risk with increasing consumption. Although risk ratios relating duration of coffee drinking to ovarian cancer were unaffected by adjustment for several characteristics, further study is needed to exclude potential confounding by other unmeasured characteristics.
Conference Paper
Various interventions for cardiovascular disease (CVD) slow or reverse the progression of atherosclerosis and reduce the risk of clinical coronary events. Although the cardiovascular benefits of hormone replacement therapy have been demonstrated in observational studies in predominantly healthy women, no benefit has been found in a randomized clinical trial conducted in older women with established CVD. It is possible that the benefit of hormone therapy occurs when it is used relatively early in the progression of atherosclerosis. Techniques are now available to monitor the various stages of atherosclerosis. Quantitative coronary angiography, a technique used to evaluate relatively late-stage atherosclerosis, has been shown to predict the risk of subsequent clinical coronary events. B-mode ultrasonography of the intima-medic wall thickness (IMT) of the carotid artery can assess the earlier stages of atherosclerosis and correlates with atherosclerosis risk factors, as well as with clinical cardiovascular and cerebrovascular outcome. This technique offers a relatively rapid and cost-effective method to test therapies for CVD and to screen for individuals who are at high risk for cardiovascular events. As an example of the use of atherosclerosis imaging to evaluate possible therapeutic interventions, measurements of IMT were performed in a randomized, controlled trial comparing oral 17beta-estradiol with placebo. The results demonstrated that 17beta-estradiol significantly reduces the progression of subclinical atherosclerosis in healthy, postmenopausal women when compared with placebo. (C) 2002 by Excerpta Medica, Inc.
Article
OBJECTIVE: To use nationally representative data to produce prevalence estimates of combination estrogen-progestin therapy and estrogen-only therapy by covariates, and to evaluate differences between current use of short duration (less than 5 years) and current long-term use. METHODS: We analyzed data from female respondents 40 years of age and older (n = 9400) who were interviewed in the 1999 National Health Interview Survey. Hormone therapy use was categorized into four types: current estrogen-progestin therapy use, current estrogen-only therapy use, former hormone therapy use, and never use. We calculated the prevalence of hormone therapy by different levels of previously identified covariates of hormone therapy, as well as overall prevalence of hormone therapy use by length of use. RESULTS: Approximately 24% of women aged 40 years or older were current hormone users. Of these, 30% were taking estrogen-progestin therapy, and 70% were taking estrogen-only therapy. The prevalence of hormone use differed dramatically by hysterectomy status and age, and less so by many demographic, health-risk behavior, medical access, and medical history variables. Among women with no hysterectomy, the associations with many of the covariates were stronger for estrogen-progestin therapy use than for estrogen-only therapy use. Only 3% of women were estimated to be current estrogen-progestin therapy users for 5 or more years, whereas 10% were current estrogen-only therapy users for 5 or more years. CONCLUSION: Although many women at midlife and older were current hormone users, very few were long-term users of estrogen-progestin therapy.
Article
This report presents final 2001 data on U.S. deaths and death rates according to demographic and medical characteristics such as age, sex, Hispanic origin, race, marital status, educational attainment, injury at work, State of residence, and cause of death. Trends and patterns in general mortality, life expectancy, and infant and maternal mortality are also described. A previous report presented preliminary mortality data for 2001. In 2001 a total of 2,416,425 deaths were reported in the United States. This report presents descriptive tabulations of information reported on the death certificates. Funeral directors, attending physicians, medical examiners, and coroners complete death certificates. Original records are filed in the State registration offices. Statistical information is compiled into a national database through the Vital Statistics Cooperative Program of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. Causes of death are processed in accordance with the International Classification of Diseases Tenth Revision (ICD-10). The age-adjusted death rate for the United States in 2001 was 854.5 deaths per 100,000 standard population, representing a decrease of 1.7 percent from the 2000 rate and a record low historical figure. Life expectancy at birth rose by 0.2 years to a record high of 77.2 years. Considering all deaths, age-specific death rates rose only for those 25-44 years, and declined for a number of age groups including those under 1 year, 5-14 years, 55-64 years, 65-74 years, 75-84 years, and 85 years and over. The 15 leading causes of death in 2001 remained the same as in 2000. Heart disease and cancer continued to be the leading and second leading causes of death, together accounting for over half of all deaths. Homicide became the 13th leading cause in 2001, rising from the 14th leading cause in 2000 as a result of the September 11, 2001, terrorist attacks. The infant mortality rate remained at a record low level, declining slightly but insignificantly from 6.9 in 2000 to 6.8 in 2001. Generally, mortality patterns in 2001 were consistent with long-term trends. Life expectancy in 2001 increased again to a new record level. The age-adjusted death rate declined to a record low historical figure. Although statistically unchanged from 2000, the trend in infant mortality has shown a steady, although slowing, decline. The declining trend in the homicide death rate was reversed primarily as a result of the September 11, 2001, terrorist attacks.
Article
Risk of breast cancer was assessed in relationship to gynecologic operations using data from a record-linkage study involving 15,844 women in the Uppsala Health Care Region of Sweden, who underwent surgery between 1965 and 1983. Data abstracted from medical records for the breast cancer cases and a random sample of the cohort allowed examination of risk associated with these operations in regard to menopausal status and indications for the operations. Among women who were pre-menopausal at the time of operation, a bilateral oophorectomy before the age of 50 years was associated with a 50% reduction in the risk of breast cancer compared with the background population, a reduction in risk evident within 10 years of the operation. A bilateral oophorectomy after the age of 50 years in pre-menopausal women or after a natural menopause was not associated with any reduction in risk. There were no reductions in risk associated with a unilateral oophorectomy or hysterectomy among women who were pre-menopausal at the time of operation. In fact, hysterectomy alone was associated with a slight increase in breast cancer risk when the operation was due to myomas, abnormal bleeding, and, possibly, severe forms of endometriosis but not to other reasons. Risk did not vary substantially by indications for oophorectomy, including benign ovarian neoplasms and functional ovarian cysts, though endometriosis was associated with a non-significant increase in breast cancer risk. Int. J. Cancer, 70:150–154, 1997. © 1997 Wiley-Liss, Inc.
Article
Elderly women with the lowest serum estrogen levels are at the greatest risk of bone loss and fractures, but it is controversial whether the ovaries contribute to estrogen production after menopause, and therefore, whether bilateral oophorectomy in postmenopausal women might have adverse skeletal effects. To address this potential problem, we estimated long-term fracture risk among 340 postmenopausal Olmsted County, MN, women who underwent bilateral oophorectomy for a benign ovarian condition in 1950-1987. In over 5632 person-years of follow-up (median, 16 years per subject), 194 women experienced 516 fractures (72% from moderate trauma). Compared with expected rates, there was a significant increase in the risk of any osteoporotic fracture (moderate trauma fractures of the hip, spine, or distal forearm; standardized incidence ratio [SIR], 1.54; 95% CI, 1.29-1.82) but almost as large an increase in fractures at other sites (SIR, 1.35; 95% CI, 1.13-1.59). In multivariate analyses, the independent predictors of overall fracture risk were age, anticonvulsant or anticoagulant use for ≥6 months, and a history of alcoholism or prior osteoporotic fracture; obesity was protective. Estrogen replacement therapy was associated with a 10% reduction in overall fracture risk (hazard ratio [HR], 0.90; 95% CI, 0.64-1.28) and a 20% reduction in osteoporotic fractures (HR, 0.80; 95% CI, 0.52-1.23), but neither was statistically significant. The increase in fracture risk among women who underwent bilateral oophorectomy after natural menopause is consistent with the hypothesis that androgens produced by the postmenopausal ovary are important for endogenous estrogen production that protects against fractures.
Article
The origin of plasma sex hormones in postmenopausal women was studied by determining plasma levels under basal conditions, after ACTH stimulation, and after dexamethasone suppression, as well as after hCG stimulation. Values obtained in postmenopausal women were compared with values observed during the follicular phase of the cycle in young women on the one hand, and with values in ovariectomized women of postmenopausal age on the other hand. All sex steroid levels studied with the exception of estrone, were significantly lower in postmenopausal women than in young women during the early follicular phase of the cycle. In ovariectomized women only androgen levels (testosterone, androstenedione, dihydrotestosterone, and to a lesser extent dehydroepiandrosterone,) were lower than in normal postmenopausal women, estrogen, 17 hydroxyprogesterone, and progesterone levels being similar. ACTH increased all plasma steroid levels except estradiol, whereas after dexamethasone, all sex hormone levels were significantly decreased. hCG stimulation finally caused an increase of borderline statistical significance in testosterone, dehydroepiandrosterone, and 17-hydroxyprogesterone levels. We have concluded from this study that the adrenal cortex is almost the exclusive source of plasma estradiol, estrone, progesterone, and 17OH progesterone and the most important source of plasma dehydroepiandrosterone; that the postmenopausal ovary appears to be responsible for about 50% of plasma testosterone and 30% of androstenedione levels; and that hCG stimulation with 5000 IU daily for 3 days, hardly influences steroid secretion by postmenopausal ovaries.
Article
The relation of reproductive factors to risk of myocardial infarction in women aged 45-69 years was examined in a case-control interview study carried out in Massachusetts from 1986 to 1990. Each of 858 cases of first myocardial infarction was age-matched with a control from the same precinct of residence. Conditional logistic regression was used to control the matching factors and the major known and suspected risk factors for coronary heart disease. For parous women compared with nulliparous women, the estimated relative risk of myocardial infarction was 1.8 (95% confidence interval (CI) 1.0-3.3). Among parous women, the relative risk estimate for five or more births relative to fewer births was 1.4 (95% CI 1.0-2.0); the estimate for a first birth before age 20 relative to a later age at first birth was 1.7 (95% CI 1.1-2.6). The greatest increase in risk was observed for women who had both an early age at first birth and five or more children. However, confounding by factors related to socioeconomic status may have contributed to the results. Compared with women who had a natural menopause at age 50 or older, women who reached the menopause before age 45 were at increased risk regardless of type of menopause: The estimated relative risks were 2.1 (95% CI 1.3-3.2), 1.7 (95% CI 1.0-2.7), and 1.7 (95% CI 1.0-2.8) for early natural menopause, bilateral oophorectomy, and hysterectomy with retention of one or both ovaries, respectively. These results suggest that early cessation of ovulatory function, whether due to natural causes or to surgery, increases the risk of myocardial infarction. Age at menarche was not related to myocardial infarction risk.
Article
Data collected from 2,197 white ovarian cancer patients and 8,893 white controls in 12 US case-control studies conducted in the period 1956-1986 were used to evaluate the relation of invasive epithelial ovarian cancer to reproductive and menstrual characteristics, exogenous estrogen use, and prior pelvic surgeries. Clear trends of decreasing risk were evident with increasing number of pregnancies (regardless of outcome) and increasing duration of breast feeding and oral contraceptive use. Ovarian dysfunction leading to both infertility and malignancy is an unlikely explanation for these trends for several reasons: 1) The trends were evident even among the highly parous; 2) risk among nulliparous women did not vary by marital status or gravidity; and 3) risk among ever-married women showed little relation to length of longest pregnancy attempt or history of clinically diagnosed infertility. Risk was increased among women who had used fertility drugs and among women with long total duration of premenopausal sexual activity without birth control; these associations were particularly strong among the nulligravid. No consistent trends in risk were seen with age at menarche, age at menopause, or duration of estrogen replacement therapy. A history of tubal ligation or of hysterectomy with ovarian conservation was associated with reduced ovarian cancer risk. These observations suggest that pregnancy, breast feeding, and oral contraceptive use induce biological changes that protect against ovarian malignancy, that, at most, a small fraction of the excess ovarian cancer risk among nulliparous women is due to infertility, and that any increased risk associated with infertility may be due to the use of fertility drugs.
Article
Several hypotheses predict that tubal sterilization and hysterectomy may influence a woman's risk of developing ovarian cancer. To examine the relation between these surgeries and epithelial ovarian cancer, the authors analyzed data from the Cancer and Steroid Hormone Study, a case-control study of women aged 20-54 years. Eight population-based cancer registries in the United States identified women with newly diagnosed epithelial ovarian cancer during 1980-1982 (n = 494). A comparison sample of female residents of these eight areas (n = 4,238) was identified through random digit dialing. Women who had had tubal sterilization (relative risk (RR) = 0.69, 95% confidence interval (Cl) 0.50-0.95), a hysterectomy only (RR = 0.55, 95% Cl 0.38-0.81), or a hysterectomy with unilateral oophorectomy (RR = 0.60, 95% Cl 0.31-1.17) had lower risks of ovarian cancer than did women who had never had any sterilization surgery. However, the negative associations with tubal sterilization and hysterectomy only appeared to wane after two decades. These findings may be partly explained by the screening for occult ovarian pathology that often accompanies pelvic surgery: Women whose ovaries screen as "negative" may be temporarily at low risk of being diagnosed with ovarian cancer. However, because the decreased risks persisted for so long, it is conceivable that hormonal, mechanical, or circulatory sequelae of these sterilization procedures may act to lower ovarian cancer risk.
Article
Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of Miami/Jackson Memorial Medical Center. Ninety-five of them (12.6%) had previously undergone hysterectomy with preservation of one or both ovaries. Sixty women (7.9%) had undergone hysterectomies after the age of 40. Review of the literature reveals a 4.5-14.1% incidence of prior hysterectomy in women developing ovarian cancer. Prophylactic oophorectomy in women undergoing hysterectomy at age 40 or older would have prevented 138 of 2632 cases (5.2%) of ovarian cancer in a combined literature series. Applied nationally, such an approach could be expected to prevent over 1000 cases of ovarian cancer annually. We recommend routine prophylactic oophorectomy in all women undergoing hysterectomy after the age of 40. This strategy would have prevented 60 cases of ovarian cancer treated at the University of Miami during the past 14 years.
Article
A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporotic fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed.
Article
Vaginal exposures to talc and other particulates may play an etiologic role in epithelial ovarian cancer. Surgical sterilization may protect against ovarian cancer by blocking entry of such particulates into the peritoneal cavity. The authors assessed histories of talcum powder use, tubal sterilization, and hysterectomy with ovarian conservation in 188 women in the San Francisco Bay Area with epithelial ovarian cancers diagnosed in 1983-1985 and in 539 control women. To investigate the roles of blood-borne environmental exposures on ovarian cancer risk, they assessed lifetime consumption of coffee, tobacco, and alcohol in these women. Of the 539 controls, 280 were hospitalized women without overt cancer, and 259 were chosen from the general population by random digit telephone dialing. Ninety-seven (52%) of the cancer patients habitually used talcum powder on the perineum, compared with 247 (46%) of the controls. Adjusted for parity, the relative risk (RR) = 1.40, p = 0.06. There were no statistically significant trends with increasing frequency or duration of talc use, and patients did not differ from controls in use of talc on sanitary pads and/or contraceptive diaphragms. Fewer ovarian cancer patients (7%) than controls (13%) reported prior fallopian tube ligation (RR, adjusted for parity, = 0.56, p = 0.06), and fewer patients (20%) than controls (28%) reported prior hysterectomy (RR = 0.66, p = 0.05). The protective effect of hysterectomy was confined to those who underwent this surgery 10 or more years prior to interview and to those who had not undergone prior tubal sterilization. Consumption of cigarettes and alcohol did not differ between cases and controls. By contrast, 11 (6%) cases never regularly consumed coffee, compared with 31 (11%) hospital controls and 26 (10%) population controls (RR, adjusted for smoking, = 2.2, p = 0.03, for the comparison using all controls). Overall, ovarian cancer risk among women who had drunk coffee for more than 40 years was 3.4 times that of women who had never regularly consumed coffee (p less than 0.01). However, the data exhibited no clear trends in risk with increasing consumption. Although risk ratios relating duration of coffee drinking to ovarian cancer were unaffected by adjustment for several characteristics, further study is needed to exclude potential confounding by other unmeasured characteristics.
Article
To determine the relation of menopause to the risk of coronary heart disease, we analyzed data on a prospective cohort of 121,700 U.S. women 30 to 55 years old who were followed from 1976 to 1982. Information on menopausal status, the type of menopause, and other risk factors was obtained in 1976 and updated every two years by mailing questionnaires. Through 1982, the follow-up rate was 98.3 percent for mortality and 95.4 percent for nonfatal events. After we controlled for age and cigarette smoking, women who had had a natural menopause and who had never taken replacement estrogen had no appreciable increase in the risk of coronary heart disease, as compared with premenopausal women (adjusted rate ratio, 1.2; 95 percent confidence limits, 0.8 and 1.8). Again compared with premenopausal women, the occurrence of a natural menopause together with the use of estrogens did not affect the risk (rate ratio, 0.8, 95 percent confidence limits, 0.4 and 1.3). Women who had undergone bilateral oophorectomy and who had never taken estrogens after menopause had an increased risk (rate ratio, 2.2; 95 percent confidence limits, 1.2 and 4.2). However, the use of estrogens in the postmenopausal period appeared to eliminate this increased risk among these women as compared with premenopausal women (rate ratio, 0.9; 95 percent confidence limits, 0.6 and 1.6). These data suggest that, in contrast to a natural menopause, bilateral oophorectomy increases the risk of coronary heart disease. This increase appears to be prevented by estrogen-replacement therapy.
Article
The concentrations of testosterone, androstenedione, 17 β estradiol, and estrone were measured in peripheral and ovarian vein sera obtained at the time of surgery from 10 postmenopausal women undergoing bilateral oophorectomy. A higher ovarian than peripheral vein concentration was found for all hormones studied. The differences between ovarian and peripheral vein concentrations were 15 fold for testosterone (3033 ± 1046 pg/ml versus 198 ± 27 pg/ml, p<0.01); 4-fold for androstenedione (3455 ± 1330 pg/ml versus 754 ± 174 pg/ml, NS) and 2 fold for both 17 β estradiol (31.1 ± 6.3 pg/ml versus 14.6 ± 2.9 pg/ml, p<0.05); and estrone (71.5 ± 13.3 pg/ml versus 30.3 ± 3.4 pg/ml, p<0.05). It is concluded that the postmenopausal ovary continues to secrete a large amount of testosterone and a moderate amount of androstenedione. The small magnitude of the peripheral and ovarian vein estrogen differences could account for only minimal ovarian estrogen secretion.
Article
We evaluated the relation between age at menopause and the risk of nonfatal myocardial infarction (MI) among 121,964 nurses who responded to a mail questionnaire. Of 279 women who reported having been hospitalized for MI, 123 (44%) were postmenopausal (i.e., no longer menstruating) at the time of hospitalization, compared with 1,859 (33%) of 5,580 age-matched control subjects. Among women who became menopausal because of bilateral oophorectomy, the estimated relative risk of MI increased with decreasing age at menopause, and women who underwent bilateral oophorectomy before age 35 were estimated to have a risk of hospitalization for MI approximately 7.2 times (95% confidence interval, 4.5 to 11.4) that of premenopausal women. Hysterectomy without the removal of both ovaries was only weakly associated with an increased risk. The data support the hypothesis that premature cessation of ovarian function increases the risk of nonfatal MI.
Article
The endocrine activity of the postmenopausal ovary and the effect of pituitary down-regulation were studied in a group of 35 postmenopausal women. All women underwent oophorectomy with or without hysterectomy. Fifteen women received a single dose of a depot GnRH agonist (GnRHa) 2 weeks before operation, whereas 20 women formed the control group. Peripheral venous levels of LH, FSH, estrone, 17 beta-estradiol, testosterone (T), androstenedione (A), sex hormone-binding globulin, and dehydroepiandrosterone sulfate were measured 2 weeks before, during, and 6 weeks after surgery. Ovarian venous blood was sampled during surgery. In the GnRHa and control groups, ovarian venous levels of A and T were significantly higher, and those of dehydroepiandrosterone sulfate and sex hormone-binding globulin significantly lower, compared to the peripheral levels. A significant decrease in T was found in the peripheral and ovarian vein samples during pituitary down-regulation with GnRHa. Six weeks after operation, peripheral T levels were significantly lower than those during surgery in the group that was down-regulated at the time of oophorectomy. We conclude that the postmenopausal ovary produces significant amounts of A and T, although only T contributes significantly to its peripheral serum levels. T production by the postmenopausal ovary is in part stimulated by the high levels of circulating gonadotropins, although pituitary down-regulation does not completely abolish androgenic activity.
Article
The objective of this study was to determine the ability to predict benign adnexal masses in postmenopausal women and to evaluate the effectiveness of laparoscopic management in selected patients. Postmenopausal women found to have an adnexal mass were prospectively evaluated with clinical examination, sonography, and serum CA-125 levels. Women with cystic masses greater than 3 cm but less than 10 cm, with distinct borders, without solid parts or septations greater than 2 mm, without ascites or matted bowel, and with serum CA-125 levels less than 35 IU per mL were operated upon by laparoscopy. Sixty-one women gave consent for the study. Cyst size ranged from 3 to 10 cm. All masses were accurately predicted to be benign. Fifty-eight (95 percent) women were successfully managed by operative laparoscopy and three required laparotomy. For the patients managed by laparoscopy, the mean operative time was 63 minutes, the mean postoperative hospitalization period was 12 hours, and the mean return to normal activity was 5.6 days. The combination of clinical examination, sonographic appearance and serum CA-125 levels can accurately predict benign masses in postmenopausal women. Operative laparoscopy is acceptable for these patients and provides for a short period of hospitalization and a rapid recovery.
Article
To assess whether tubal ligation and hysterectomy affect subsequent risk of ovarian cancer. Prospective cohort study with 12 years of follow-up. United States, multistate. A total of 121,700 female registered nurses who were 30 to 55 years of age in 1976; the follow-up rate was 90% as of 1988. Ovarian cancer of epithelial origin confirmed by medical record review. We observed a strong inverse association between tubal ligation and ovarian cancer, which persisted after adjustment for age, oral contraceptive use, parity, and other ovarian cancer risk factors (multivariate relative risk [RR], 0.33; 95% confidence interval [CI], 0.16 to 0.64). The association was similar when we assessed tubal ligation status at the baseline questionnaire and excluded cases in the first 4 years to eliminate any possible short-term decrease in risk due to screening of the ovaries during ligation surgery. We noted a weaker inverse association between simple hysterectomy and ovarian cancer (RR, 0.67; 95% CI, 0.45 to 1.00). Neither vasectomy nor condom use by a partner was associated with risk of ovarian cancer. These data indicate that tubal ligation, and perhaps hysterectomy, may substantially reduce risk of epithelial ovarian cancer.
Article
To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). Consecutive prospective study with 12 month follow ups. Two British trauma receiving centres. 1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.
Article
Findings from basic neuroscience have provided information on the effects of estrogen on brain morphology and chemistry that explain how this sex steroid may influence brain function. The clinical literature shows that estrogen enhances mood and specific aspects of cognitive functioning in postmenopausal women. There is also evidence that estrogenic effects on various psychological functions are dissociable and specific. Although several recent epidemiologic case-control studies have suggested a protective effect of estrogen against Alzheimer disease, these findings need to be verified by prospective, controlled investigations.
Article
Although an association of occurrence of menopause and subsequent oestrogen deficiency with increased cardiovascular disease has been postulated, studies on this association have not shown convincing results. We investigated whether age at menopause is associated with cardiovascular mortality risk. We studied a cohort of 12115 postmenopausal women living in Utrecht, Netherlands, aged 50-65 years at enrolment in a breast cancer screening project. During follow-up of up to 20 years the women attended screening rounds at which we asked questions on menopausal status, age of menopause, medication use, cardiovascular risk factors, and ovarian function. Deaths were ascertained from the patient's family physicians. Life-table analysis and Cox regression analysis were used to investigate the association between aga at menopause and cardiovascular mortality. All analyses were adjusted for biological age. 824 women died of cardiovascular causes. 1459 women had left the study area. The risk of cardiovascular mortality was higher for women with early menopauses than for those with late menopauses. The age-adjusted hazard ratio of age at menopause was 0.982 (95% CI 0-968-0-996, p=0.01)_ie, for each year's delay in the menopause the cardiovascular mortality risk decreased by 2%. The extra risk of early menopause seemed to decrease with biological age (p for interaction 0.07); at biological age 60 the reduction of the annual hazard was 3%, but at age 80 there was no reduction. Adjustment for known cardiovascular risk factors and indicators of ovarian function did not significantly alter the risk estimate. These results support the hypothesis that longer exposure to endogenous oestrogens protects against cardiovascular diseases. The effect of an early menopause may be more important at younger biological ages.
Article
This study investigated three aspects of general nutritional status (dietary intake, biochemical markers, and anthropometric measurements) in relation to subsequent hip fracture risk by using prospective data from the First National Health and Nutrition Examination Survey (NHANES I) epidemiologic follow-up studies. A cohort of 2,513 white women 45 years and over who participated in the NHANES I survey in 1971-1975 were subsequently followed in the three follow-up studies in 1982-1984, 1986, and 1987, respectively. Multiple nutritional variables were measured at baseline, and 130 incident hip fractures were identified by hospital records or by death certificates during the follow-up period. Cox regression analyses showed that baseline dietary energy intake; serum albumin; and weight, body mass index, skinfold, and arm muscle area were significantly and inversely related to subsequent hip fracture risk (relative risks for a 1-standard deviation increment in these variables ranged from 0.68 to 0.83). The authors suggest that poor nutritional status, evident in inadequate dietary intake, reduced serum albumin, and decreased body mass and soft tissues, increases the risk for subsequent hip fracture. The study also showed that age and previous fracture history were significant risk factors; however, self-reported physical activity, parity, and alcohol use were not significantly related to subsequent hip fracture.
Article
To address the controversy of ovarian preservation during a hysterectomy for benign indications by using our experience with residual ovary syndrome (ROS). Over a period of 20 years, 2561 hysterectomies (during which one or both ovaries were preserved) were performed at the Golda Medical Center, Israel. A retrospective, quasi, case-control analysis was undertaken. The incidence of ROS was 2.85%. While chronic pelvic pain was the principle indication for subsequent reexploration in 52 patients (71.3%), an asymptomatic pelvic mass noted during routine follow-up examination accounted for 24.6% of operations for ROS. The majority (75.4%) of patients underwent surgery during the first 10 years, while the highest incidence occurred within the first 5 years (46.6%). Furthermore, histological examination revealed functional cysts, benign neoplasm and ovarian carcinoma in 50.7%, 42.6% and 12.3% of the cases, respectively (in nine patients more than one pathology was observed). Since ROS was found to occur in 1/35 women who had undergone previous hysterectomies mainly due to physiologic ovarian function and benign cyst formation, but not malignancy, we believe that routine oophorectomy is justified in premenopausal women over 45 years of age. However, the final decision to perform elective oophorectomy at the time of hysterectomy for benign disease should be established on an individual basis, taking into consideration age, individual and family risk factors, the patient's preference and ability to ensure long-term compliance to exogenous hormone replacement therapy.
Article
To test the effects of declining ovarian hormone levels on cardiovascular risk factors, blood pressure, lipids, weight, and physiological responses to stress were evaluated in 29 middle-aged premenopausal women prior to and following elective hysterectomy and/or bilateral salpingo oophorectomy (BSO). Prior to surgery, there were no group differences in standard or putative risk factors, with the exceptions of body composition measures and total cholesterol level. After surgery, women who had undergone BSO (n = 10) had higher levels of atherogenic lipids and stress-induced lipids and tended to have higher circulating levels of epinephrine and stress-induced systolic and diastolic blood pressure than women who had undergone hysterectomy only (n = 19). This study is consistent with the hypothesis that presence of ovarian hormones plays a key role in determining women's risk factor status.