UPDATE ON TECHNOLOGY

This hysteroscopic method (Essure, Bayer) avoids the risks of general anesthesia, but successful bilateral placement may not be possible in a small percentage of women. It also requires a 3-month interval between placement and confirmation of tubal occlusion (via HSG). During this interval, alternative contraception must be used. Once occlusion is confirmed, this method is highly reliable.

Option 4: Laparoscopic sterilization

This approach was the method of choice prior to the introduction of Essure in 2002. There now is a resurgence of interest in laparoscopic sterilization due to recent publications describing the distal portion of the fallopian tube as the “true source” of high-grade serous ovarian cancers.

In pathologic analyses of fallopian tubes removed prophylactically from women with a BRCA 1 or 2 mutation, investigators found a significant rate of serous tubal intraepithelial carcinoma.⁸ Researchers began to study the genetics of these cancers and concluded that, in women with a BRCA mutation, high-grade serous carcinomas may arise from the distal fallopian tube.

Until recently, all of the literature on these tubal carcinomas related only to women with a specific tumor suppressor gene p53 mutation in the BRCA system. Other investigators then reviewed pathology specimens from women without a BRCA mutation who had high-grade serous carcinomas that were peritoneal, tubal, or ovarian in origin. They found serous tubal intraepithelial carcinomas in 33% to 59% of these women.⁹

“Research suggests that bilateral salpingectomy during hysterectomy for benign indications or as a sterilization procedure may have benefits, such as preventing tubal disease and cancer, without significant risks,” wrote Gill and Mills.¹⁰ In conducting a survey of US physicians to determine how widespread prophylactic salpingectomy is during benign hysterectomy or sterilization, they found that 54% of respondents performed bilateral salpingectomy during hysterectomy, usually to lower the risk of cancer (75%) and avoid the need for reoperation (49.1%). Of the 45.5% of respondents who did not perform bilateral salpingectomy during hysterectomy, most (69.4%) believed it has no benefit.¹⁰

Although 58% of respondents believed bilateral salpingectomy to be the most effective option for sterilization in women older than 35 years, they reported that they reserve it for women in whom one sterilization procedure has failed or for women who have tubal disease.¹⁰

As for the 45.5% of respondents who did not perform prophylactic salpingectomy, they offered as reasons their concern about increased operative time and the risk of complications, as well as a belief that it has no benefit.¹⁰

The lifetime risk of ovarian cancer in the general population is 1 in 70 women. Although it is possible that high-grade serous ovarian cancers originate in the distal fallopian tube, as the research to date suggests, it also is possible that we might find in-situ lesions in tissues other than the distal tube, suggesting a more global genetic defect underlying ovarian cancers in the peritoneal and müllerian tissues. Randomized trials are under way in an effort to determine whether excision of the fallopian tubes will prevent the majority of high-grade serous cancers. It will be many years, however, before the results of these trials are available.

CASE 2: Resolved

This patient has used combination OCs for more than 10 years, so her lifetime risk of ovarian cancer has been reduced by approximately 50%. Because her family history indicates that a BRCA mutation is highly unlikely, her lifetime risk of ovarian cancer now has declined from 1:70 to roughly 1:140.

Prophylactic salpingectomy might offer a very small reduction in this patient’s absolute risk of ovarian cancer—from 0.75% to 0.50% lifetime risk—but the current data are not robust enough to suggest that it should be recommended for her. The operation would carry the risks associated with general anesthesia and peritoneal access. Although these risks are small, there is a documented risk of death from laparoscopic sterilization procedures in the United States, from complications related to bowel injury, anesthesia, and hemorrhage.

For these reasons, I would counsel this patient that her best options for contraception are combination OCs, transcervical tubal sterilization, or a long-acting reversible contraceptive such as the IUD or implant.

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