Oophorectomy or salpingectomy—which makes more sense?

Clearly, oophorectomy followed by initiation of estrogen and statins for women younger than 50 is unlikely to be effective.

THE LIKELIHOOD OF FUTURE ADNEXAL SURGERY IS LOW
Only about 6.2% of women who undergo hysterectomy with ovarian conservation require reoperation over the succeeding 20 years. The risk for age-matched women without hysterectomy is 4.8%, so the absolute difference is only 1.4% over 20 years.¹³

Although asymptomatic ovarian cysts are rather prevalent (6.6%) in postmenopausal women, they do not undergo transformation to cancer and usually resolve spontaneously.¹⁴ Therefore, the majority of these cysts do not need to be removed.

The suggestion that oophorectomy can avert the need for future adnexal surgery appears to be unfounded.

OVARIAN CANCER DOES NOT COME FROM THE OVARY
Seventy percent of epithelial ovarian cancers are of the serous high-grade and clinically aggressive type. The ovary contains no epithelial cells.¹⁵ Almost all high-grade cancers are associated with p53 mutations. Cancer precursor lesions called serous tubal intraepithelial cancer (STIC) have been found in the fallopian tubes of both BRCA-positive and BRCA-negative women, but no corresponding precursor lesions have ever been found in the ovary. Moreover, STIC precursor lesions have p53 mutations matching those found in high-grade serous “ovarian” cancers, but no similar p53 mutations have been found in low-grade, more indolent and treatable cancers found inside the ovary (ie, Stage 1). Therefore, the deadly form of ovarian cancer is, in fact, tubal cancer.

THE CASE FOR SALPINGECTOMY
Because convincing evidence points to the tubal origin of ovarian cancer, some experts have proposed salpingectomy for prophylaxis. Salpingectomy should remove the source of aggressive cancers and preserve functioning ovaries. However, some wondered whether salpingectomy would compromise collateral circulation to the ovaries and predispose women to early ovarian failure.

A recent study of 79 women found similar antral follicle counts and mean ovarian diameters (as measured sonographically) and similar serum levels of anti-Müllerian hormone and follicle-stimulating hormone at baseline (prior to salpingectomy) and 3 months following surgery.¹⁶ Therefore, bilateral salpingectomy may be a reasonable choice for women who have completed childbearing and who are considering pelvic surgery. As the Society of Gynecologic Oncologists stated in recent guidelines: “For women at average risk of ovarian cancer, salpingectomy should be discussed and considered prior to abdominal or pelvic surgery, hysterectomy, or in lieu of tubal ligation.”¹⁷

CASE: RESOLVED
After you review the risks and benefits of prophylactic oophorectomy versus prophylactic salpingectomy, the patient chooses the latter option and undergoes a successful surgery.

BOTTOM LINE: IN WOMEN WITH AN AVERAGE RISK OF OVARIAN CANCER, SALPINGECTOMY IS PREFERRED
Reasonable evidence now suggests that oophorectomy is associated with higher risks of CHD, colorectal and lung cancers, and overall mortality. Almost all high-grade serous cancers arise from the fallopian tubes, not the ovaries. Therefore, for women at average risk for ovarian cancer who have completed childbearing, salpingectomy should be considered at the time of pelvic surgery.

After decades of failure to achieve early diagnosis or curative treatment of “ovarian” cancer, we finally may have a way to reduce the incidence of this deadly disease.

TELL US WHAT YOU THINK!
Share your thoughts on this article or on any topic relevant to ObGyns and women’s health practitioners. Tell us which topics you’d like to see covered in future issues, and what challenges you face in daily practice. We will consider publishing your letter and in a future issue.
Send your letter to: obg@frontlinemedcom.com Please include the city and state in which you practice.
Stay in touch! Your feedback is important to us!