OOPHORECTOMY AT THE TIME OF HYSTERECTOMY

What is your opinion of doing bilateral salpingo Oophorectomy at the time of hysterectomy. Coz patients are of the opinion that if they undergo Tubectomy,they will land with a BIGGER operation that is hysterectomy.therefore some people come asking to do a hysterectomy after child bearing. If only hysterectomy is done when indicated and later if they require laparotomy for ovarian cyst /tumour,patients question "why you didn't remove these appendages earlier. One patient had hysterectomy,followed by laparotomy again for an ovarian cyst,later another cyst on other side -third surgery .she again developed cystic mass in the pelvis for which she had fourth surgery . Though we leave ovaries ,their function gradually comes down after hysterectomy and they have PMS and osteoporosis. When I have to do a hysterectomy ,I remove the appendages if she is above 40 years and retain them if she is young. What are your opinions

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Choosing to remove healthy ovaries is often done to reduce the risk of ovarian cancer.however removing the ovaries at the time of hysterectomy should be looked at on a case to case basis.age and menopause to be considered. Endogenous estrogen produced in body is linked to several protection benefits that are lost when ovaries are removed. If women at 40-45 not attained menopause undergoes EO have double the risk of heart attacks and osteoporosis and decrease sexual function. When hyst done for benign condition like fibroid ovary removal not reqd unless diseased. If ovaries are removed before menopause she should bo on HRT. IN my view dr doing surgery is best person to decide knowing her history of breast cancer in family and explaining the risk of removing or preseving ovaries.
Dear Dr.Suverchala and Curofians! Greetings! Let me argue my case of preserving ovaries intact in Hysterectomy . Why do women need ovaries for a lifetime !? I did a research of some sort to come to this conclusion and I strongly believe that you shall also agree with me. My apologies, if I am harsh with my comments. The vast majority of hysterectomies are performed in India are on flimsy benign indications and sometimes very trivial, supposedly with a fond hope to improve quality of life. As the surgical procedure itself is generally associated with few complications, it has become a popular choice of the patients and lucrative(sic) one for the medical profession In india. There are long-term adverse effects of hysterectomy by itself on the pelvic floor, leading to vulval prolapse, urinary incontinence, bowel dysfunction, sexual function and pelvic fistula formation. These sequelae often occuring a long time after the surgical procedure and severely impair quality of life. Retrospective studies have shown that those young women who underwent early hysterectomy have been observed to have early menopause and decreased QOL, much more evident with those women who also had both ovaries removed for some cause. The percentage of women who require reoperation after hysterectomy with ovarian conservation is low, with residual ovary syndrome occurring at a low rate of approximately 2.8%. EvenThough asymptomatic cystic ovarian tumors or cysts are relatively prevalent (6.6%) in postmenopausal women.These cysts do not undergo transformation to cancer, however, and in most cases do not need to be removed. Another study reported that only 0.75% of women developed ovarian cancer after hysterectomy and ovarian conservation performed by the vaginal or abdominal route. Performing oophorectomy to avoid future surgery appears unfounded. Prophylactic surgery should be performed only if there is evidence that it clearly benefits the patient. Recent evidence suggests that there may be long-term health benefits and longer survival for women who choose ovarian conservation at the time of hysterectomy for benign disease. However, bilateral salpingo-oophorectomy is advisable for women who have a high risk of ovarian and breast cancer because of gene mutations. But the decision about oophorectomy for other women is unfounded. Bilateral oophorectomy at the time of hysterectomy for benign disease has been commonly requested by the ignorant patients. Although the lifetime risk of ovarian cancer is 1.4% Nevertheless, the lifetime risk of ovarian cancer among women withBRCA1mutations the risk is 36% to 46%, and for BRCA2mutations the risk is 10% to 27%.. Some educated women with a family history of ovarian cancer may wish to have their ovaries removed because of concerns about the possibility of developing ovarian cancer. Then such a request can be entertained only, after a full discussion with her and family, of her specific risk for ovarian and breast cancers and the risks and benefits of the surgery , Oophorectomy appears to be associated with long-term health risks. It immediately reduces blood levels of ovarian estrogens and androgens. Even after menopause, the ovaries continue to produce significant amounts of testosterone and androstenedione, which undergo peripheral conversion to estrone by skin, muscle, and fat cells. Evidence indicates that endogenous estrogens are beneficial to the cardiovascular system and for long-term health and reduce cognitive impairment or dementia risk by 50%. Bilateral oophorectomy before 50 years of age was associated with increased risks of all-cause mortality, CHD, and stroke. After oophorectomy, women had a markedly reduced risk of ovarian cancer; however, they had higher risks of lung cancer and total cancer mortality . Oophorectomy has been shown to increase the risks of Parkinson disease and anxiety or depression. Estrogens and androgens inhibit bone resorption, and androgens stimulate bone formation.The women who undergo bilateral oophorectomy have an increased risk of osteoporosis because of the reduction in hormone levels. About 90% of surgically induced menopausal women experience mood changes, a decline in feelings of well- being, decreased sexual desire, sleep disturbances, and headaches.Over time, vaginal dryness, painful intercourse, bladder dysfunction, and symptoms of depression may occur, to say in few words, their QOL suffers. Endogenous bioavailable testosterone and estrogen in postmenopausal women are partly protective against the loss of muscle strength that predisposes these women to falls and against the continuing loss of bone mineral density that increases the risk of fractures.Therefore, even in older women, these ovarian hormones may have benefit, So these women need these ovaries for life. If we are worried about the ovarian Cancers then other strategies may be taken to decrease the risk of ovarian cancer, including 1. Taking OCs for 5 or more years decreases the risk of ovarian cancer by 50%,and 2. Tubal ligation decreases the risk by 34%. 3. Hysterectomy alone decreases the risk of ovarian cancer by 33%.
Excellent explanation doctor. Hysterectomy should be the last resort after trying various medical modes of management .But what I observed is the increasing incidence of PID in lower social economic group In the Western countries,the indication for a hysterectomy is multiple fibroids or adenomyosis or endometriosis. In india the common indication for hysterectomy is PID and chronic cervicitis In some conditions , though we advice them not to undergo the surgery ,they get it done elsewhere.Added to this these RMP's motivating and getting hysterectomy done is common.what do to.Even a software Engineer says "He is my family doctor" about an RMP.
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The deliemma over whether to preserve or remove ovaries at the time of hysterectomy has long been debated ... A thorough discussion of the advantages & disadvantages of oophorectomy should be undertaken in premenopausal women who are undergoing hysterectomy for benign diseases ... Benefits of oophorectomy are : 1) decreased risk of ovarian cancer 2) decreased risk of reoperation & 3) Lower risk of mortality from breast cancer when oophorectomy was performing before 45 years.. On the other there are numerous disadvantages of prophylactic oophorectomy: 1) Increased risk of fracture, CHD mortality & colorectal cancer 2)Cognitive impairment 3) Mood swings , irritability & hot flushes 4)Decline in sexual function & Overall there is decrease in QUALITY OF LIFE.. Prophylactic surgery should be performed only if the weight of the evidences establish that it clearly benefits the patients for example in women with germline mutation ( BRCA1 & BRCA2) & with family history of ovarian/ breast cancer ... Current guidelines from ACOG recommends BSO for women known to be at risk for ovarian cancer but ovarian preservation for those without such risks ...
Hi Dr Amit all r discussing about TLH with BSO in Pre menopausal women but is it justifiable in post menopausal women with h/o grandmother died of cervical ca n mother died of stomach ca?
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Mam, TAH,+ BSO can be done.,if age is more than 40yrs. , Because cyst formation is more common if only ovaries are left.some doctors do oophorectomy on one side. ,In these cases ovarian cysts are more common. 3. In cases where hysterectomy is needed in young women, look for the ovaries while doing hysterectomy,whether they are healthy or not. 5.start calcium and photo isoflavones.
Agree with you mam.. Another important question is, how long should calcium and isoflavones be given for, post hysterectomy, in pre and post menopausal women, respectively?? Any priming needed prior to hysterectomy??
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I quite agree with you madam. In fact this question has been bothering me also, for a while. The most difficult moment for me,when I have to take a call is..patient young, hysterectomy indicated, cyst in one of the ovaries and the other ovary apparently normal. My question is, does it make sense to leave the normal looking ovary.. What is a logical option in this case??
Had same type of patient yesterday 33 yrs old pt with adenomyosis with complex ovarian cyst of 6 cm in rt ovary Lt ovary is normal What should be done with lt ovary...should be preserved or removed?
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Mam conservative surgery ...coz...it's the health benifit which would be the first priority...if overy apperas normal rt now...it should be conserved...and patient should be explained about the health benifit of conserving it...
And this is not the same with all cases...it if explained to patient ...it would not b the problem ...thank you mam
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Hi Dr K.S. Gayathri Dinesh ... Yes , in postmenopausal women BSO is justifiable especially if there is some risk factor or positive family history ..
Thanks fr ur valuable feedback Dr Amit .but all talk about ovarian n breast ca as risk factor. Ca CX is it a risk factor
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Dr Suvarchala mam good question fr discussion. thanks
* indication for hysterectomy is main criteria to decide whether to go for or not BSO. * Those having been donefor DUB only atleast one Ovary is to be preserved . * I have seen patient of 26 yrs of age of premature menopause & of 63 yrs of patient with regular cycle without any complain * For Abdo. Hysterectomy no visceral peritonisation should done if Ovary is to be preserved as it comprises vascular supply & later cause cyst. * For TLH, isolated meticulous cautrisation Of ovarian ligament is to be done
Contd..... As combined cautrisation of all of round ligaments, tube& ovarian ligament is avoided as it may hamper vascular supply & leads to ovarian cyst. * But now a days in TLH , if preservation of Ovary is thought , only tubes are also removed which also require more coagulation ultimately compromise blood supply of Ovary. * In case of PID and/or adhesions preferable BSO
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It depends on age of the patient, pathology for which we are removing the uterus and condition of the patient. Yes it's always individualized. But in today's era it's better to discuss about removal or preservation of ovary with patients before surgery. Fallopian tubes are removed always when we remove uterus, though not during vaginal hysterectomy
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