Adverse outcomes of hysterectomy with bilateral salpingo-oophorectomy

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A recent meta-analysis reveals associations between hysterectomy combined with bilateral salpingo-oophorectomy and various health risks, urging a nuanced assessment of its benefits and drawbacks.

Adverse outcomes of hysterectomy with bilateral salpingo-oophorectomy | Image Credit: © Jo Panuwat D - © Jo Panuwat D - stock.adobe.com.

Adverse outcomes of hysterectomy with bilateral salpingo-oophorectomy | Image Credit: © Jo Panuwat D - © Jo Panuwat D - stock.adobe.com.

The addition of bilateral salpingo-oophorectomy (BSO) alongside hysterectomy is associated with multiple adverse outcomes, according to a recent study published in the American Journal of Obstetrics & Gynecology.

Takeaways

  1. Over 600,000 women annually undergo hysterectomy for conditions like fibroids, adenomyosis, and endometriosis. Thirty-two percent of UK women who had a hysterectomy between 2004 and 2014 also underwent a concomitant BSO.
  2. While BSO reduces the long-term risk of ovarian cancer, it is linked to various adverse health outcomes, including colorectal cancer, CVD, and increased mortality risk in some age groups.
  3. A systematic review and meta-analysis encompassing 38 studies evaluated the health outcomes of hysterectomy with BSO against those without the surgery. Outcomes covered a range from cancer risks to neuropsychiatric outcomes and bone health.
  4. There was a significant reduction in ovarian cancer risk (HR: 0.11) and breast cancer risk (HR: 0.78) following hysterectomy and BSO, particularly in women under 45 years. However, there was an increased risk of colorectal cancer (HR: 1.27) and kidney cancer (HR: 1.23) associated with the procedure.
  5. Hysterectomy with BSO was associated with heightened risks of CVD (HR: 1.18) and osteoporosis (HR: 1.51). All-cause mortality risk was also increased (HR: 1.22).

Over 600,000 women undergo hysterectomy per year for the management of conditions such as fibroids, adenomyosis, and endometriosis. BSO is commonly performed alongside hysterectomy, with 32% of UK women who received a hysterectomy from 2004 to 2014 also receiving a concomitant BSO.

While BSO decreases long-term risks of ovarian cancer, it is also associated with multiple adverse health outcomes. A systematic review in January 2015 evaluated the health sequelae of BSO, but long-term outcomes were not evaluated.

Investigators conducted a systematic review and meta-analysis to evaluate health outcomes of BSO with hysterectomy and reported associations. The PubMed, Web of Science, and Embase databases were searched for relevant literature published from January 2015 to August 2022.

Studies comparing long-term outcomes of women with a hysterectomy and BSO with those who did not undergo surgery were included. Outcomes evaluated included cancer, neuropsychiatric outcomes, mortality, cardiovascular disease (CVD), CVD risk factors, and bone health. 

Exclusion criteria included hysterectomy with BSO for cancer treatment or gender affirmation surgery, participants with high cervical cancer risk, under 3 years of follow-up, and evaluating short-term outcomes. Abstrackr, a free online abstract screening tool, was used to screen titles and abstracts. 

Extracted data was formatted into an Excel spreadsheet. Evidence quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

There were 38 studies included in the final analysis, 24 of which were retrospective cohort studies, 12 prospective cohort studies, 1 case-control study, and 1 case-cohort study. Most analyses were stratified by age, with sample sizes between 2900 and 5 million. 

CVDs, diabetes mellitus, hypertension, hyperlipidemia, cancer, depression, dementia, carpal tunnel syndrome, restless leg syndrome, parkinsonism, fat and lean body mass changes, bone fracture, all-cause mortality, and cause-specific mortalities were reported in the studies.

A high GRADE rating was reported for evidence evaluating the association of hysterectomy with BSO and breast cancer. Associations with all-cause mortality, coronary heart disease, and all-cancers risk had a moderate GRADE rating, while remaining outcomes had a low or very low rating.

A significant reduction in ovarian cancer risk was reported following hysterectomy and BSO, with a hazard ratio (HR) of 0.11. Breast cancer risk was also decreased by hysterectomy with BSO compared to only hysterectomy or no surgery, with an HR of 0.78. This association was found in women aged under 45 years, but not 50 years or older.

Hysterectomy with BSO was associated with increased colorectal cancer risk compared to hysterectomy only or no surgery. In patients aged under 45 years, an HR of 1.27 was reported, vs an HR of 1.25 in patients aged 50 years and older. 

Colorectal cancer mortality also had an increased association in patients aged under 50 years, with an HR of 1.78.Kidney cancer risk had an HR of 1.23 in patients with hysterectomy and BSO, indicating increased risk. 

CVD risk was also heightened by hysterectomy and BSO, with an HR of 1.18 in patients who underwent surgery when aged under 50 years. However, this association was not observed in patients receiving the surgery when aged 50 years and older.Similar results were observed for CVD mortality and stroke.

An increased risk of osteoporosis after hysterectomy compared to no surgery was observed in 1 study, with an HR of 1.51. No evidence of increased hip fracture risk was reported. However, all-cause mortality risk had an HR of 1.22, indicating increased risk from hysterectomy with BSO.

These results indicated reduced breast and ovarian cancer risk from hysterectomy with BSO, but increased risk factors for adverse outcomes. Investigators concluded the risks and benefits should be carefully balanced.

Reference

Hassan H, Allen I, Sofianopoulou E, et al.Long-term outcomes of hysterectomy with bilateral salpingo-oophorectomy: a systematic review and meta-analysis. Am J Obstet Gynecol. 2024;230(1):44-57. doi:10.1016/j.ajog.2023.06.043

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