Family CVD history and decision-making about BSO

Some women proactively choose bilateral salpingo-oophorectomy (BSO) to minimize cancer risk, but new research from Menopause indicates that in women with a family history of premature myocardial infarction, the procedure may increase their risk of premature death because of cardiovascular disease (CVD).  

Methods
The study used data from the National Health and Nutrition Examination Survey (NHANES), an ongoing stratified, multistage, probability survey conducted in the noninstitutionalized US population. NHANES consists of an interviewer-administered questionnaire, physical examination, and specimen collection. 

The authors analyzed data from 2,763 postmenopausal women aged 40 years or older who participated in the survey between 1988 and 1994. They were followed through December 31, 2015. For this study, women with BSO were considered to be postmenopausal, while women without BSO were classified as postmenopausal if they reported having no menstrual period over the past 12 months. The authors also applied Cox regression to identify mortality outcomes.

The average age of participants at baseline was 62 (standard error: 0.19) years. Of the 2,763 participants, 610 had BSO (24%) and 338 with FHPMI (15%). Ninety-five women reported having both BSO and FHPMI (5%). 

Findings
Compared to women without BSO or FHPMI, women with FHPMI but not BSO had a higher prevalence of central obesity (71.8% vs 55.5%), were current smokers (28.0% vs 17.5%, were ever users of birth control pills (48.2% vs 30%) and had higher levels of glycohemoglobin. A higher proportion of women with BSO without FHPMI were African American (10.7% vs 6.6%) and centrally obese (64.9% vs 53.0%). Women with both BSO and FHPMI were younger, reached menarche, and underwent BSO at earlier ages. They also had a higher prevalence of nulliparity, hypertension, diabetes (and family history of diabetes), and higher white blood cells count and total cholesterol levels than women with BSO without FHPMI.

During median follow-up of 22 years, there were 1,713 deaths, 395 of which were attributed to HD and and 542 to CVD. Cumulative incidence of HD, CVD, and all-cause mortality was significantly highest among women with FHPI and BSO. Overall, FHPMI was positively associated with HD (HR 1.46; 95% CI 1.07 – 1.98) and all-cause mortality (HR 1.45, 95% CI 1.28 – 1.65). The association of FHPMI with CVD mortality (1.18; 95% CI 0.90 – 1.55) did not approach statistical significance.

In models that adjusted for CVD risk factors and hormone therapy use, HD mortality was greater among women with both BSO and FHPMI compared to those without either of the conditions (2.88, 95% CI 1.72 – 4.82, P_Interaction = 0.016). HD mortality was higher among women with FHPMI and BSO at an earlier age (< 45 years, HR 4.32, 95% CI 1.95 – 9.50 vs ≥ 45 years, HR 1.60, 95% CI 0.63 – 4.09). The authors noted similar associations for CVD and all-cause mortality. 

Conclusions
Based on these findings, the researchers believe that risk of HD, CVD, and all-cause mortality in women with BSO was modified by an FHPMI, with risk limited to women undergoing BSO at younger ages. Although the American College of Obstetricians and Gynecologists (ACOG) strongly recommends that retention of normal ovaries be considered in premenopausal women, results of the current study also suggest factoring in FHPMI into decision-making about prophylactic oophorectomy in young patients.