What are the indications and considerations for a salpingo-oophorectomy?

Indications and Considerations for Salpingo-Oophorectomy

Salpingo-oophorectomy is strongly indicated for ovarian cancer treatment, risk reduction in BRCA mutation carriers, and management of certain benign conditions, with the specific approach determined by the patient's age, cancer risk, and fertility desires.

Therapeutic Indications

Malignant Conditions

• Ovarian Cancer Treatment

  • Complete surgical resection including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, systematic pelvic and para-aortic lymph node dissection, peritoneal biopsies and cytological analysis is the standard surgical procedure for ovarian cancer 1
  • For high-grade endometrioid carcinoma, clear cell carcinoma, and high-risk mucinous ovarian carcinoma, complete surgical resection with bilateral salpingo-oophorectomy is recommended 1

• Endometrial Cancer

  • Total hysterectomy with bilateral salpingo-oophorectomy is the standard treatment for endometrial cancer 1
  • In premenopausal women with stage I endometrial cancer, ovarian preservation can be considered if there is <50% myometrial invasion, no obvious extra-uterine disease, and no family history of ovarian cancer risk 1

Risk-Reducing Surgery

• BRCA1/2 Mutation Carriers

  • Risk-reducing bilateral salpingo-oophorectomy (RRBSO) is the gold standard for prevention of ovarian cancer with 80-96% risk reduction in BRCA1/2 mutation carriers 1
  • Recommended timing:
    • BRCA1 carriers: between ages 35-40 years
    • BRCA2 carriers: between ages 40-45 years
    • RAD51C or RAD51D carriers: between ages 40-50 years
    • BRIP1 or PALB2 carriers: between ages 45-50 years 1
  • RRBSO does not eliminate the risk of primary peritoneal carcinoma (residual risk approximately 4.3% at 20 years after oophorectomy) 2

• Lynch Syndrome

  • Concomitant hysterectomy with RRBSO is justified due to increased risk of endometrial cancer 1
  • Cumulative incidence of endometrial cancer by age 75 varies by gene: 37% in MLH1, 48.9% in MSH2, 41.1% in MSH6, and 12.8% in PMS2 mutation carriers 1

Benign Conditions

• Endometriosis
  • Unilateral salpingo-oophorectomy is cost-effective and preferred over surveillance for management of incidental endometrioma in premenopausal patients not desiring fertility 3
  • This approach prevents 1 diagnosis of ovarian cancer in every 40 patients and averts 1 death in every 82 patients 3

Special Considerations

Fertility Preservation

• Early-Stage Ovarian Cancer

  • Fertility-sparing surgery should be discussed in young patients with early-stage ovarian carcinoma 1
  • Unilateral salpingo-oophorectomy with surgical staging is recommended in young patients with malignancy apparently confined to the ovary who want to preserve fertility 1
  • Appropriate for borderline tumors, non-epithelial tumors, low-grade stage IA (serous, endometrioid, or mucinous expansile subtype) and selected IC1 stages 1

• Teenage Girls with Ovarian Cancer

  • For teenage girls desiring fertility preservation, unilateral salpingo-oophorectomy preserving the uterus and contralateral ovary is recommended 4
  • Comprehensive surgical staging is still required to rule out occult higher-stage disease 4

Surgical Approach

• Minimally Invasive Surgery
  • Minimally invasive surgery avoiding tumor rupture is an acceptable approach for women who wish to preserve fertility 1
  • Not recommended to biopsy the unaffected ovary unless there is suspicion of involvement 1

Impact on Ovarian Function and Quality of Life

• Salpingectomy alone generally does not appear to significantly affect ovarian reserve or function based on serum markers and IVF response 5, 6
• Bilateral salpingo-oophorectomy before natural menopause causes surgical menopause which may:
  • Increase risk of cardiovascular disease, osteoporosis, cognitive impairment
  • Impact quality of life with vasomotor symptoms and changes in sexual functioning 7
  • Hormone replacement therapy may mitigate some but not all symptoms 7

Post-Surgical Management

• Women who undergo fertility-sparing surgery need to be managed in an oncofertility clinic 1
• Cryopreservation of gametes rather than ovarian tissue is recommended for patients wishing to retain fertility 1
• After completion of childbearing, hysterectomy and salpingo-oophorectomy is recommended for patients who underwent fertility-preserving therapy 1

Opportunistic Salpingectomy

• May offer opportunity to decrease risk of ovarian cancer in patients already undergoing pelvic surgery for benign disease 6
• Does not appear to increase risk of complications compared with hysterectomy alone or tubal ligation 6
• Does not significantly affect ovarian function based on surrogate serum markers 6

Salpingo-oophorectomy remains a critical procedure in gynecologic oncology and risk-reduction strategies, with the specific approach determined by the underlying condition, cancer risk profile, and patient's reproductive desires.