Prophylactic Hysterectomy with Bilateral Salpingo-Oophorectomy Is Not a Primary Prevention Strategy for Endometriosis
Prophylactic hysterectomy with bilateral salpingo-oophorectomy is not recommended as a primary prevention strategy for endometriosis in the general population. Rather, it is only considered as a treatment option for existing endometriosis or as a preventive measure in specific high-risk populations.
Current Evidence on Surgical Management of Endometriosis
- Hysterectomy with bilateral salpingo-oophorectomy (BSO) is considered a definitive treatment for existing endometriosis, not a primary prevention strategy for those without the disease 1, 2
- While hysterectomy with BSO may be one of the only procedures that can potentially cure endometriosis, it is recommended as a treatment after diagnosis, not as prophylactic prevention 1
- Even after complete surgical removal through hysterectomy with BSO, recurrence of endometriosis can still occur in approximately 3.5% of patients who receive hormone replacement therapy 3
Specific Populations Where Prophylactic Surgery May Be Considered
- Prophylactic surgery (hysterectomy and bilateral salpingo-oophorectomy) is recommended to be discussed at age 40 as an option for Lynch syndrome mutation carriers to prevent endometrial and ovarian cancer, not specifically for endometriosis prevention 4, 5
- For women with Lynch syndrome, annual screening beginning at age 35 is recommended due to high risk of endometrial cancer, with prophylactic surgery considered after completion of childbearing 4
Limitations of Surgery as Prevention
- A recent study of patients who underwent hysterectomy for endometriosis showed that those with BSO had lower reoperation rates compared to those with ovarian conservation, but there was little difference in pain-related outcomes between groups 6
- Persistent endometriosis after total hysterectomy with BSO, while rare, has been documented in medical literature 7
- Approximately 40% of patients who undergo hysterectomy with BSO for endometriosis do not fill hormone replacement therapy prescriptions, which may have significant health consequences due to premature surgical menopause 6
Current Recommendations for Endometriosis Management
- Medical therapies that interrupt normal cyclic ovarian hormone production (danazol, progestational agents, oral contraceptives, GnRH analogs) are the first-line treatments for endometriosis-associated pain 2
- Conservative surgery that maintains reproductive organs is an effective treatment for endometriosis-associated pain in those wishing to preserve fertility 2
- Hysterectomy with BSO remains a treatment option for endometriosis-associated pain in patients who have completed childbearing, not as a preventive measure 2
Important Considerations for Surgical Decision-Making
- Strong consideration should be given to ovarian conservation at the time of hysterectomy for endometriosis, as ovarian status may not significantly impact pain outcomes 6
- For young patients who wish to maintain fertility and have early-stage disease, a unilateral salpingo-oophorectomy (preserving the uterus and contralateral ovary) may be adequate 4
- After completion of childbearing in patients with atypical hyperplasia/endometrial intraepithelial neoplasia, hysterectomy and salpingo-oophorectomy is recommended, but this is for management of existing disease, not primary prevention 4, 5
In conclusion, while hysterectomy with BSO may be an effective treatment for existing endometriosis, current evidence and guidelines do not support its use as a primary prevention strategy for endometriosis in the general population.