Is prophylactic salpingectomy (removal of fallopian tubes) recommended during hysterectomy for a premenopausal woman with a BRCA1 or BRCA2 mutation or strong family history of ovarian or breast cancer?

Prophylactic Salpingectomy During Hysterectomy in BRCA Mutation Carriers

Prophylactic salpingectomy alone (without oophorectomy) is NOT recommended as standard of care during hysterectomy for premenopausal BRCA1/2 mutation carriers—risk-reducing bilateral salpingo-oophorectomy (RRBSO) remains the gold standard for ovarian cancer risk reduction. 1, 2

The Standard of Care: RRBSO, Not Salpingectomy Alone

RRBSO (removal of both fallopian tubes AND ovaries) is the only proven strategy that reduces ovarian cancer risk by 80-90% and all-cause mortality by 77% in BRCA mutation carriers. 1, 2 The evidence supporting this approach is robust and based on prospective observational data demonstrating mortality benefit. 1

Why Salpingectomy Alone Is Insufficient

• Risk-reducing salpingectomy (bilateral salpingectomy alone or with delayed oophorectomy) is not recommended outside clinical trials. 1

• NCCN explicitly states that salpingectomy alone should not be offered as standard risk-reduction strategy for BRCA carriers, as it exposes patients to unacceptable cancer risk without proven efficacy. 1, 2

• Carriers who undergo salpingectomy without oophorectomy lose the breast cancer risk reduction benefit that oophorectomy provides (45% reduction in BRCA1 carriers with premenopausal RRSO). 1, 3

• Multiple ongoing trials (WISP, PROTECTOR, SOROCk, TUBA) are investigating salpingectomy with delayed oophorectomy, but results are not yet available to support widespread implementation. 1

Timing of RRBSO Based on Mutation Type

The timing of RRBSO should be determined by BRCA mutation type and family history:

• BRCA1 carriers: RRBSO at age 35-40 years after childbearing is complete (cumulative ovarian cancer risk is 0.55% by age 35, with mean diagnosis age of 51.3 years). 1, 4

• BRCA2 carriers: RRBSO at age 40-45 years (ovarian cancer onset occurs 8-10 years later than BRCA1, with mean diagnosis age of 61.4 years). 1, 4

• Earlier timing may be warranted if family history shows early-onset ovarian cancer. 1

The Hysterectomy Question

Hysterectomy should not be routinely recommended at the time of RRBSO solely to reduce cancer risk. 1

When to Consider Concurrent Hysterectomy

• If the patient wishes to use estrogen-only HRT (which has decreased breast cancer risk compared to combined estrogen-progesterone therapy required when the uterus remains). 1

• If other indications exist: Lynch syndrome mutations (MLH1, MSH2, MSH6), other endometrial cancer risk factors, or benign uterine pathology. 1

• The absolute risk of serous uterine cancer in BRCA carriers remains low (2-3 fold increased risk primarily in BRCA1), and the magnitude of benefit from hysterectomy may not justify procedural risks. 1

Critical Surgical Considerations

• Minimally invasive laparoscopic approach is preferred to reduce morbidity, hospitalization time, and improve aesthetic outcomes. 1, 2

• Pathologic evaluation must include SEE-FIM protocol (Sectioning and Extensively Examining the FIMbriated End) with fine sectioning of ovaries and fallopian tubes. 1

• Peritoneal washings should be performed at surgery. 1

• Occult cancers are found in 23% of prophylactic surgeries, emphasizing the importance of thorough pathologic examination. 4

Managing Premature Menopause Consequences

HRT is essential after RRBSO in premenopausal women and should be continued until at least age 50-51 years. 2, 5

• Estrogen-only HRT is appropriate after hysterectomy and has a more favorable safety profile than combined therapy. 2, 5

• Failing to prescribe HRT after premenopausal RRBSO significantly increases risks of cardiovascular disease, osteoporosis, cognitive dysfunction, and early mortality. 2, 5

• HRT does not negate the breast cancer risk reduction achieved by oophorectomy. 1

Common Pitfalls to Avoid

• Do not offer salpingectomy alone as definitive risk reduction—this is investigational and should only be performed within clinical trials. 1, 2

• Do not assume older patients (>40) choosing salpingectomy will complete oophorectomy later—research shows 22.7% of BRCA carriers who underwent salpingectomy were not planning future oophorectomy, and those who had salpingectomy after the recommended age were significantly less likely to plan completion (28.6% vs 66.7%). 6

• Do not withhold HRT in premenopausal women after RRBSO unless specific contraindications exist. 2, 5

• Do not perform RRBSO before age 35 in BRCA1 carriers or before 40 in BRCA2 carriers unless family history warrants earlier intervention—premature menopause consequences are severe. 1