Special Feature
Tubal Sterilization: Has the Time Come for Routine Bilateral Salpingectomy?
By Rebecca H. Allen, MD, MPH
Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports no financial relationships relevant to this field of study.
Ovarian cancer causes approximately 14,000 deaths in the United States each year, making it the most common cause of gynecologic cancer death and the fifth leading cause of cancer death in women after lung, breast, colorectal, and pancreatic cancer.1 The lifetime risk of developing ovarian cancer for the average woman in the United States is 1.4%. Unfortunately, there are no effective screening tests for the disease, it is often diagnosed in the late stages, and the survival rates are poor. The recent discovery that epithelial ovarian serous carcinomas, the most common histologic subtype, actually originate in the distal fallopian tube has important implications for ovarian cancer prevention.2 The possibility that ovarian cancer could be prevented by removing the fallopian tubes at the time of other gynecologic surgeries (e.g., hysterectomy and tubal sterilization) is tantalizing. This approach, termed "opportunistic salpingectomy," is defined as removing the fallopian tubes in low-risk women who have completed childbearing and are undergoing pelvic surgery for another indication.3 The practice is now becoming widespread in North America among gynecologists. Nevertheless, long-term studies on the effectiveness of this strategy for prevention of ovarian cancer are lacking. In addition, there are no data on the potential theoretical harms in terms of salpingectomy affecting ovarian blood supply and inducing premature menopause.
While the American Congress of Obstetricians and Gynecologists (ACOG) has yet to comment on the matter, the Society of Gynecologic Oncology (SGO) in the United States issued a statement in November 2013 that said, "For women at average risk of ovarian cancer, risk-reducing salpingectomy should also be discussed and considered with patients at the time of abdominal or pelvic surgery, hysterectomy, or in lieu of tubal ligation."4 They also recommend that pathologic evaluation include representative sections of the tube, any suspicious lesions, and entire sectioning of the fimbriae. Similarly, SGO’s counterpart in Canada stated that, "Due to its cancer prevention potential, it is recommended that physicians discuss the risks and benefits of bilateral salpingectomy with patients undergoing hysterectomy or requesting permanent, irreversible contraception."5
In 2010, gynecologic oncologists from the province of British Columbia in Canada began an educational initiative that informed general gynecologists about the role of opportunistic salpingectomy in ovarian cancer prevention.3 The investigators recommended that gynecologists 1) consider bilateral salpingectomy at the time of hysterectomy, 2) consider bilateral salpingectomy for permanent sterilization instead of tubal ligation, and 3) refer all women with high-grade serous cancer for genetic counseling and testing for BRCA 1/2 mutations. According to a recent report, from 2008 (before the initiative) to 2011 (after the initiative), hysterectomy with bilateral salpingectomy (BS) increased from 5% of all hysterectomies to 35%. Similarly, BS for sterilization increased from 0.5% to 33% of sterilization procedures. Among the 44,000 women included, a retrospective cohort analysis showed that the mean additional surgical time for BS with hysterectomy and BS for sterilization was 16 minutes and 10 minutes, respectively. While the authors reported that some of the sterilizations were postpartum, other than saying "most" were done at the time of cesarean, they did not mention more details. However, there were no differences between traditional hysterectomy and tubal ligation and hysterectomy with BS and sterilization with BS in terms of length of stay, blood transfusion, or hospital readmission even controlling for postpartum procedures. The authors plan to follow this cohort and population level rates of ovarian cancer in the province to determine whether these surgeries reduce the risk of future ovarian cancer, an analysis which may take 15-30 years.
While adding BS to hysterectomy or interval sterilization is feasible and does not seem to increase short-term complications, the effect of this routine practice on future ovarian function is unknown. Preliminary studies on this have been underpowered and too short in length (3-6 months postoperatively) to determine if any effect is apparent.6 It has been documented for some time that hysterectomy by itself can be associated with early menopause; therefore, adding bilateral salpingectomy may not have much of an additional impact. However, routine salpingectomy for sterilization is another story.
Tubal ligation, by itself, has been associated with reduced ovarian cancer incidence. Interestingly, recent studies have clarified that this protection seems to be limited to the endometriosis-related subytpes of ovarian cancer, clear cell and endometriod.7 Removing the entire tube, therefore, may protect against all subtypes of epithelial ovarian cancer. In addition, some argue that bilateral salpingectomy is a superior sterilization technique compared to tubal ligation.8 Nevertheless, opting for bilateral salpingectomy rather than tubal ligation could have unforeseen consequences. In the short term, routine salpingectomy after delivery for sterilization may require larger incisions after vaginal delivery, and there may be more bleeding complications due to the engorged pelvic vessels. Even if limited to interval sterilization, bilateral salpingectomy may have an effect on future ovarian function. We just do not have any data on the long-term effects of routine BS for premenopausal women undergoing sterilization. For women at low risk of ovarian cancer, the risks of reduced ovarian function on cardiac health may outweigh the benefit of decreased ovarian cancer rates. Let’s not forget that cardiac disease is the number one cause of death among women.
Furthermore, where does this leave hysteroscopic sterilization? This is an innovation that moved sterilization into the office with its attendant convenience for women and decreased complications compared to laparoscopic sterilization.9 While some argue that given the required follow-up, the ultimate failure rate of hysteroscopic sterilization is higher than laparoscopic surgery,10 there is still a role for a sterilization procedure that does not require abdominal surgery. Ultimately, it will be up to the individual woman to decide which risks and benefits are most important to her based on her personal and family history when considering opportunistic salpingectomy. While it seems reasonable and safe to offer women BS who are undergoing hysterectomy or other pelvic procedures, women should be informed that there are no long-term data demonstrating that opportunistic salpingectomy reduces the risk of ovarian cancer or what the effects will be on ovarian function. While we anticipate that is the case and it seems logical, I wonder what the number needed to treat will be; in other words, how many women will have to undergo bilateral salpingectomy to prevent one case of ovarian cancer? This issue is evolving and more studies clearly need to be done before we have good answers for our patients. Nevertheless, it seems that everyone has already jumped on the bandwagon of opportunistic salpingectomy. Let’s hope that in 30 years, opportunistic salpingectomy is not revealed to be an unnecessary procedure.
References
- American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer Society; 2014.
- Kurman RJ, Shih IM. Am J Surg Pathol 2010;34:433-443.
- McAlpine JN, et al. Am J Obstet Gynecol 2014;210:471.e1-11.
- Society of Gynecologic Oncology. Available at: https://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention/. Accessed Nov. 10, 2014.
- The Society of Gynecologic Oncology of Canada. GOC Statement Regarding Salpingectomy and Ovarian Cancer Prevention. Available at: https://www.g-o-c.org/en/news/positionstatements.aspx. Accessed Nov. 10, 2014.
- Tanner EJ, et al. Fertil Steril 2013;100:1530-1531.
- Sieh W, et al. Int J Epidemiol 2013;42:579-589.
- Creinin MD, Zite N. Obstet Gynecol 2014;124:596-599.
- Duffy S, et al. BJOG 2005;112:1522-1528.
- Gariepy AM, et al. Contraception 2014;90:174-181.
