Reoperation and Pain-Related Outcomes After Hysterectomy for Endometriosis, by Oophorectomy Status

Abstract

BACKGROUND

More research is needed comparing outcomes between those who underwent hysterectomy for endometriosis with conservation of one or both ovaries, compared to bilateral salpingo-oophorectomy.

OBJECTIVE

To compare the rate and types of reoperation (primary outcome) and use of other pain-related health services (secondary outcomes) between people undergoing hysterectomy with conservation of both ovaries, hysterectomy with unilateral salpingo-oophorectomy and hysterectomy with bilateral salpingo-oophorectomy.

METHODS

A population-based retrospective cohort study of 4489 patients aged 19-50 in British Columbia, Canada, undergoing hysterectomy for endometriosis between 2001 and 2016. Index surgeries were classified as: hysterectomy alone (conservation of both ovaries), hysterectomy with unilateral salpingo-oophorectomy, or hysterectomy with bilateral salpingo-oophorectomy. Reoperation rate was the primary outcome. Secondary outcomes (measured at 3-12 months and 1-5 years after hysterectomy) included: physician visits for endometriosis and pelvic pain, prescriptions filled for opioids, and use of hormonal suppression medications and hormone replacement therapy.

RESULTS

Reoperation rates were low across all groups, with 89.5% of all patients remaining reoperation free by the end of follow-up (median of 10 years, IQR=6.1 to 14.3 years). Patients undergoing hysterectomy alone were more likely to undergo at least one reoperation compared to those having hysterectomy with bilateral salpingo-oophorectomy (13% vs 5%, p<0.0001), most commonly oophorectomy and adhesiolysis. When oophorectomy as reoperation was removed in a sensitivity analysis, this difference was partially attenuated (6% of hysterectomy alone group vs. 3% of hysterectomy with bilateral salpingo-oophorectomy group undergoing at least one reoperation). All groups were very similar with respect to rates of physician visits for endometriosis or pelvic pain and the number of days of opioid prescriptions filled. Further, the rate of use of hormonal suppression medications was similar between the groups, while the rate of prescriptions filled for hormone replacement therapy after hysterectomy with bilateral salpingo-oophorectomy was 60.6% filling at least one prescription at 3-12 months after index surgery.

CONCLUSION

Patients who underwent hysterectomy with bilateral salpingo-oophorectomy had a lower reoperation rate than those who had hysterectomy with conservation of one or both ovaries. However, there was little difference between the groups for the secondary outcomes measured, including physician visits for endometriosis and pelvic pain, opioid use, and use of hormonal suppression medications, suggesting that persistent pelvic pain after hysterectomy for endometriosis may not differ significantly based on ovarian conservation status. One limitation was the inability to stratify patients by stage of endometriosis, and the impact of endometriosis stage or presence of adnexal disease or deep endometriosis on outcomes. Moreover, hormone replacement therapy use was not filled by about 40% of patients after hysterectomy with bilateral salpingo-oophorectomy, which may have significant health consequences for these individuals undergoing premature surgical menopause. Therefore, strong consideration should be given to ovarian conservation at the time of hysterectomy for endometriosis.