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MRCOG PART 2 SBAs and EMQs

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ESSAY 232 - HYSTERECTOMY

Posted by Sarwat F.
I will ask her history regarding presence of dysmenorrohea, chronic pelvic pain, endometriosis, premenstrual syndrome. I will also ask about any family history of ovarian malignancy or breast or bowel cancers. I will tell her that the overall risk of ovarian cancer in general population is 2%. Family history of ovarian or breast cancer increases this risk to 25 to 40% depending on genes of different syndromes transmitted through family. I will also tell her that hysterectomy is also associated with residual ovary syndrome which can cause pelvic pain when ovaries are left. This can be due to interruption of blood supply to the ovaries. Removal of ovaries may decrease this risk as has been shown in different studies. She will also be explained that in case any benign ovarian disease is found at the time of surgery, removal of ovaries may be needed. However in case oophorectomy is undertaken, a woman may suffer from estrogen deficiency symptoms which include hot flushes, night sweats, palpitations, urological problems like urgency, frequency and incontinence, longterm complications include osteoporosis and alzheimers disease. Estrogen replacement can be given in the form of HRT which is beneficial for both short term and long term symptoms but there is considerable hype in the media regarding its risks. There is a risk of breast cancer although it is more after 50 years of age as duration of exposure is the risk factor. There is also a risk of venous thromboembolism and it is not beneficial if there is any history of coronary heart disease. There are other side effects related to estrogen and progesterone like weight gain, fluid retention, acne, greasy skin, headache, nausea and vomiting. I will provide information leaflet and respect woman?s wishes.
I will tell her that sometimes during the surgery it is technically difficult to remove both uterus and cervix that is the neck of the womb. When cervix is left behind it is called subtotal hysterectomy. Subtotal hysterectomy may be needed when there is a distortion of anatomy due to fibroids. Benefits of subtotal hysterectomy include less risk of injury to bladder, ureter and adjacent structures, less risk of haemorrhage, reduce operating time, less risk of postoperative complications. There is also less risk of dysperunia because of better vaginal lubrication. However risks include need for cervical smears as cervix is not removed and cervical screening program has to be continued. There is a risk of cervical pathology like polyp and ectropion similar to general population. Post hysterectomy bleeding may occur cyclically because of endometrial remnants. I will provide written information to patient and maternal wishes will be considered in final decision.
Posted by Randa E.

A detailed history including smoking, family history of breast, bowel or ovarian cancer is important. Associated severe symptoms of premenstrual syndrome may help in the decision of oophoractomy. She should be told that the benefits of concurrent removal of the ovaries is the relief from premenstrual syndrome if present. Also there is no possibility of residual ovary syndrome after hysterectomy. She should know that there is also a reduction in the future risk of ovarian cancer. The general population lifetime risk is around 2%. The disadvantages of the procedure is surgical menopause and its sequel. Also there is need for HRT for prolonged periods which can have a potential for poor compliance. She should also be told that oophorectomy does not reduce the risk of ovarian cancer completely because perotineal metastases can still occur. She should also be told that there are risks associated with the use of HRT. There is an increased risk of breast cancer and venous thromboembolism associated with HRT. The risk of breast cancer increases from 2 in 1000 after 5years to 7 in 1000 after 10 years of use. There is 2-3 increase risk of VTE above background for current users. If done without adequate counselling this ?female castration? can result in great psychological morbidity. After thorough counselling she is allowed to make her own choice regarding having or not having oophorectomy and this should be clearly documented in notes. Accurate written information should be provided to support verbal information and a written consent obtained.
b) This patient should be advised that there is no substantial evidence available for or against the advantages of subtotal hysterectomy (removing the uterus but not the cervix) provided that her smears were normal in the past. The potential benefits of subtotal hysterectomy is the shorter anaethetic and operation time which leads to reduced morbidity. There is also reduced risk of primary haemorrhage and damage to surrounding organs such as the bladder and ureters. There is less morbidity from secondary haemorrhage, haematoma, bladder and bowel dysfunction, infection and tubal prolapse and vault granulations. There is also a good potential of early resumption of sexual activity, lesser incidence of dyspareunia and sexual dysfunction with better vaginal lubrication.
The potential disadvantages are that she can menstruate from the endometrial remnants. There is also need to continue cervical smears. Also cervical pathology such as chronic cervicitis causing discharge, polyps and stump carcinoma(up to 0.3%) can arise in the future, which might necessitate further treatment. She should be advised that the choice for total or sub-total hysterectomy is up to her provided she understands the advantages and disadvantages involved in both procedures. This discussion should be documented in the notes and information leaflets should be provided.
Posted by Freha Z.
Prophylactic oophorectomy means removal of ovaries during hysterectomy. A history should be taken of premenstrual syndrome, endometriosis, smoking and family history of breast and ovarian cancer if present women should be encouraged to have oophrectomy. Pelvic ultrasound can also be considered to look for adenexal mass if suspected. She should be told that average age of menopause is 51 years in Uk. This is reduced by smoking and is also reduced by few years after hysterectomy.
The life time risk of ovarian carcinoma is 1.1 which is markedly reduced by oophorectomy but a low risk of primary peritoneal carcinomatosis remains. The risk of ramnant ovarian syndrme is also reduced where the ovary might be surrounded by adhesions after hysterectomy causing pelvic pain.
She may also suffer from surgical menopause which may consist of serious menopausal symptoms and she will require hormone replacement therapy after the surgery at least for upto the age of her natural menopause. Serious risk associated with hormone replacement therapy are three fold increase risk of venous thromboembolism and risk of breast cancer after use for 5 years or more. She should also be told that the presence of ovarian pathology may also warrant decision of removal during surgery.
She should be given information in written form and involved in decision making. Oophorectomy without careful counselling may laed to psychological sequele.
(b) She should be informed that sutototal hysterectomy is associated with less morbidity shorter operation time and anaesthetic. Risk of primary and secondary haemorrhage, badder and bowel dysfunction is low. As a result there is low risk of infection. Return to sexual activity is quick and less dyspareunia and better lubrication. But there is need to continue cervical smears and bleeding from endometrial ramnant can occur. Whereas in total abdominal hysterectomy the risk of injury to bladder and ureter and is higher. The risk of vault prolapse and formation of vault granulationis higher.
All the information should be backed by leaflets and careful documentation of the discussion made.
Posted by Farzana N.
a)Prophylactic oophrectomy can be offered to woman at the age of 40-45 ,provided she understands the benefits and risks. Benefits are in terms of prevention of ovarian cancer, benign ovarian disease and residual ovary syndrome.
A detailed history should be taken about any family h/o ovarian or breast cancer. The life time risk of having ovarian ca is 2%,.In case of a positive family history this may rise to 7% .In established hereditary predisposition with positive BRCA1 or BRCA2 mutations the risk may be as high as 30-40%.If she has any such history ,prophylactic oophrectomy will prevent ovarian cancer.But a small risk of primary peritoneal cancer still remains. Hysterectomy itself carries a risk of increased incidence of premature ovarian failure.If ovaries are conserved, residual ovary syndrome with cyclical unilateral pelvic pain may occur in 3-10% of cases.
Oophrectomy does not increase the operative morbidity but there is a small risk of damage to ureter in the ovarian fossa.Major risk of prohylactic oophrectomy is premature menopause. Woman needs to clearly understand the implications of premature menopause in terms of vasomotor symptoms, osteoporosis ,urogenital symptoms, libido, cardiovascular complications. She would require long term therapy with HRT to prevent these complications. There is increased risk of breast cancer with HRT after the age of 50yrs.Alternatively Tibolone or Raloxifene may be offered in cases where estrogen therapy is contraindicated. Verbal information should be supplemented with written information and documented.Woman`s wishes ,expectations and fears should be given due consideration and written consent obtained.
b)Sub total hysterectomy entails removal of uterus but the cervix is conserved.She should be informed clearly about the benefits and risks.It is beneficial in terms of being technically easier,requires lesser operative time.Reduced risk of intraoperative hemorrhage,visceral injury particularly bladder and ureteric injury.Shorter hospital stay and reduced incidence of post op pyrexia,secondary hemorrhage , infection and vault granulation.She will be able to resume intercourse early and have better lubrication from cervical mucus.
Long term bladder and bowel dysfunction is not significantly different from total hysterectomy.
Dis advantages of subtotal hysterectomy are that risk of cervical cancer in the stump is ~0.3%,and she should continue with cervical screening.Benign conditions such as cervical polyps may cause bleeding or discharge.Endometrial remnanats may cause cyclical vaginal bleeding leading to concerns and anxiety.Having understood advantages and disadvantages woman should give informed consent for her choice of surgery.

Posted by neera  B.
a) I will ascertain family and past history of cancer of breast and ovary. If history is positive, screening for BRCA 1 and 2 mutations will be offered. The benefits of prophylactic oopherectomy are to reduce future risk of cancer ovary which is especially beneficial for BRCA mutation careers. Lifetime risk of cancer ovary is 1 in 80 and 60% present in advanced stages; over all five year survival is only 40%. Future benign ovarian pathology like cysts are also prevented by prophylactic oopherectomy. It may give relief in dysmenorrhoea or PMS that she might have had. Some women develop cyclical abdominal pain due to residual ovary syndrome if only hysterectomy is performed. Prophylactic oopherectomy prevents this syndrome.
But risk of cancer ovary is not nullified because cancer ovary can still occur from primary peritoneal carcinomatosis. The surgical menopause after surgical removal of both ovaries is sudden and severe, so she may need to take hormone replacement therapy (HRT). Prolonged HRT intake is associated with 3 to 4 fold increase in risk of venous thromboembolism though absolute risk is small. Risk of cancer breast is increased while taking HRT but five years after stopping HRT returns to the same as non users. Risk of cardiovascular diseases is also increased with HRT. Decrease in libido is difficult to treat with HRT.
Leaflets will be given to enable her to make informed choice. Discussion will be documented.
b) I shall enquire about risk factors for cancer cervix like smoking, multiple partners and status of previous cervical smears. I shall tell her that subtotal hysterectomy involves removal of only the body of womb while cervix is retained. In total hysterectomy, both the womb and neck of womb are removed. Benefits of subtotal are shorter operating time, less exposure to anaesthesia, and lower blood loss compare to total hysterectomy. Less of bladder dissection is needed, so risk of bladder and ureteric injury is lower with subtotal hysterectomy. Subtotal is especially useful in case of bladder adhesions as in previous pelvic surgery. Earlier resumption of sexual activity is possible with subtotal. It does not carry risk of vault granulation.
Risks involve possibility of developing benign or cancerous disease of cervix later because cervix is retained in subtotal hysterectomy. So follow up cervical smears will be needed after subtotal. She can still menstruate from endometrial remnants left behind during subtotal hysterectomy.
Leaflets will be given to enable her to make informed decision and the discussion will be documented.
Posted by Abi T.
The decision to perform prophylactic oohorectomy should take into account her wishes, risk of ovarian and breast CA and other coexisting problems such as PMT and endometriosis. She should be aware that in premenopausal women who are low risk, oophorectomy is not generally indicated as the risks of HRT secondary to a surgical menopause outweight the benefits.
A thorough history should be obtained to enable a risk assessment. Family history of breast, ovarian and colon CA may put her at high risk of developing ovarian and breast CA. Otherwise she should be told that she has a 1% lifetime risk of ovarian CA and at present there is no accurate way of detecting this and oophorectomy will not completely eliminate this risk. She may wish to consider genetic testing and if she has a positive familty history. Oophorectomy would significantly reduce her risk of ovarian CA by 95% and breast CA by 50% if she is a BRCA 1&2 carrier. There may still be a 1% risk of primary peritoneal malignancy.
If she has severe PMT symptoms, endometriosis or mid cylce pain oophorectomy will alleviate these symptoms. However she should have a 3 month trial of ovarian suppression prior to the procedure to ensure symptoms subside to justify that oophorectomy will be succesful.
PID, endometriosis or previous adnexal surgery may make removal of the ovaries difficult and unsafe if there are significant adhesions and an oophorectomy will not be adviced.
2% of women may have residual ovarian syndrome which can produces pelvic pain which may require removal at a later date.
The benefits of oophorectomy should be balanced against the risks of HRT due to surgical menopause. It should be explained that she is likely to need HRT for a longer period to control vasomotor symptoms.The different routes of administration, risks and side effects should be discussed. There is an increased risk of cardiovascular disease, VTE and breast CA. The side effects can be weight gain, acne and fluid retention. She should be aware that alternatives do exist to treat these symptoms but limited data exist on their long term benefits, risks and efficacy.
It is important to explain to her that if there are frankly malignant features on the ovary at hysterectomy then oophorectomy will be necessary. A TVS should be done prior to the procedure to exclude any obvious cysts.
The consultation as well as patient wishes should be clearly documented in the notes and patient information leaflets should be provided. It should also be clearly documented on the consent form as to her wish to conserve the ovaries or remove them and the specific circumstances for removal.

b)She should be aware that there is no general consensus regarding removal or retention of the cervix and this is based on individual circumstances.
A smear history should be be taken and if it is normal then removal may not be necessary. However there is a 1% risk of cervical CA in the stump and she should continue to have smears done.
Certain factors may make a subtotal hysterectomy the safer and easier option, eg High BMI, previous C/section and significant adhesions from PID or endometriosis and this should be ellicited from historyand examination (fixed uterus, tender pelvis).
The presence of a cervical fibroid may make a subtotal hysterectomy safer, hence fibroid mapping should be done preoperatively.
A subtotal hysterectomy also has a shorter operating time and lesser morbidity relating to ureteric and bladder injuries.
There is no current evidence to support the fact that removing the cervix diminshes sexual sensation and orgasms and a subtotal hysterectomy should not be recommended for this.
There may be residual endometrium left and 5% of women may experience persistent or cyclical bloody vaginal discharge which may be a nuisance requiring diathermy to the stump.
The above consultation should be documented in the notes and supported with leaflets.



Posted by Parveen  Q.
prophylactic oophorectomy is removal of ovaries at the time of hysterectomy. The woman should be explained about the risks and benfits to have an informed choice. this will alleviate the psycological sequlae if she is not adequately informed. i will take detail history about her menstrual history, premenstrual tension, any history suggestive of endometriosis and chronic pelvic pain. prophylactic oophorectomy can be offered in this case, but in case of PMS , a trial of GnRH agonists with add back oestrogen for 3months will predict the chance of therapeutic success. the life time risk of developing ovarian cancer is 2%, when there is a hereditary predisposition, this may be high as 50%.Prophylactic oophorectomy removes this risk. It should be considered when there is a history of surgery for bengin cysts whether it was a cystectomy or unilateral oophorectomy. The risk of oophorectomy is surgical menopause, she should be informed about the use of HRT to relieve the symptoms. The risk of long term use of HRT is associated with increase breast cancer risk of 7/1000after 7years, and risk of venous thromboembolism 3times above the back ground risk. All informations should be backed by leaflets, and further oppointment given.

(b)Subtotal hysterctomy is where the body of uterus removed, but cervix is conserved. The benefits are less morbidity, wound infection, hematomas. The operating time is less, and it is easy to perform. There is less risk of intra operative hemmorrhage, less injury to bladder, ureter and viscera. Lower risk of secondary hemorrahge, postoperative infection. Vault granulation donot occur, where as it complicates 21%in total hysterectomy. The hospital stay is short and early resumption of sexual activity. The risk is development of stump cervial carcinoma which is less than 3%, so need to continue screening.Benign cervical polyp can occur which may increase her anxiety. Risk of cyclical vaginal spotting from endometrial remnants within the cervical canal. Verbal information should be backed by leaflets, and documentation done clearly.
Posted by NIRMALA SARASWA P.
Prophylactic oophorectomy should be offered to all women undergoing hysterectomy,the benefits and the risks are discussed thoroughly and documented clearly.A detailed history will help in counselling the women regarding the benefits of the surgery, any justifiable reasons for oophorectomy like malignancies if she wishes to conserve the ovaries,any contraindications for HRT if she undergoes oophorectomy.
I will ask her if she is suffering from chronic pelvic pain,the severity,premenstrual symptoms,the severity,if they were treated before and the outcome.Family history of ovarian,breast cancer(BRCA1) carrier,h/o breast cancer,VTE,coronary heart disease,stroke etc.,After the history,I would explain the women that,if she is suffering from chronic pelvic pain,endometrioses,severe prementrual symptoms,beningn ovarian disease she would definitely be benefitted by therapeutic oophorectomy.The significant family history of breast and ovarian cancers,indicate the justifiable reason for prophylactic oophorectomy although the woman should understand that the risk of the ovarian cancer is not eliminated totally.The risk of peritoneal adenocarcinoma of 1% appr still persists.
If the oophorectomy is performed the risk of surgical menopause and the need for HRT.I would explain her the benefits and risks of HRT and the alternatives.If she has significant history of cardiovascular disease she may be considered for an alternative as HRT is contraindicated.The risk of Breast Cancer,although the risk is appreciated after a long term use of HRT over 5yrs.2/1000 cases for over 5yr use of HRT.HRT would definitely have effect on the menopausal symptoms like hot flushes,night sweats and vaginal dryness.On balance I would suggest her that oophorectomy is definitely beneficial at this age as after hysterectomy ovarian function cease gradually and no beneficial effect of conserving ovaries,no need for a recurrent operation for a beningn cause and there is no risk of a residual ovary syndrome.,Written information is provided to her in the form of a leaflet.


The benefits and risks of sub total hysterectomy over total hysterectomy are based only on small randomised controlled trials and observational studies.I would explain the women that in subtotal hysterctomy the womb is removed and the cervix is retained.
The benefits are,the shorter operating times compared to total abdominal hysterectomy,technically easier surgery,with less amount of intra operative hemorrhage,short hospital stay.Less risk of damage to the viscera esp the bladder and the ureter.Decreased risk of secondary hemorrhage,infection,vault granulation.Lower risk of post operative pyrexia.There is no significant difference in the long term risk of bowel and bladder function.Potential for early resumption of sexual intercourse and vaginal lubrication from cervical mucous,though randomised trials show no significant difference in the post operative sexual function.
The disadvantages are,there is a need to continue with the cervical screening as the risk of stump carcinoma of cervix is 0.3%.Beningn conditions of the cervix may cause bleeding and discharge.Cyclical vaginal bleeding from the endometrial remnants within the endocervial canal.
I will provide a written information.The decision of woman is final about the choice of operation after being counselled.Careful documentation of the information provided is essential.
Posted by NIRMALA SARASWA P.
Prophylactic oophorectomy should be offered to all women undergoing hysterectomy,the benefits and the risks are discussed thoroughly and documented clearly.A detailed history will help in counselling the women regarding the benefits of the surgery, any justifiable reasons for oophorectomy like malignancies if she wishes to conserve the ovaries,any contraindications for HRT if she undergoes oophorectomy.
I will ask her if she is suffering from chronic pelvic pain,the severity,premenstrual symptoms,the severity,if they were treated before and the outcome.Family history of ovarian,breast cancer(BRCA1) carrier,h/o breast cancer,VTE,coronary heart disease,stroke etc.,After the history,I would explain the women that,if she is suffering from chronic pelvic pain,endometrioses,severe prementrual symptoms,beningn ovarian disease she would definitely be benefitted by therapeutic oophorectomy.The significant family history of breast and ovarian cancers,indicate the justifiable reason for prophylactic oophorectomy although the woman should understand that the risk of the ovarian cancer is not eliminated totally.The risk of peritoneal adenocarcinoma of 1% appr still persists.
If the oophorectomy is performed the risk of surgical menopause and the need for HRT.I would explain her the benefits and risks of HRT and the alternatives.If she has significant history of cardiovascular disease she may be considered for an alternative as HRT is contraindicated.The risk of Breast Cancer,although the risk is appreciated after a long term use of HRT over 5yrs.2/1000 cases for over 5yr use of HRT.HRT would definitely have effect on the menopausal symptoms like hot flushes,night sweats and vaginal dryness.On balance I would suggest her that oophorectomy is definitely beneficial at this age as after hysterectomy ovarian function cease gradually and no beneficial effect of conserving ovaries,no need for a recurrent operation for a beningn cause and there is no risk of a residual ovary syndrome.,Written information is provided to her in the form of a leaflet.


The benefits and risks of sub total hysterectomy over total hysterectomy are based only on small randomised controlled trials and observational studies.I would explain the women that in subtotal hysterctomy the womb is removed and the cervix is retained.
The benefits are,the shorter operating times compared to total abdominal hysterectomy,technically easier surgery,with less amount of intra operative hemorrhage,short hospital stay.Less risk of damage to the viscera esp the bladder and the ureter.Decreased risk of secondary hemorrhage,infection,vault granulation.Lower risk of post operative pyrexia.There is no significant difference in the long term risk of bowel and bladder function.Potential for early resumption of sexual intercourse and vaginal lubrication from cervical mucous,though randomised trials show no significant difference in the post operative sexual function.
The disadvantages are,there is a need to continue with the cervical screening as the risk of stump carcinoma of cervix is 0.3%.Beningn conditions of the cervix may cause bleeding and discharge.Cyclical vaginal bleeding from the endometrial remnants within the endocervial canal.
I will provide a written information.The decision of woman is final about the choice of operation after being counselled.Careful documentation of the information provided is essential.
Posted by NIRMALA SARASWA P.
Dear Sir
I am sorry.I was not sure if the answer was submitted,so submitted again.
Posted by Shyamaly S.
A)It is important to discuss oophorectomy with women undergoing hysterectomy- there are significant quality of life issues and it is a source of litigation. An oophorectomy will cause a sudden surgical menopause- she may experience symptoms of hot flushes, mood swings, vaginal dryness etc. An early menopause puts her at risk of long-term health problems such as osteoporosis and cardiovascular disease, therefore Hormone replacement therapy is recommended until the average age of the menopause (51). As the HRT is to treat a premature menopause, it is not associated with the increased risks of breast cancer and cardiovascular disease that have been well publicised recently. As her uterus is being removed she may have oestrogen only HRT, which may be given as tablets, gels, patches, suppositories, and even an implant that may be inserted at the time of surgery.
The advantages of oophorectomy is that it reduces the risk of ovarian cancer to 1%- the risk is not completely eliminated as there is still a risk of primary peritoneal cancer. The risk of ovarian cancer is especially reduced if she has a family history of ovarian cancer, and certainly if she is a carrier of the BRCA genes which put her at a higher risk of developing it herself. Oophorectomy also removes the risk of benign ovarian disease. If she also suffers from PMS or endometriosis, removal of her ovaries may improve related symptoms- a pre-operative trial of zoladex will show if this occurs. Oophorectomy does not significantly prolong operating time. However the disadvantages are that there is potential for ureteric damage when operating in the ovarian fossa, there is a need for HRT and also the ovaries are an important source of testosterone in the postmenopausal woman- removal may significantly affect her libido.
When the ovaries are conserved after hysterectomy there is a risk of a slightly earlier (5 years) menopause and it is possible that she may suffer from residual ovary syndrome (pain and symptoms related to ovarian function) and she may therefore need further surgery at a later date to remove them.
The patient should be given written information to support this discussion. At the end of the discussion her feelings should be known, respected and clearly documented in her notes and the consent form. If she opts for ovarian conservation she should be aware that if during her operation her ovaries look suspicious of cancer it is recommended that one or both are removed.

B)Subtotal hysterectomy is when the body of the uterus is removed but the cervix is preserved as opposed to a total hysterectomy (TAH) when the cervix is removed. There are advantages and disadvantages to both and the data to assess these is bases on small trials and observational studies. She should be aware that with a fibroid uterus it may not physically be possible to perform a TAH safely, but in this case she will be informed post-operatively.
STAH is associated with shorter operating time, less blood loss a reduced risk of bladder and ureteric damage and therefore a lower risk of thromboembolic disease and post op infections and pyrexia. Women may resume sexual activity at an earlier date and the presence of cervical mucus improves vaginal lubrications. There has been a suggestion that the presence of the cervix improves orgasm at intercourse but this has not been supported by RCTs. Similarly the view that STAH are associated with a reduced risk of pelvic organ prolapse has not been supported by RCTs.
The disadvantage of STAH is that cervical screening for cervical cancer needs to be continued, as the cervix is still present. If there is a previous history of abnormal smears, there is a strong case for performing a colposcopy and total abdominal hysterectomy. If the cervix is normal at histology after TAH, no further follow up is required. Residual endometrial tissue may be present with a STAH causing nuisance cyclical blood stained vaginal discharge requiring further excision or cautery.
Again, written information should be given to the woman and her decision clearly documented in the notes and the consent form.
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