Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study

Am J Obstet Gynecol. 2021 Jun;224(6):585.e1-585.e30. doi: 10.1016/j.ajog.2020.12.1206. Epub 2020 Dec 24.


Background: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown.

Objective: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research.

Study design: We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications.

Results: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records.

Conclusion: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.

Keywords: gynecologic surgical procedures; hysterectomy; ovariectomy; physicians; practice patterns; risk factors; surgeons.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Female
  • Guideline Adherence / statistics & numerical data*
  • Healthcare Disparities / statistics & numerical data*
  • Humans
  • Hysterectomy / methods*
  • Logistic Models
  • Menopause
  • Middle Aged
  • Ontario
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians' / standards
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Quality Assurance, Health Care
  • Retrospective Studies
  • Salpingo-oophorectomy / methods
  • Salpingo-oophorectomy / standards
  • Salpingo-oophorectomy / statistics & numerical data*
  • Unnecessary Procedures / standards
  • Unnecessary Procedures / statistics & numerical data*