The authors of the systematic review of benefits and risks of salpingooophorectomy did an excellent job of identifying and reviewing the literature on this important topic.1 We are perplexed, however, by the approach used for grading the evidence. Suggesting that bilateral salpingo-oophorectomy to reduce the risk of pelvic floor prolapse, based on one study of level B evidence, should receive the same 2B grade as three studies with level A evidence assessing ovarian conservation to reduce all-cause mortality does not appear appropriate. Moreover, the risk of reoperation after ovarian conservation up to 31% is misleading because those women had significant endometriosis. Another cited study found the risk of reoperation to be 9.2% after ovarian conservation compared with 7.3% in matched controls; this difference is 19 per 1,000 women over 30 years of follow-up. Importantly, the data were collected between 1965 and 2002, predating our current understanding that most adnexal masses in premenopausal and postmenopausal women resolve without any intervention.2 The concept of relative risk, as used in this study, can lead to misunderstanding of absolute risk. Using one study of long-term outcomes after hysterectomy, the risk of dying from any cause was 136 per 1,000 with ovarian conservation compared with 187 per 1,000 with oophorectomy; an absolute difference of 51 women per 1,000 over 30 years of follow-up.3 Although a patient might consider bilateral oophorectomy to avoid reoperation, would she trade that single benefit for increased risks of developing heart disease, dementia, depression, or menopausal symptoms or of dying from other causes?3,4 Although patients may make a decision based on concerns or fear about one type of risk, full understanding of all associated risks and benefits is rarely available. We suggest that the authors consider calculating absolute risks and benefits for each condition they considered. If the data were presented in a risk-versus-benefit format, the information would be extremely useful for women and physicians alike and would be a major contribution to women’s health care.
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