Ovarian cancer remains the most deadly gynecologic cancer, with less than half of patients living more than five years after diagnosis across all stages [1]. The lifetime risk of developing ovarian cancer in the general population is 1.5% [2]. BRCA1 and BRCA2 pathogenic variants increase the lifetime risk of ovarian cancer (44% and 17%, respectively) [3]. In addition to prostate and pancreatic cancers and in some studies, melanoma [4,5], carriers of these variants are at substantial risk of breast cancer (44–78% and 31–56% risk by age 70, respectively) [6]. In patients harboring BRCA1 or BRCA2 variants, risk-reducing bilateral salpingo-oophorectomy (BSO) reduces ovarian-cancer specific (HR 0.25, 95% CI 0.26–0.61) and all-cause mortality (HR 0.40, 95% CI 0.26–0.61) [7]. Additional candidates for risk-reducing BSO include Lynch syndrome patients who have a lifetime risk of ovarian cancer of 4–38% (highest risk in MSH2), though controversy exists regarding lifetime risk and mortality reduction by specific gene variant with the National Comprehensive Cancer Network (NCCN) making no specific recommendations for MSH6 and PMS2 variant carriers given insufficient evidence for increased ovarian cancer risk [[8], [9], [10]]. Patients with variants in BRIP1, PALB2, RAD51C, and RAD51D are recommended to undergo RRSO after age 45 due to lifetime risk of ovarian cancer of up to 13%, 3%, 6%, and 14% respectively [11,12]. The Society of Gynecologic Oncology (SGO) recommends discussing risk-reducing BSO with individuals who have a strong family history of breast or ovarian cancer but no identified pathogenic variants [13]. Finally, therapeutic BSO is also offered to premenopausal individuals at high risk of hormone receptor (HR) positive breast cancer recurrence for ovarian function suppression [[14], [15], [16]].

Standardized indications for concurrent hysterectomy at time of risk-reducing or therapeutic surgery do not exist. Recent literature suggests that BRCA1 patients are at increased risk of uterine serous cancer, a more aggressive histologic subtype associated with poorer outcomes [17]. As of 2019, the NCCN recommended discussion of concurrent hysterectomy for prophylactic BSO in BRCA1 patients [18]. Concurrent hysterectomy may also provide the benefit of simplifying post-operative hormone therapy (HT) with estrogen-only regimens, significant given that in both the general population and pathogenic variant carriers, estrogen-only as opposed to combined estrogen and progesterone regimens do not appear to increase breast cancer risk, and in some studies, demonstrate a protective effect [19,20].

Surgically induced menopause through BSO leads to more acute and severe manifestations of typical menopause symptoms including genito-urinary syndrome of menopause, vasomotor symptoms, mood disturbances, cognitive decline, premature bone loss, and increased cardiovascular risk [[21], [22], [23], [24]]. SGO's clinical practice statement on HT reports underutilization of HT after prophylactic BSO and endorses use in pathogenic variant carriers without a history of breast cancer [25].

The objectives of our study were to determine the proportion of patients over time who underwent concurrent uterine surgery during BSO for risk-reducing or therapeutic indications, identify contributing factors to decision-making for type of surgery, and to analyze patterns of HT use in the post operative period.