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- [00:01]
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- [00:39]
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It's game time. Can you spot the core differences?
- [00:46]
Dr. Chapa
Yep. Our words matter and more importantly, our actions matter. Now, this is exactly the case when we talk about opportunistic salpingectomy. Some call that OPS or os. And the other term risk reducing salpagectomy, otherwise known as rrs. Even though sometimes people use these things interchangeably, they are absolutely not. In fact, there are four big differences between opportunistic salpingectomy and risk reducing salpingectomy.
- [01:26]
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Baby tv hey kids, it's game time. Can you spot the core differences?
- [01:36]
Dr. Chapa
Remember when you were a kid and you played the game spot the difference? Well, this is exactly what we're doing here. We're gonna cover a brand new clinical opinion that is coming out April 2026, officially in print in the Gray Journal that has to do with this very issue of risk reducing salpingectomy as opposed to opportunistic salpingectomy. These are big deals, guys, that we've got to educate patients on and know the differences here. For example, only one is actually ACOG and FIGO and National Comprehensive Cancer Network approved. The other is not. Only one has proven benefit, the other does not. And we're gonna get to the other differences, the remaining two for the four total in this episode. So there are four big differences here, guys, between risk reducing salpingectom and opportunistic salpagectomy. And I think I've set it up enough. We'll be right back. This is Dr. Chapa's OBGYN no Spin podcast.
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Dr. Chapa
Cause there's always something new.
- [03:13]
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- [03:28]
McDonald's Promoter
Hunters, Haja Boy's Breakfast Meal and Hunt Trick's Meal have just dropped at McDonald's. They're calling this a battle for the fans. What do you say to that, Rumi? It's not a battle. So glad the Saja Boys could take breakfast and give our meal the rest of the day.
- [03:41]
Dr. Chapa
It is an honor to share. No, it's our honor.
- [03:45]
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It is our larger honor.
- [03:47]
McDonald's Promoter
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- [03:55]
Dr. Chapa
and participate in McDonald's while supplies last. All right, first off, podcast family, we're talking about what to do with the tubes. This has nothing to do with the ovaries. Okay? And therein lies the big difference here. And I'll get into that in a minute. We're going to talk about the four key differences between opportunistic salpingectomy and risk reducing salmogectomy at the end of the day, though, of course, we'll talk about it as we go through this process here. But let's start in 2007 with the crumb publication. This was the one that changed the paradigm, changed the conversation on epithelial ovarian cancer. All right, so this was a group out of Brigham and Women's, out of Harvard Medical School called the Crumb publication. They actually published, quote, intraepithelial carcinoma of the fimbria and pelvic serous carcinoma and evidence for a causal relationship, end quote. Okay? So this was 2007, where they took patients that were at high risk of ovarian malignancy or had ovarian malignancy and took a look at the distal end of the tube in a very precise form. Okay? So remember this key term, because if you ever do an ops, which we're supposed to do, we are endorsed and recommended to do that at time of other primary schools surgery. That's an important thing to do. But you gotta tell the pathologist, hey, this is an ops, so you gotta follow the CFIM protocol. Cfim, S E, E, F, I, M. Cfim. That stands for Sectioning and extensively Examining the fimbrial end. Sectioning and Extensively examining the fimbrial end. So the CFIM protocol is a specific way that all opportunistic salpingectomies are supposed to be looked at. All right? So you put on the pathology form or in your emr. This is opportunistic salpingectomy. Some call that ops, some call that os, whatever. But you have to Tell the pathologist, hey, you're supposed to look at this with the CFIM universal protocol. You're supposed to do that. Okay? Now, what they found in this study was eye opening. In that they found something called ticks, okay? Tubal intraepithelial carcinomas, or stichs, which was serous tubal intraepithelial carcinomas. These things actually patients that had ovarian involvement or primary peritoneal carcinomatosis, it kind of started in the tube. So this changed the conversation. And not just in the tube. This was in the distal end fimbria. That's why it's the CFIM protocol. Yes, salpingectomy gets a lot of attention, and it should, because if you're gonna remove just the fimbria, we may as well remove the rest of the tube so you don't get a mucocele or something else Weir later on, because basically you have no function left of the tubes, just take out the whole thing. But what really started this was the finding that in the distal part of the tube, specifically the distal third, and more specifically in the fimbria, the CRUMP publication found. Yeah, this thing actually starts in the distal end of the fallopian tube. For epithelial high risk ovarian malignancies, there's nothing to do with germ cells, nothing to do with sex cord stroma. But for the most common kind of epithelial ovarian cancer, which is epithelial high grade, this thing starts in the distal end of the fallopian tube. Okay, so this changed the paradigm shift. Now, since that pivotal publication came out, there's been a variety of other sources that have said, yes, this is actually confirmed. So starting in 2007, where we kind of changed the shift that epithelial ovarian cancer has a tubal origin, that's where this thing started to gain ground. Now, this brings us to ops. Let's talk about OPS first. Okay, first of all, OPS has to do with population level risk for epithelial ovarian cancer. And it works as an epithelial ovarian cancer risk reducing strategy for sure. The landmark population based Swedish study that showed this reduction in a population level was called the Falconer publication. That was in 2015 in the Journal of the National Cancer Institute. 2015. And showed that women who underwent bilateral salpingectomy. Listen to this, guys. In the general population, 65% risk reduction in the risk of ovarian cancer, whereas women who underwent a tubal sterilization, that's a BTL with a portion of the tube removed had a 28% reduction. So yes, let me just say it right here. Tubal ligation still is protective. However, it's not the most protective. And this has also caused a trend in practice change where most people now if they're doing a just a traditional bilateral tubal ligation, have abandoned that in favor of the total salpingectomy. If not then at least a mid portion of the tube down to the fimbria and having a partial salpingectomy bilaterally. But without question, guys, people have looked at this, this is published that these practice patterns have definitely changed and that's been tracked. All right, and it should remember that ACOG endorses opportunistic salpingectomy either as a, remember as that as that secondary procedure, that's why it's called opportunistic, or as a primary in cases of like sterilization. All right, so this has changed everything. Now there has been data that has looked at this, whereas by mid-2016 salpingectomy has surpassed tubal ligation as the most common sterilization method. And at Cesare delivery, that's published. Okay, so and it should now nothing wrong with a btl if you want to do the old Parkland tubal ligation, bilateral partial midsingental salpingectomy that gives ovarian cancer risk reduction. It does, but it's nowhere close to total salpingectomy. I want to say that again. You know, I trained with the Parkland tubal. It's, it's my home residency in medical school, you know, ALMA material. But that is not the most risk reducing strategy. So people have asked, you know, through our podcast chat channels, you know, hey, should we still do a tubal ligation or just go for the salpingectomy? Well, at least in the US since it's been tracked, there has been an absolute increase really since 2014 and 2015 in the rates of salpingectomy. The tube is not going to be doing anything after a middle segmental salpingectomy anyway. And that has a certain chance of failure even though it's small. But the chance of failure is dramatically reduced if you take away the whole tube. And her risk of ovarian cancer is also greatly dramatically reduced rather than just doing a btl. So let me say right here, even though it's hard to say what is quote unquote standard of care, because they both get the job done and they both have a degree of ovarian cancer risk reduction, the general practice trend, guys, in The US is that the preferred method for postpartum sterilization is the salpingectomy. Okay, so if we're going to talk about the percent of ovarian cancer risk reduction with a btl, that's the Nurses health study by Rice et Al in 2014 and then the bigger population based study out of Sweden that showed that salpingectomy had up to a 65% reduction in ovarian cancer. That's. That's where salpingectomy is preferred. Yes. If you're asking my opinion, if you're going to do a postpartum tubal, please do a complete salpingectomy. It's much lower failure rate and it's much better for the patient in terms of more bang for her buck. So whether it's done as a primary, where that's the indication of sterilization, or a secondary, which is opportunistic salpingectomy, meaning you're doing that by chance because you have a primary surgery like a C section or you're doing whatever, I don't know, some other kind of gynecological procedure. If the tubes are accessible and she's dealing with fertility, opportunistic salpingectomy. If you have the opportunity to remove the tubes on a population level, that works for ovarian cancer risk reduction. So that's the big difference here. The first one is OPS is for the general population and yes, it should be offered to all patients. That is in ACOG's committee opinion, 774. That's a thing. That's from 2019 and that is also supported by the National Comprehensive Cancer Network. So if you're gonna be doing some other gynecological procedure and infertility is not an issue, let's say it's a hysterectomy, take the tubes with them. Now, ovarian, you know, function is something else. Most of the data shows that the balance between cardiovascular risk and dementia and all the other issues of estrogen deficiency versus ovarian cancer risk reduction prevention, that kind of tips the scale at or after 50. Okay, so under 50 there's still a benefit to leave them in the ovaries. I mean, but the tubes should absolutely come out if you're doing a hysterectomy or whatever the case, which means even our general surgeons, and I've talked to our head general surgeon, I'm like, brother, you know, just FYI, if you're in there for an appi on a, that presents late, let's say in a 48 year old woman and she's got her tubes and she's not using them anymore, you should really consider getting an old gin consult to get those tubes out or you do it yourself. Okay? That's an opportunistic salpingectomy. If there is a chance to take away the tubes, either as a primary indication like sterilization, or as a secondary issue where you have the opportunity, a window of opportunity, that's why it's called opportunistic, then you should do that. Okay, fine. My goodness. All of that has to do with the general population, whereas rrs. Guys, here's the difference. RRS has to do with high risk population. Now let me say right off the bat, RRS is not a thing. Risk reducing salpingectomy is not endorsed by any professional society for patients with a germline mutation which increases the risk of ovarian cancer. Now the prototype, the prototypical patient of that is either BRCA 1 or 2, where their published guidance of when you should do a bilateral salpingo oophorectomy as the only cancer reduction strategy that has shown efficacy. So remember, BRCA1 hits earlier. So those patients are recommended to have an RRSO risk reducing Salpingo olpherectomy between the ages of 35 and 40. And BRCA2, because it hits a little bit later, you can wait until 40 to 45. All right, so 35 to 40 for BRCA1, 40 to 45 for BRCA2. And by the way, it's not just BRCA, it's also for lynch syndrome. But lynch isn't just one mutation. They're different inherited germline mutation, DNA mismatch repair gene mutations that can hit. So it depends on which specific gene mismatch mutation you have for lynch, which dictates when you should have your risk reducing salpingo oophorectomy. So it's not just brca. Lynch patients also should have risk reducing salpingo oophorectomies. But the time to do that is based on their specific mutation. For example, because of the increased risk in endometrial and ovarian cancer with lynch, these patients are recommended to have both a historic and a BSO in general, in general, over the age of 40. But again, it depends on which specific mutation you have. If lynch is caused by the PMS2, so there's a specific mutation, okay, PMS2 that presents later on, they can actually have a delayed hysterectomy and risk reducing bilateral subpingo oophorectomy starting at the age of 50. Okay, so it depends. There's also the MSH, the Mish6 MSH6 mutation for Lynch. If they have that, then you can do it in a staged approach. You can do a hysterectomy with opportunistic bilateral salpingectomy alone at age 40 and then leave the bilateral oophorectomy at 50. Okay, so lynch, here's the take home message. Guys. Lynch is complicated. It has to do with specific mutation you have that dictates what to do. And that includes hysterectomy, either hist and prophylactic BSO at the same time or hist and prophylactic tubal removal with delayed olfactomy. That is the only time, guys, in a high risk population, let me say right here, the only time in a high risk population where you can separate salpingectomy and olpherectomy in time. And that has to do with the MSH, I call it the Mish, MSH6 mutation. For lynch, you can do a hist and bilateral salpingectomy at 40 and then leave the oophorectomy at 50. But for BRCA, let's say it again, guys, BRCA 1 or 2, you're all in. You are taking out the tubes and the ovary, not just the tubes. So once again, OPS is a general population thing. RRS has to do specifically with high risk populations. And RRS is not a thing by itself for anyone. For brca you're going to do an RRSO risk reducing something, go olpherectomy, that's age appropriate. And even for lynch, you're not going to do a risk reducing salpingectomy by itself. You're going to do that together with a hist. Now you can do that first and then delay the olpherectomy or do them together based on a specific mutation. But notice high risk population, guys, no protocol here it is no protocol employs recommendations to just take away the tubes. So in high risk patients, just taking away the tubes is not a thing. RRS is actually not a thing. So the reason is not very easy. Let's do a 0.1 and a 0.2 on this. Number one, there is incomplete cancer risk elimination just by taking away the tubes. And in these high risk patients, including brca, number one, there's incomplete cancer risk elimination in these high risk groups. So RS is not a thing. Number two, there's no data, we don't have any proven efficacy, unlike in the general population that just removing tubes in BRCA patients or in lynch patients does any good. What? Amazing. Okay, so ops. Yes, that is a thing. Remember, I'm giving you your four rapid fire differences here. Coming up. We're going to be done here like in 5 minutes, minutes or less. And we're wrap it up in a minute. So OPS is a thing. RRS actually is not a thing. So let's stop calling it risk reducing salpingectomy because there's no data that just removing tubes in either BRCA or Lynch patients does any good. Podcast family that brings us to April of 2026 in the gray journal the American Journal of Obgyn. And this publication is under current opinion and it is salpingectomy in individuals at high risk for tubo ovarian cancer consensus and precaution. Exactly what we're talking about here. Now here's the spoiler. It's exactly what we've already stated, that in those patients who have a hereditary pathogenic variant of some kind of mutation that puts them at risk for tubo ovarian malignancy, including lynch, we should not be advocating just for removing of the tubes. Now I get it, I get it. And I'm gonna read you the excerpt here in a minute. In trying to be a patient advocate so that she doesn't get menopausal symptoms. I get that. And there's been some commentaries in the past that have actually said this and they're wrong. Is. Well, you know, let's at least we know it begins in the tube. Let's remove the tube so that we can push down the menopausal complications and the menopausal symptoms for some time. Great intention. Wrong implementation.
- [20:38]
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- [21:08]
Dr. Chapa
Okay, so even though it's very honorable and just to try to leave the ovaries in for patients who are at high risk of ovarian malignancy, it doesn't eliminate the risk and we don't have any data that it proves to be effective and in these patients. So let me read this quote here and then I'm going to give you the four differences quote. This is from the April 2026 clinical opinion quote. Although these procedures, meaning stop injectomy, are assuredly offered with good intention, just like we said, to reduce the risk of cancer while minimizing the drawbacks of iatrogenic menopause. Here it is guys. Their performance in standard clinical practice without careful counseling may falsely reassure high risk patients and lead to missed opportunities for tubo ovarian cancer prevention among those at the highest risk. End quote. In other words, I get it, I get it. Getting homlashed in cardiovascular risk reduction. I'm sorry, cardiovascular risks are real with olpherectomy, but cancer death is also real. So in patients who have a mutation, the prototype of course is brca. Risk reducing salpingectomy should only be done in terms of a clinical trial. And if they're not gonna be in a clinical trial, then you gotta tell them that that is not an endorsed method for ovarian cancer risk reduction. Okay, so I'm gonna give you the four differences here in a minute but I found this to be so wise and it's something we've got always said, but people still confuse the terms. OPS versus RRS are two entirely different things. So I'm thankful for this clinical opinion from April of 2026. It was out actually ahead of print like in November, the end of 2025, but now it's officially out April 2026. And, and, and they're called, they're calling the bluff. Hey, stop saying that taking out the tubes in patients with a germline mutation is good enough. It is not. They should be either involved in a clinical trial to do so or tell them that the standard is age appropriate risk reducing salpingo oophorectomy and that may include a hysterectomy for lynch patients. So, so important. So here it is guys, as we wrap this up, here are the four differences between OPS and rrs. Number one, OPS and RRS have different target populations. OPS is in the general population, whereas RRS is supposed to target high risk individuals with a mutation. Number two, OPS actually does work in the general population but RRS has no data of efficacy in these high risk patients. So we don't know if it works and it doesn't seem to be enough to reduce residual risk. Number three, OPS is, is acog, figo and National Comprehensive Cancer Network endorsed. But RRS is not so know which one is endorsed and which was it isn't. And number four, according to ACOG and FIGO and the National Comprehensive Cancer Network, OPS should be offered at time of some other index primary surgery whereas RRS should be left to clinical trials. So OPS is absolutely not the same thing as RRS because RRS is not enough in high risk individuals. Again we have covered. Podcast Family A new clinical opinion from the Gray Journal which explains these two key differences. OPS we should be looking for remove the tubes when fertility is done, and you've got a chance to do that, whereas risks reducing salpingectomy isn't even a thing. Podcast Family as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home. This is Dr. Chapma's OBGYN no Spin podcast.
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It.