Hysterectomised women’s perceptions and experiences of the risks and benefits of opportunistic salpingectomy: A qualitative interview study

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As opportunistic salpingectomy is performed as a preventive intervention without a medical indication, it is essential that the decision to undergo the procedure be made through a shared decision-making process. This study explores women’s perceptions and experiences of opportunistic salpingectomy, factors influencing their decision to participate in a randomised trial, and the lasting impact of the procedure. Methods A qualitative interview study with focus group discussions was conducted with women who had undergone hysterectomy with or without opportunistic salpingectomy 2–7 years prior. Women were recruited from the HOPPSA (Hysterectomy and OPPortunistic SAlpingectomy) cohort through purposive sampling. HOPPSA is a randomised controlled trial in which women aged < 55 years undergoing benign hysterectomy were randomised to hysterectomy with or without opportunistic salpingectomy. Focus group discussions guided by a semi-structured format were recorded digitally, transcribed verbatim, and analysed using qualitative manifest and latent content analysis. Results Twenty women (mean age 45.8 years, range 28–53 years) with varying indications for hysterectomy participated in this study. Fifteen were randomised in HOPPSA, whereas five declined randomisation but joined the follow-up. The analysis identified three categories: Decision on whether to participate in the randomised trial, Deciding on opportunistic salpingectomy, and Health after surgery. Participation in HOPPSA stemmed from a desire to contribute to research or acceptance to let chance decide on tubal removal, though some participants later expressed regret. Limited information from healthcare personnel on the risks and benefits of opportunistic salpingectomy hindered shared decision-making. After surgery, women noted an inadequate focus on health during menopause. Conclusions Decision-making regarding opportunistic salpingectomy is complex and influenced by health illiteracy, personal priorities, and trust in healthcare. Findings highlight the need for personalised consultations on the preventive procedure and long-term support during the transition to menopause. When clinical evidence on risks and benefits is limited, such as for opportunistic salpingectomy, shared decision-making is crucial. Opportunistic salpingectomy hysterectomy shared decision-making qualitative ovarian cancer early menopause focus group discussion Background Opportunistic salpingectomy (OS) refers to the surgical removal of healthy Fallopian tubes. This procedure is carried out during abdominal or pelvic surgery performed for an unrelated reason, such as hysterectomy or sterilisation. It is performed as a preventive measure to lower the risk of ovarian cancer based on observational evidence that many cases of ovarian cancer originate in the Fallopian tubes (1, 2). The adoption of OS is increasing both in Sweden and globally (3–6) despite several systematic reviews emphasising the lack of sufficient evidence on potential negative effects (7–9). Concerns include the risk of surgical complications from the additional procedure and a potential negative impact on ovarian function, which may contribute to menopause at a lower age. The hormonal transition in early menopause is associated with an increased risk of cardiovascular disease, osteoporosis, and mortality (10). However, these issues remain insufficiently clarified and require further investigation to guide future recommendations regarding the risks and benefits of OS. HOPPSA (Hysterectomy and OPPortunistic SAlpingectomy) is an ongoing Swedish register-based randomised controlled trial that was registered at clinicaltrials.gov (NCT03045965) on 8 February 2017 (11). Consenting women under 55 years of age who were scheduled for benign hysterectomy were randomised to either hysterectomy with OS or hysterectomy only. The aim of the trial was to evaluate the risks and benefits of OS. To date, recommendations regarding OS differ between countries; some national societies have issued statements recommending OS as a preventive measure, whereas others, including Sweden, have taken a more cautious stance, opting to await the results of the HOPPSA trial before making definitive recommendations (12). As a result, the topic remains controversial and widely debated among gynaecologists. The lack of consensus contributes to significant variability in clinical practice and patient counselling, not only across hospitals, but even among individual surgeons (13). This variation, which is often driven by the preferences of the gynaecologists rather than by the informed choices of the patients, is problematic and inconsistent with the principles of patient-centred care (14). To facilitate shared decision-making, professional healthcare should focus on the individual’s needs, respect their preferences, and promote their active participation in healthcare decisions, in line with the principles outlined by the World Health Organization (15). Factors influencing decision-making regarding OS have been studied primarily from the gynaecologist’s point of view (13, 16), but some studies have been from the patient’s perspective (17, 18). A Swedish qualitative interview study conducted with women awaiting hysterectomy highlighted health literacy and dependency on consultants as limitations to achieving shared decision-making regarding the preventive intervention (18). Women’s experiences and perceptions of the risks and benefits of hysterectomy with or without OS several years after surgery have not yet been studied. The aim of the present study was to explore women’s perceptions of the risks and benefits of OS with a focus on the factors influencing their decisions regarding OS, their participation in a randomised trial, and the procedure's lasting impact. Methods Research design We used an exploratory qualitative study design to gain a deeper understanding of how women under 55 years of age perceive and experience the risks and benefits of OS following hysterectomy for benign reasons. A qualitative study design enables in-depth exploration of individuals' experiences within their natural context. This approach has proven particularly valuable in areas where existing knowledge on the study topic is limited (19). Focus group discussions (FGDs) were chosen as the data collection method, as they are well-suited for exploring people's perceptions and views on a special topic (20). The study's findings are presented in accordance with Standards for Reporting Qualitative Research (SRQR) guidelines (19). Population Eligible women in this study were recruited among women who were randomised in HOPPSA and among women who declined randomisation but agreed to participate in the follow-up without being randomised (11). Women were recruited through purposive sampling to ensure a diverse and comprehensive understanding, considering variations in age, type of surgical intervention (hysterectomy with OS or hysterectomy only), geographic location, and whether the surgery was performed at a university or county hospital (21). Contact details for 500 women were obtained through the Swedish Tax Agency. Eligible women were contacted by letters that included comprehensive details about the study, an invitation to participate, a consent form, and the contact information for the first author (AD). Women interested in participating in the study contacted AD by responding via letter or email. Interview arrangements, including scheduling and location, were then made. In geographical areas with more than four respondents, an in-person meeting was proposed as the preferred setting, but a digital meeting was offered as an alternative. All respondents were offered various times to accommodate different preferences, including both daytime and evening options. Both oral and written consent were obtained from participants prior to participation in the study. Data collection A semi-structured interview guide (Supplementary data 1) was developed by the research group for this study and adjusted as needed after the first FGD to enhance the flow of the dialogue. The FGDs were conducted in Swedish, with each FGD facilitated by a moderator (AD) and supported by a notetaker (AS, MF, HE, or SK). When possible, an observer from the research team was also present during the sessions. The aim was to include 6 to 8 participants in each FGD. However, for digital sessions, a smaller group of 4 to 6 participants was preferred to encourage open and comfortable discussions. In the end, late dropouts due to personal reasons resulted in FGDs with 2 to 6 participants. Before each FGD, participants were reminded about the voluntary nature of their participation and their right to withdraw at any time without providing a reason. Saturation was deemed to have been reached after FGD4, as no new categories of perceptions or experiences emerged. FGD5 confirmed this, revealing no significant new information (22). Data analysis The interviews were transcribed verbatim by a professional secretary. When working with the transcript, notes and headings were added to both the text and margins, and units of meaning were identified and coded through open coding by AD, MF, and HE. To achieve a comprehensive understanding of the data, the recorded interviews and transcripts were reviewed multiple times, focussing on developing a broad comprehension rather than exclusively on individual informants' descriptions. The data were analysed using an inductive approach through qualitative manifest and latent content analysis inspired by Graneheim and Lundman (23). The analysis was conducted by AD, MF, and HE. The codes were compiled into subcategories, which were compared and grouped based on similarities and differences, resulting in the creation of generic categories. To ensure preservation of significant meanings throughout the analysis, continuous checks of the transcripts were carried out for content validation. Codes, subcategories, and categories were identified through open dialogue and consensus among the analysing authors (AD, MF, and HE), enhancing the credibility of the study (23). Quotes were selected to illustrate each subcategory and were translated into English by a native speaker experienced in gynaecology and qualitative research. Results Twenty Swedish-speaking women participated in five FGDs, including one in-person session and four online sessions. The background characteristics of the women included in this analysis are presented in Table 1 . The mean age at surgery was 45.8 years (range 28 to 53 years), and the mean age at the time of the interview was 50.7 years (range 35 to 58 years). The women reported a varying level of education, but the majority had high school or higher education. Heavy menstrual bleeding and fibroids were the most commonly reported indications for hysterectomy. Of the interviewed women, 75% (n = 15) had been randomised in the HOPPSA trial, whereas the remaining 25% (n = 5) had declined randomisation and were treated according to standard care. Among the randomised women, 60% underwent OS. Among the five participants who declined randomisation, three underwent salpingectomy, whereas two retained intact Fallopian tubes. All surgical procedures were performed at a county hospital. Table 1 Background characteristics of included participants (N = 20) Characteristic Mean Min-Max n (%) Age at surgery (years) 45.8 28–53 Age at interview (years) 50.7 35–58 Time since surgery (years) 4.9 2–7 Parity 2 0–4 Region of birth Sweden 18 (90%) Europe 1 (5%) Asia 1 (5%) Education level Compulsory school 1 (5%) High school 9 (45%) Higher education or university 10 (50%) Indication for surgery 1 Pelvic pain 7 (35%) Pressure symptoms 5 (25%) Menorrhagia or metrorrhagia 16 (80%) Myoma 17 (85%) Endometriosis 2 (10%) Participation in HOPPSA Randomised 15 (75%) Non-randomised 5 (25%) Fallopian tube surgery Salpingectomy 2 12 (60%) No salpingectomy 8 (40%) Fallopian tube surgery among participants declining randomisation (n = 5) Salpingectomy 3 (60%) No salpingectomy 2 (40%) Hospital where surgery was performed County hospital 20 (100%) University hospital 0 (0%) 1 Indication reported by the participants. Total > 100% due to multiple choices being possible. 2 Unilateral or bilateral salpingectomy. Three categories were identified: Decision on whether to participate in the randomised study, Deciding on opportunistic salpingectomy, and Health after surgery. Each category contains subcategories and are presented in Table 2 . The categories and subcategories are briefly summarised below, with quotes provided to enhance understanding of their meaning. Table 2 Categories and subcategories Category Subcategories Decision on whether to participate in the randomised study Let chance decide Contributing to research I know what I want Study information provided by healthcare professionals Deciding on opportunistic salpingectomy The woman's knowledge about her internal reproductive organs Women’s voices on balancing risks and benefits in decisions on tubal removal Trusting the consultant Desiring equal healthcare Health after surgery Post-operative care, information, and follow-up Awareness of menopause Living without a uterus Having regrets Decision on whether to participate in the randomised study This category summarises the thoughts and experiences women encountered when deciding whether to participate in the HOPPSA trial and whether to leave it to chance as to whether the Fallopian tubes would be removed during hysterectomy. It encompasses four subcategories: Let chance decide, Contributing to research, I know what I want, and Study information provided by healthcare professionals. Let chance decide Most women did not know Fallopian tube removal was a choice before coming to the preoperative visit. Some women expressed no thoughts or opinions about tubal removal after learning about the ongoing study. One woman described her desire to have her Fallopian tubes removed and viewed participation in the study as an opportunity to achieve this when the gynaecologist was reluctant to do so. Lack of strong feelings on the matter made the decision to participate in the study easier. “Yes, but that wasn’t really that important. I was…I wouldn’t say indifferent, but not very…it didn’t matter whether they took it [Fallopian tubes] out or not.” (FGD2) However, after the surgery, some women expressed regret about agreeing to be randomised in the study, as they had not fully understood that it could result in the Fallopian tubes being left in place. They wished they had been removed while the opportunity was available. Contributing to research Women who were willing to be randomised in the study cited contributing to research on women's health issues as a key motivator for participating. They highlighted the lack of research in this area and expressed a desire to help other women facing similar situations in the future. “I felt that too little research is done on women’s illnesses, so as far as I was concerned, it went without saying that I should participate [in the randomised study] for that reason.” (FGD4) Women advocated for equal healthcare and criticised the casual acceptance of women’s health concerns as being less significant. I know what I want A strong opinion on whether the Fallopian tubes should be removed was a significant reason for not participating in the study. The need for control and not letting anything be decided by chance was also expressed. However, some women expressed a desire for tubal removal, prioritising the potential reduction in future ovarian cancer risk. Others wished to retain their tubes, unwilling to accept the potential risk of experiencing earlier menopause. “I felt that the menopause, at the age of 47, and thought ‘No, not just yet’. Since my body has carried on functioning normally, I reckon it probably wouldn’t have made much difference whether I still had them or not, but I wasn’t ready to deal with that bit [menopausal symptoms] at that point.” (FGD4) Study information provided by healthcare professionals Women had mixed opinions on the oral and written study information they received from healthcare personnel regarding the risks and benefits of Fallopian tube removal. Though some found the information sufficient for informed decision-making, others felt it was inadequate. In response, participants sought additional details online, consulted knowledgeable friends or colleagues, or accepted participation without further inquiry. Some women were uncertain whether they fully understood the study information or realised the decision to remove their tubes would be random. Many women expressed a desire for clearer information to make a well-informed decision. "The decision will often be better if you’re part of the process, and if you get information on the pros and cons then you can be included in the process, can’t you? And of course I think that the gynaecologist should say, ‘Yes, but in this case I would recommend you have that removed anyway.’” (FGD2) Deciding on opportunistic salpingectomy This category outlines the factors influencing the decision to undergo OS and highlights the complexity of choosing whether to remove the Fallopian tubes, encompassing four subcategories: The woman's knowledge about her internal reproductive organs, Women’s voices on balancing risks and benefits in decisions on tubal removal, Trusting the consultant, and Desiring equal healthcare. The woman's knowledge about her internal reproductive organs A lack of knowledge about the anatomy and physiological functions of the female reproductive organs was identified as a barrier to participating in shared decision-making about Fallopian tube removal. Some women had difficulty distinguishing between the Fallopian tubes and ovaries and lacked knowledge about the physiology of menopause, including whether removing the uterus would trigger immediate menopause. Some felt ashamed of their lack of knowledge, which discouraged them from asking questions, despite their desire for answers. Instead, women sought information from alternative sources, such as the internet and friends. “I thought, ‘I really don’t understand.’ It says Fallopian tubes and then ovaries. And I didn’t dare ask either, to come see the doctor and ask, ‘What does this mean?’ Then they’ll think, ‘Don’t you know anything about your body?’” (FGD2) “No, I thought, but like, that’s just it. ‘What will happen now, now I’m having my uterus taken out, will I end up going through menopause?’” (FGD2) Women’s voices on balancing risks and benefits in decisions on tubal removal Women described the decision to remove the Fallopian tubes as complex, influenced by varying levels of knowledge, personal experiences, and perceptions of risk. A lack of robust scientific evidence regarding the risks and benefits, such as the extent of the reduction in ovarian cancer risk or the likelihood of early menopause, was highlighted as a challenge. “They didn’t, like, say, ‘There’s a 100% chance you’ll reduce your risk of cancer.’ It wasn’t like that, and there wasn’t a 100% chance you’d start menopause more quickly either…or that’s how I understood it anyway when I read it, that it was ‘Maybe it’s like this’ and ‘Maybe it’s like this.’ So that’s why it was a bit like, ‘Hm, what do I think is most important?’” (FGD1) “I think that if had gone down from 1–0.5% I would definitely have done it or would have wanted to do it, you know...no, but you get what I mean, menopausal symptoms that is, like I said before, I’d much rather take them than cancer because I…well, I don’t want that, if you know what I mean." (FGD5) For many, ovarian cancer was seen as particularly aggressive and frightening. Personal experiences with cancer often shaped decisions, leading to a strong desire to reduce risk whenever possible. “Because I’ve had cancer in several parts of my body and it…even if I’m alive and well, it’s...it’s a bloody great pressure weighing on the rest of my life. So if they can remove an organ in order to prevent the rest of that tissue from getting it, then, ‘Go for it,’ that’s how I feel." (FGD3) In contrast, the risks of cardiovascular disease and osteoporosis linked to early menopause were perceived as more manageable through personal actions, such as maintaining a healthy lifestyle. However, many women were unaware of these associations when deciding on tubal removal. “When they talk about cardiovascular disease and osteoporosis, it’s cardiovascular disease that’s especially scary. It is, isn’t it? But I didn’t have a clue about that, that there was any risk at all. I would probably have thought about it and reconsidered and not been completely sure if I really should have had them removed if I’d known." (FGD4) Symptom relief was frequently prioritised, with hysterectomy seen as the primary solution. Tubal removal was regarded as an additional benefit rather than a main focus, particularly for women with severe symptoms. “As far as I’m concerned, it was mostly that I just wanted to stop bleeding and I wanted them to remove my entire uterus. Whether they should leave the Fallopian tubes or not wasn’t the primary issue for me.” (FGD1) However, age was a significant factor in decision-making. Women approaching menopause often felt that the risk of earlier menopause was less relevant. “If I’d have been younger, around 30, then I probably wouldn’t have had them removed, but I was 48, wasn’t I, so I don’t think it made much difference to me." (FGD4) There was broad agreement that the role of the Fallopian tubes was no longer relevant once the uterus was removed. Some women did not consider the Fallopian tubes to be healthy organs, as they were attached to a uterus they viewed as non-functional. The Fallopian tubes were not seen as having any particular significance in terms of gender identity or perception. “I’ve had my two children and I’m not going to have any more. The organ’s [the Fallopian tubes] function is, like, more or less over.” (FGD1) Trusting the consultant There was trust in the healthcare system and in the consulting gynaecologist to make the right decisions based on what would be best for her as an individual. However, the women also expressed scepticism towards the healthcare system to not have the time to make individually adapted decisions. Women wanted consultants to discuss individual risks for illness, balancing the potential advantages of the reduction in cancer risk against the potential risk of earlier menopause so decisions could be deeply influenced by their personal health priorities and experiences. “I think it’s more about maybe, even if they have just a little time for patients nowadays, they must find the time to discuss the medical… background history: ‘What are your risks? What are your thoughts about this?’” (FGD3) Women often trusted their surgeons to carefully re-evaluate the preventive procedure of OS during surgery, balancing the risks of complications against the potential benefit. Desiring equal healthcare The participants emphasised the need for consistent guidance tailored to individual risk factors for early menopause and ovarian cancer. Participants wanted decisions about OS to be based on evidence rather than the hospital’s practices or the surgeon’s preferences. They also voiced concerns about the insufficient focus on women’s health issues and called for increased research in this field. “And so I think it’s like a lottery who you see in that case or which healthcare region it is and then no, I would rather that it be the same, based on a joint decision or if there’s any scientific research or something, not just what some doctor randomly thinks.” (FGD4) Health after surgery This category encapsulates the transformative and multifaceted experiences of women navigating life after hysterectomy, highlighting relief, lingering uncertainties, and the need for ongoing support. It consists of four subcategories: Postoperative care, information, and follow-up; Awareness of menopause; Living without a uterus; and Having regrets. Postoperative care, information, and follow-up Women experienced varying levels of support during postoperative care, ranging from indifferent and impersonal attention to compassionate and supportive care. “Everybody needs a different amount of support. And after my operation, it was just about shutting the door to my room and ‘Alright, alright, I guess I was meant to cope on my own’...Everything has been very, very...It didn’t need to have gone so wrong.”(FGD3) Some women reported uncertainty or forgetfulness about which organs were removed during surgery. Randomised patients were often unaware if their Fallopian tubes had been removed, leaving some uncomfortable with not knowing. Others, informed at the hospital, struggled to retain details, especially when receiving information in the post-operative ward. There was also a lack of clarity about expectations after surgery, particularly regarding menopausal status, with some unsure whether hysterectomy would result in menopause. “But if you still have your ovaries, then OK, I won’t start the menopause then because it still produces eggs, but where do those eggs go?... It was more that kind of thought.”(FGD2) Most women viewed the lack of postoperative follow-up negatively, emphasising the importance of assessing surgical outcomes and addressing risks associated with either removing or retaining the Fallopian tubes. Participants also highlighted the importance of a rehabilitative approach to minimise risks following surgery. They advocated for proactive measures, such as monitoring blood lipids and bone health, and providing vitamin D and calcium supplements. One participant explained: “But it’s reasonable, if you know something, that you follow it up so that it doesn’t end up like, ‘Yes, but we knew that,’ and then you get a fracture or whatever, like, and it turns out that they knew all along somehow that you could end up in that situation.” (FGD2) Awareness of menopause Menopause was portrayed in various ways, ranging from a positive perspective of it as a natural and inevitable part of ageing that required little thought, to a more negative view, as a phase of life that was not something to look forward to. For some, the surgery heightened their awareness of menopausal changes. Others reflected on the inevitability of the process and how the procedure made them more attuned to their bodies. Some women reported believing that the surgery had not influenced their time to menopause, regardless of whether the Fallopian tubes were removed. For others, the absence of bleeding made it harder to discern whether vague symptoms were due to menopause or daily stress. However, experiencing hot flashes often made menopausal symptoms easier to identify. “After my operation I was almost going around and waiting...I, like, felt in my body that ‘It’ll start now’ and ‘It’ll start now’ and I was, like, searching for symptoms.” (FGD1) Some women experienced only mild symptoms, if any, whereas others reported that menopause significantly impacted their daily lives. Symptoms of excessive sweating required frequent clothing changes and sleep disturbances led to daytime fatigue, but many expressed that they would rather endure menopausal symptoms than the issues they faced before the hysterectomy. “Menopause is a part of our natural ageing process also and then you might not want to hurry the natural ageing process along by regulating our hormone balance in an unnatural way, like you do with an operation.” (FGD5) The need for menopause counselling and support was also emphasised. One woman in FGD1 described her experience living in a Swedish municipality offering free menopause counselling for women over a certain age, calling it "very beneficial." Some women reported difficulties seeking help for menopausal symptoms, often encountering dismissive attitudes that suggested these issues were simply part of being a woman. Others highlighted challenges in accessing menopausal hormone therapy at pharmacies, noting that such issues likely would not occur if the medication was for men. “I think that we’ll all end up there eventually, but I think that what you’re telling me, it just makes you want to scream out loud. Because I think it’s terrible when they throw it in your face that, ‘Yes, but you just have to put up with it’ or ‘No, that’s what it’s like to be a woman.’” (FGD2) Living without a uterus The decision to remove the uterus was viewed as a significant and final step, symbolising the end of the childbearing phase, though few reported any special attachment to the uterus or Fallopian tubes in their perception of gender. Some women were initially hesitant, influenced by a desire to keep their bodies intact and concerns about feeling empty and losing their sense of femininity. None reported that these feelings persisted after the surgery. “I know I had thoughts wondering if I was going to have an empty feeling. Because it’s also the most beautiful thing in my body that I’ve used, isn’t it, that’s my uterus in having my children, like. It hit me that, ‘But what if it’ll feel empty and feel…’ I went around thinking about that a bit, but it hasn’t been...it hasn’t crossed my mind since then.” (FGD1) This concern also arose from women being informed that, after surgery, there was no need to seek further care from women's health services, as all their gynaecological organs had been removed. This left some questioning whether healthcare still recognised them as women. “They said, ‘Now that we’ve taken everything out, so if there’s a problem it’s not us you should come to see if you have any symptoms, it’s…’ I thought that was a bit strange, ‘Oh, ok, I see.’ So I don’t belong to being a woman anymore or why shouldn’t I keep coming to the gynae department anymore? I guess I’ll have to go elsewhere and where should I go then?” (FGD3) Women expressed fears that removing the uterus might make it harder to detect ovarian cancer. For some, monthly bleeding was seen as a sign that their gynaecological organs were functioning properly. “I’ve always thought that…well, when you’re on your period, well, it’s still, like, that your body works and things are alright.” (FGD2) There was also concern about missing symptoms of ovarian cancer or other gynaecological conditions due to the lack of regular check-ups after a hysterectomy. Some women reflected on how Pap smears had provided a sense of reassurance, not only as a test for cervical cancer, but as a general health check for gynaecological wellbeing. “When I’ve gone and had my Pap smears, and it, like, yes, it’s been like a little health checkup and so on.” (FGD2) For others, the absence of regular follow-ups after surgery left them questioning whether they should proactively seek examinations. “There aren’t so many regular follow-ups with gynae exams so...sometimes I think you should be checked up just to have them examined a bit and check that everything is OK. There’s nothing else that would be a good reason for me to go there and, like you said, well cancer could be growing for quite a while until you notice it or other people can see it.” (FGD2) The majority of women described their current lives as transformative, emphasising relief from excessive bleeding, pain, and the constant reliance on sanitary pads. “When I finally recovered it was…it was a new life, it was wonderful that it was gone, wasn’t it? So I was very pleased.” (FGD1) Many also highlighted the freedom of no longer needing to take sick leave due to their periods. “That I’m so very happy not to have to bleed, because it’s more than just the blood. It’s all the pain, as well, all the cramps. I mean, I lay there all curled up and couldn’t even move several days each month.” (FGD3) Having regrets Several women expressed regret over waiting too long to seek help for their bleeding issues, resulting in many years of suffering unnecessarily. “Perhaps I should have tried to get help sooner…because if I’d known how well it would turn out, I would have done it much earlier.” (FGD4) Some women expressed that they should have advocated more strongly for a hysterectomy, as they felt that all the attempted medical treatments only prolonged their suffering. Other women expressed regret for not following the gynaecologist’s recommendation for a hysterectomy earlier. “Maybe I feel somehow that somebody should have suggested this type of operation sooner. Because there were many, many years where I...lots of sick days just because I was on my period.” (FGD3) Discussion This study highlights the multifaceted experiences and reflections of women regarding their decisions about OS during benign hysterectomy, as well as their perceptions and experiences after surgery. The findings are organised into three key categories, each with four subcategories. Main findings Lack of strong opinions on OS and a willingness to contribute to research on women's health, seen as a chance to help other women, facilitated participation in the randomised study and leaving the decision to undergo OS to chance. Most women were unaware of OS as an option during a hysterectomy and, therefore, were highly dependent on the information provided by healthcare personnel. Insufficient study information, in terms of both limited details provided by healthcare professionals and lack of existing evidence on risks and benefits, was identified as a barrier to participation. Conversely, a strong desire to potentially reduce ovarian cancer risk or avoid earlier menopause often led to opting out of randomisation and choosing the preferred procedure. Our results are in line with a Cochrane review identifying key factors influencing the decision to participate in randomised trials, including the communication of trial information, personal influences, understanding of the risks and benefits, and a wish to contribute to research (24). Age was identified as a factor that greatly influenced the decision on OS. The closer a woman perceived herself to be to menopause, the more willing she was to have her Fallopian tubes removed, as the downside of the intervention was then perceived to be reduced. Our study highlights that patients having a hysterectomy often feel inadequately informed about the advantages and disadvantages of OS, constituting an obstacle for decision-making concerning tubal removal. This has also been reported in previous studies of women scheduled for a hysterectomy with or without OS (18) and in postoperative studies (17, 25). Most women could state a reduced risk of ovarian cancer as an advantage, but few were aware of the possible disadvantages of the procedure. This may be due to the lack of existing evidence on the preventive effect size and uncertainty of the long-term health risks after the procedure, constituting a barrier in OS counselling (17). Limited knowledge of the link between early menopause and the risks of cardiovascular disease and osteoporosis was identified. This aligns with an Australian study on menopausal risk perception, which highlighted a significant gap between the perceived and actual risk of cardiovascular disease when entering menopause (26). However, our study found that women’s primary concern with OS was the risk of experiencing menopausal symptoms earlier. Women described other risk factors for cardiovascular disease, such as not smoking and maintaining a healthy lifestyle, as likely having a greater influence on these risks than having the Fallopian tubes removed. The study revealed a desire for individualised counselling, with time allocated to explore the patient's background risk for ovarian cancer and the risks associated with early menopause, which is in line with patient-centred care. Patient involvement is essential to providing patient-centred care, with shared decision-making as a cornerstone (27). Shared decision-making is complex and involves more than just discussing the risks and benefits of a treatment; it also includes individualised communication between the patient and consultant, addressing feelings, priorities, and preferences related to those risks and benefits (28). When clinical evidence of risks and benefits is limited, as in the case of OS (8), shared decision-making becomes even more complex, emphasising the importance of consultants to engage in collaborative conversations that explore the patient’s values and preferences concerning the uncertainty of the risks and benefits (29). Moreover, consultants must recognise their own biases and how these may influence patients' decisions, potentially steering them toward the consultant's personal preferences. Women expressed mixed emotions about menopause as a natural aspect of ageing given its wide range of symptoms. However, many welcomed the relief from period-related issues, finding menopausal symptoms preferable to the challenges they faced before undergoing hysterectomy. A lack of focus on women’s health during the menopause transition after surgery was noted, with a call for better health promotion actions, especially for those undergoing salpingectomy due to the potential risks accompanying the procedure. Rehabilitative approaches and menopause counselling were highly valued. In some countries, midlife health checks are reimbursed, with the aim of improving health and access among those with lower health literacy (30). As these checkups are performed at an age when women are generally approaching the menopausal transition, this is also an opportunity to discuss possible menopausal symptoms and increase knowledge of menopause (31). Concerns were expressed about missing out on Pap smear testing after hysterectomy, reflecting that women value the reassurance of regular gynaecological check-ups. A misconception that the test served as a check-up for all gynaecological cancers was identified; this belief was also shared in a Swedish qualitative study (22) conducted in a similar setting. These concerns reveal a gap in information after hysterectomy, stressing the importance of clear guidance on cancer screening. The decision to remove the uterus was seen as final, marking the end of the childbearing phase. Though few women felt attached to the uterus, some initially feared feeling empty or less feminine after the hysterectomy, though these concerns faded post-surgery. However, previous studies noted such fears present preoperatively to persist after the procedure (32). Differences in hysterectomy rates across populations and variations in social and cultural constructs may explain the contrasting findings. Yet, none of the women in the present study indicated that the Fallopian tubes held any significance in their perception of gender, and there was consensus that the purpose of the organ was rendered irrelevant once the uterus was removed. Finally, women reflected on delays in seeking help for severe bleeding, prolonging unnecessary suffering. Some wished they had opted for a hysterectomy sooner or advocated more strongly for it. Regrets about agreeing to randomisation in the HOPPSA trial were also expressed, with participants feeling they missed out on the chance to reduce the risk of ovarian cancer. Strengths and limitations A strength of this study is that it addressed the central concepts of trustworthiness, dependability, confirmability, transferability, and credibility throughout the whole process of the study (33). Recruitment of participants was conducted through purposive sampling, ensuring diversity, including variations in age, type of surgical intervention (hysterectomy with OS or hysterectomy only), and geographic location across Sweden, which strengthens the credibility of the study. Another strength is the wide variation in education level among participants. Including participants with diverse experiences enhances the likelihood of exploring the research question from multiple perspectives. However, recruitment was conducted through letters sent to eligible patients and it is possible that respondents were more likely to express satisfaction after surgery or have complaints compared to non-respondents. In addition, patients with limited health literacy may have opted not to participate. Furthermore, conducting all interviews exclusively in Swedish may have restricted the inclusion of perspectives from other cultural backgrounds. The transcripts were independently coded by members of the research team. The construction of subcategories and categories was carried out through triangulation until consensus was achieved, enhancing the study's dependability. To enhance the understanding of each subcategory and support interpretation and abstraction, quotes were included, strengthening the study's confirmability. The quotes were translated by a native English speaker with extensive experience in the field of gynaecology in collaboration with the first author to ensure correct interpretation during the translation. The research team consisted of consultants in gynaecology and obstetrics, two senior consultants in gynaecology and obstetrics, and a senior consultant midwife, all of whom have experience across various areas of women's health. This provides understanding and knowledge about the subjects discussed in the interviews, strengthening the credibility and offering deeper insight into women's experiences with hysterectomy. However, this can also constitute a limitation due to potential bias from preconceived notions. A limitation of our study was the inability to conduct face-to-face meetings because patients were geographically spread across Sweden, which often restricted us to digital meetings. However, some women in the digital meetings expressed that they preferred this alternative because it did not require time to travel to and from the hospital for interviews, an issue reported as a potential barrier to participation in this study. In addition, participants in all FGDs, whether digital or face-to-face, expressed appreciation and comfort in sharing their opinions in both settings. This suggests that the meetings fostered an open atmosphere where participants could freely express their feelings, which supports the credibility of the results. The main findings of the study, the need for improved communication and personalised care to enhance shared decision-making regarding OS during hysterectomy, are likely to be a global health issue. Despite cultural differences in the perception of ovarian cancer risk, views on menopause, and variation in the prevalence of ovarian cancer (34), the vasomotor symptoms (35) and potential long-term health effects of the menopausal transition at a younger age may influence transferability to other settings. Conclusion This study underscores the complexity of decision-making regarding OS during benign hysterectomy. Factors such as health illiteracy, personal priorities, past experiences, and the lack of robust evidence on OS risks and benefits significantly influence women's choices. These factors must be addressed during consultations to support informed decision-making aligned with patient-centred care principles. Given the limited clinical evidence on OS, shared decision-making becomes even more important. This study also emphasises the need for enhanced post-operative care and health promotion, including discussions on post-operative health expectations related to the menopausal transition. A major concern for women was the potential impact of OS on menopausal symptoms, stressing the need for further research on this topic. The findings of this study emphasise the need for and may contribute to the development of a decision aid tool to promote shared decision-making and improve OS counselling. Such a tool could enhance patient involvement, facilitate informed choices, and ultimately improve patient satisfaction with their surgical care. Declarations Availability of data and materials Not applicable Disclosure of interests The authors have no competing interests to declare. Funding This research was supported by grants from the foundation of Hjalmar Svensson (grant number HJSV2024048), the Swedish Cancer Society (CAN 21 1408 PJ and CAN 21-848 PJ), and the Swedish state under the ALF-agreement (grant numbers ALFGBG-971191 and ALFGBG-1005815). Acknowledgements We would like to express our sincere gratitude to the participating women for their time and effort in sharing their perceptions on the issues addressed in this study. Special thanks to Annette Nattland for transcribing all of the interviews, and to Joy Ellis for translating the quotes. Author contributions All authors designed the study and contributed to the construction of the interview guide and the gathering of data. AD, MF, and HE analysed the data. AD wrote the first draft of the manuscript, which was thereafter critically reviewed and revised by all authors. All authors have read and approved the final version of the manuscript. Ethics approval and consent to participate The study received approval from the Swedish Ethical Review Authority (Dnr: 2024-01592-02, 24April 2024). Oral and written consent were obtained prior to participation. References Kurman RJ, Shih Ie M. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol. 2010;34(3):433-43. Piek JM, van Diest PJ, Zweemer RP, Jansen JW, Poort-Keesom RJ, Menko FH, et al. Dysplastic changes in prophylactically removed Fallopian tubes of women predisposed to developing ovarian cancer. J Pathol. 2001;195(4):451-6. Mandelbaum RS, Adams CL, Yoshihara K, Nusbaum DJ, Matsuzaki S, Matsushima K, et al. The rapid adoption of opportunistic salpingectomy at the time of hysterectomy for benign gynecologic disease in the United States. Am J Obstet Gynecol. 2020;223(5):721 e1- e18. Runnebaum IB, Kather A, Vorwergk J, Cruz JJ, Mothes AR, Beteta CR, et al. Ovarian cancer prevention by opportunistic salpingectomy is a new de facto standard in Germany. J Cancer Res Clin Oncol. 2023;149(10):6953-66. Kaur P, Rufin K, Finlayson SJ, Huntsman DG, Kwon JS, McAlpine JN, et al. Opportunistic Salpingectomy Between 2017 and 2020: A Descriptive Analysis. J Obstet Gynaecol Can. 2024;46(4):102278. Collins E, Strandell A, Granasen G, Idahl A. Menopausal symptoms and surgical complications after opportunistic bilateral salpingectomy, a register-based cohort study. Am J Obstet Gynecol. 2019;220(1):85 e1- e10. Gelderblom ME, IntHout J, Dagovic L, Hermens R, Piek JMJ, de Hullu JA. The effect of opportunistic salpingectomy for primary prevention of ovarian cancer on ovarian reserve: a systematic review and meta-analysis. Maturitas. 2022;166:21-34. van Lieshout LAM, Steenbeek MP, De Hullu JA, Vos MC, Houterman S, Wilkinson J, et al. Hysterectomy with opportunistic salpingectomy versus hysterectomy alone. Cochrane Database Syst Rev. 2019;8(8):CD012858. Darelius A, Lycke M, Kindblom JM, Kristjansdottir B, Sundfeldt K, Strandell A. Efficacy of salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer: a systematic review. BJOG. 2017;124(6):880-9. Mishra GD, Davies MC, Hillman S, Chung HF, Roy S, Maclaran K, et al. Optimising health after early menopause. Lancet. 2024;403(10430):958-68. Idahl A, Darelius A, Sundfeldt K, Palsson M, Strandell A. Hysterectomy and opportunistic salpingectomy (HOPPSA): study protocol for a register-based randomized controlled trial. Trials. 2019;20(1):10. Ntoumanoglou-Schuiki A, Tomasch G, Laky R, Taumberger N, Bjelic-Radisic V, Tamussino K. Opportunistic prophylactic salpingectomy for prevention of ovarian cancer: What do national societies advise? Eur J Obstet Gynecol Reprod Biol. 2018;225:110-2. Steenbeek MP, van Lieshout LAM, Aarts JWM, Piek JMJ, Coppus S, Massuger L, et al. Factors influencing decision-making around opportunistic salpingectomy: a nationwide survey. J Gynecol Oncol. 2019;30(1):e2. Britten N, Ekman I, Naldemirci O, Javinger M, Hedman H, Wolf A. Learning from Gothenburg model of person centred healthcare. BMJ. 2020;370:m2738. WHO. Framework on integrated, people-centred health services: WHO secretariat 2016. http://apps.who.int/gb/ebwha/pdf_files/2016 [cited 2024 March 2nd]. Reade CJ, Finlayson S, McAlpine J, Tone AA, Fung-Kee-Fung M, Ferguson SE. Risk-reducing salpingectomy in Canada: a survey of obstetrician-gynaecologists. J Obstet Gynaecol Can. 2013;35(7):627-34. Gelderblom ME, Van Lieshout LAM, Piek JMJ, De Hullu JA, Hermens R. Patients' and professionals' perspectives on implementation of opportunistic salpingectomy: a mixed-method study. BMC Health Serv Res. 2021;21(1):736. Collins E, Lindqvist M, Mogren I, Idahl A. Bridging different realities - a qualitative study on patients' experiences of preoperative care for benign hysterectomy and opportunistic salpingectomy in Sweden. BMC Womens Health. 2020;20(1):198. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-51. Wilkinson S. Focus group methodology: a review. International Journal of Social Research Methodology. 1998;1 (3):181-203. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753-60. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-907. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12. Houghton C, Dowling M, Meskell P, Hunter A, Gardner H, Conway A, et al. Factors that impact on recruitment to randomised trials in health care: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;10(10):MR000045. Adams JC, Conner M, Wong J, Knittel A, Louie M. Patient preferences regarding the cervix, ovaries, and fallopian tubes at the time of hysterectomy: a qualitative study. Women Health. 2024;64(10):783-92. Deeks A, Zoungas S, Teede H. Risk perception in women: a focus on menopause. Menopause. 2008;15(2):304-9. Hedberg B, Wijk H, Andersson Gare B, Petersson C. Shared decision-making and person-centred care in Sweden: Exploring coproduction of health and social care services. Z Evid Fortbild Qual Gesundhwes. 2022;171:129-34. Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021;104(7):1591-5. Politi MC, Lewis CL, Frosch DL. Supporting shared decisions when clinical evidence is low. Med Care Res Rev. 2013;70(1 Suppl):113S-28S. Wilson LF, Dobson AJ, Mishra GD, Doust JA. Preventive health checks in Australian general practice for women during mid-life. Med J Aust. 2023;219(9):429-31. Gynaecologists TRAaNZCoOa. Menopause: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2025 [Available from: https://ranzcog.edu.au/wp-content/uploads/Menopause.pdf. Silva Cde M, Vargens OM. Woman experiencing gynecologic surgery: coping with the changes imposed by surgery. Rev Lat Am Enfermagem. 2016;24:e2780. Graneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today. 2017;56:29-34. Cabasag CJ, Fagan PJ, Ferlay J, Vignat J, Laversanne M, Liu L, et al. Ovarian cancer today and tomorrow: A global assessment by world region and Human Development Index using GLOBOCAN 2020. Int J Cancer. 2022;151(9):1535-41. Kingsberg SA, Schulze-Rath R, Mulligan C, Moeller C, Caetano C, Bitzer J. Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review. Climacteric. 2023;26(6):537-49. Additional Declarations No competing interests reported. Supplementary Files Interviewguide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 May, 2025 Reviews received at journal 30 Apr, 2025 Reviews received at journal 28 Apr, 2025 Reviewers agreed at journal 27 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviewers invited by journal 20 Apr, 2025 Editor assigned by journal 16 Apr, 2025 Editor invited by journal 25 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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This procedure is carried out during abdominal or pelvic surgery performed for an unrelated reason, such as hysterectomy or sterilisation. It is performed as a preventive measure to lower the risk of ovarian cancer based on observational evidence that many cases of ovarian cancer originate in the Fallopian tubes (1, 2). The adoption of OS is increasing both in Sweden and globally (3\u0026ndash;6) despite several systematic reviews emphasising the lack of sufficient evidence on potential negative effects (7\u0026ndash;9). Concerns include the risk of surgical complications from the additional procedure and a potential negative impact on ovarian function, which may contribute to menopause at a lower age. The hormonal transition in early menopause is associated with an increased risk of cardiovascular disease, osteoporosis, and mortality (10). However, these issues remain insufficiently clarified and require further investigation to guide future recommendations regarding the risks and benefits of OS.\u003c/p\u003e \u003cp\u003eHOPPSA (Hysterectomy and OPPortunistic SAlpingectomy) is an ongoing Swedish register-based randomised controlled trial that was registered at clinicaltrials.gov (NCT03045965) on 8 February 2017 (11). Consenting women under 55 years of age who were scheduled for benign hysterectomy were randomised to either hysterectomy with OS or hysterectomy only. The aim of the trial was to evaluate the risks and benefits of OS. To date, recommendations regarding OS differ between countries; some national societies have issued statements recommending OS as a preventive measure, whereas others, including Sweden, have taken a more cautious stance, opting to await the results of the HOPPSA trial before making definitive recommendations (12). As a result, the topic remains controversial and widely debated among gynaecologists. The lack of consensus contributes to significant variability in clinical practice and patient counselling, not only across hospitals, but even among individual surgeons (13). This variation, which is often driven by the preferences of the gynaecologists rather than by the informed choices of the patients, is problematic and inconsistent with the principles of patient-centred care (14). To facilitate shared decision-making, professional healthcare should focus on the individual\u0026rsquo;s needs, respect their preferences, and promote their active participation in healthcare decisions, in line with the principles outlined by the World Health Organization (15).\u003c/p\u003e \u003cp\u003eFactors influencing decision-making regarding OS have been studied primarily from the gynaecologist\u0026rsquo;s point of view (13, 16), but some studies have been from the patient\u0026rsquo;s perspective (17, 18). A Swedish qualitative interview study conducted with women awaiting hysterectomy highlighted health literacy and dependency on consultants as limitations to achieving shared decision-making regarding the preventive intervention (18). Women\u0026rsquo;s experiences and perceptions of the risks and benefits of hysterectomy with or without OS several years after surgery have not yet been studied. The aim of the present study was to explore women\u0026rsquo;s perceptions of the risks and benefits of OS with a focus on the factors influencing their decisions regarding OS, their participation in a randomised trial, and the procedure's lasting impact.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch design\u003c/h2\u003e \u003cp\u003eWe used an exploratory qualitative study design to gain a deeper understanding of how women under 55 years of age perceive and experience the risks and benefits of OS following hysterectomy for benign reasons. A qualitative study design enables in-depth exploration of individuals' experiences within their natural context. This approach has proven particularly valuable in areas where existing knowledge on the study topic is limited (19). Focus group discussions (FGDs) were chosen as the data collection method, as they are well-suited for exploring people's perceptions and views on a special topic (20). The study's findings are presented in accordance with Standards for Reporting Qualitative Research (SRQR) guidelines (19).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePopulation\u003c/h3\u003e\n\u003cp\u003eEligible women in this study were recruited among women who were randomised in HOPPSA and among women who declined randomisation but agreed to participate in the follow-up without being randomised (11). Women were recruited through purposive sampling to ensure a diverse and comprehensive understanding, considering variations in age, type of surgical intervention (hysterectomy with OS or hysterectomy only), geographic location, and whether the surgery was performed at a university or county hospital (21). Contact details for 500 women were obtained through the Swedish Tax Agency. Eligible women were contacted by letters that included comprehensive details about the study, an invitation to participate, a consent form, and the contact information for the first author (AD). Women interested in participating in the study contacted AD by responding via letter or email. Interview arrangements, including scheduling and location, were then made. In geographical areas with more than four respondents, an in-person meeting was proposed as the preferred setting, but a digital meeting was offered as an alternative. All respondents were offered various times to accommodate different preferences, including both daytime and evening options. Both oral and written consent were obtained from participants prior to participation in the study.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e A semi-structured interview guide (Supplementary data 1) was developed by the research group for this study and adjusted as needed after the first FGD to enhance the flow of the dialogue. The FGDs were conducted in Swedish, with each FGD facilitated by a moderator (AD) and supported by a notetaker (AS, MF, HE, or SK). When possible, an observer from the research team was also present during the sessions. The aim was to include 6 to 8 participants in each FGD. However, for digital sessions, a smaller group of 4 to 6 participants was preferred to encourage open and comfortable discussions. In the end, late dropouts due to personal reasons resulted in FGDs with 2 to 6 participants. Before each FGD, participants were reminded about the voluntary nature of their participation and their right to withdraw at any time without providing a reason. Saturation was deemed to have been reached after FGD4, as no new categories of perceptions or experiences emerged. FGD5 confirmed this, revealing no significant new information (22).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe interviews were transcribed verbatim by a professional secretary. When working with the transcript, notes and headings were added to both the text and margins, and units of meaning were identified and coded through open coding by AD, MF, and HE. To achieve a comprehensive understanding of the data, the recorded interviews and transcripts were reviewed multiple times, focussing on developing a broad comprehension rather than exclusively on individual informants' descriptions. The data were analysed using an inductive approach through qualitative manifest and latent content analysis inspired by Graneheim and Lundman (23). The analysis was conducted by AD, MF, and HE. The codes were compiled into subcategories, which were compared and grouped based on similarities and differences, resulting in the creation of generic categories. To ensure preservation of significant meanings throughout the analysis, continuous checks of the transcripts were carried out for content validation. Codes, subcategories, and categories were identified through open dialogue and consensus among the analysing authors (AD, MF, and HE), enhancing the credibility of the study (23). Quotes were selected to illustrate each subcategory and were translated into English by a native speaker experienced in gynaecology and qualitative research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty Swedish-speaking women participated in five FGDs, including one in-person session and four online sessions. The background characteristics of the women included in this analysis are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age at surgery was 45.8 years (range 28 to 53 years), and the mean age at the time of the interview was 50.7 years (range 35 to 58 years). The women reported a varying level of education, but the majority had high school or higher education. Heavy menstrual bleeding and fibroids were the most commonly reported indications for hysterectomy. Of the interviewed women, 75% (n\u0026thinsp;=\u0026thinsp;15) had been randomised in the HOPPSA trial, whereas the remaining 25% (n\u0026thinsp;=\u0026thinsp;5) had declined randomisation and were treated according to standard care. Among the randomised women, 60% underwent OS. Among the five participants who declined randomisation, three underwent salpingectomy, whereas two retained intact Fallopian tubes. All surgical procedures were performed at a county hospital.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBackground characteristics of included participants (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMin-Max\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026ndash;53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at interview (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u0026ndash;58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime since surgery (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(90%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompulsory school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(45%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education or university\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for surgery\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePressure symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia or metrorrhagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(80%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipation in HOPPSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRandomised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-randomised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFallopian tube surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalpingectomy\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo salpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFallopian tube surgery among participants declining randomisation (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo salpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital where surgery was performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCounty hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e1\u003c/sup\u003eIndication reported by the participants. Total\u0026thinsp;\u0026gt;\u0026thinsp;100% due to multiple choices being possible.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e2\u003c/sup\u003eUnilateral or bilateral salpingectomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree categories were identified: Decision on whether to participate in the randomised study, Deciding on opportunistic salpingectomy, and Health after surgery. Each category contains subcategories and are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The categories and subcategories are briefly summarised below, with quotes provided to enhance understanding of their meaning.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and subcategories\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDecision on whether to participate in the randomised study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLet chance decide\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContributing to research\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI know what I want\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy information provided by healthcare professionals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDeciding on opportunistic salpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe woman's knowledge about her internal reproductive organs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u0026rsquo;s voices on balancing risks and benefits in\u003c/p\u003e \u003cp\u003edecisions on tubal removal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrusting the consultant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesiring equal healthcare\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHealth after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-operative care, information, and follow-up\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness of menopause\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiving without a uterus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHaving regrets\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDecision on whether to participate in the randomised study\u003c/h2\u003e \u003cp\u003eThis category summarises the thoughts and experiences women encountered when deciding whether to participate in the HOPPSA trial and whether to leave it to chance as to whether the Fallopian tubes would be removed during hysterectomy. It encompasses four subcategories: Let chance decide, Contributing to research, I know what I want, and Study information provided by healthcare professionals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLet chance decide\u003c/h3\u003e\n\u003cp\u003eMost women did not know Fallopian tube removal was a choice before coming to the preoperative visit. Some women expressed no thoughts or opinions about tubal removal after learning about the ongoing study. One woman described her desire to have her Fallopian tubes removed and viewed participation in the study as an opportunity to achieve this when the gynaecologist was reluctant to do so. Lack of strong feelings on the matter made the decision to participate in the study easier.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, but that wasn\u0026rsquo;t really that important. I was\u0026hellip;I wouldn\u0026rsquo;t say indifferent, but not very\u0026hellip;it didn\u0026rsquo;t matter whether they took it [Fallopian tubes] out or not.\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, after the surgery, some women expressed regret about agreeing to be randomised in the study, as they had not fully understood that it could result in the Fallopian tubes being left in place. They wished they had been removed while the opportunity was available.\u003c/p\u003e\n\u003ch3\u003eContributing to research\u003c/h3\u003e\n\u003cp\u003eWomen who were willing to be randomised in the study cited contributing to research on women's health issues as a key motivator for participating. They highlighted the lack of research in this area and expressed a desire to help other women facing similar situations in the future.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I felt that too little research is done on women\u0026rsquo;s illnesses, so as far as I was concerned, it went without saying that I should participate [in the randomised study] for that reason.\u0026rdquo; (FGD4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWomen advocated for equal healthcare and criticised the casual acceptance of women\u0026rsquo;s health concerns as being less significant.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eI know what I want\u003c/h2\u003e \u003cp\u003eA strong opinion on whether the Fallopian tubes should be removed was a significant reason for not participating in the study. The need for control and not letting anything be decided by chance was also expressed. However, some women expressed a desire for tubal removal, prioritising the potential reduction in future ovarian cancer risk. Others wished to retain their tubes, unwilling to accept the potential risk of experiencing earlier menopause.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I felt that the menopause, at the age of 47, and thought \u0026lsquo;No, not just yet\u0026rsquo;. Since my body has carried on functioning normally, I reckon it probably wouldn\u0026rsquo;t have made much difference whether I still had them or not, but I wasn\u0026rsquo;t ready to deal with that bit [menopausal symptoms] at that point.\u0026rdquo; (FGD4)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy information provided by healthcare professionals\u003c/h2\u003e \u003cp\u003eWomen had mixed opinions on the oral and written study information they received from healthcare personnel regarding the risks and benefits of Fallopian tube removal. Though some found the information sufficient for informed decision-making, others felt it was inadequate. In response, participants sought additional details online, consulted knowledgeable friends or colleagues, or accepted participation without further inquiry. Some women were uncertain whether they fully understood the study information or realised the decision to remove their tubes would be random.\u003c/p\u003e \u003cp\u003eMany women expressed a desire for clearer information to make a well-informed decision.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The decision will often be better if you\u0026rsquo;re part of the process, and if you get information on the pros and cons then you can be included in the process, can\u0026rsquo;t you? And of course I think that the gynaecologist should say, \u0026lsquo;Yes, but in this case I would recommend you have that removed anyway.\u0026rsquo;\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDeciding on opportunistic salpingectomy\u003c/h2\u003e \u003cp\u003eThis category outlines the factors influencing the decision to undergo OS and highlights the complexity of choosing whether to remove the Fallopian tubes, encompassing four subcategories: The woman's knowledge about her internal reproductive organs, Women\u0026rsquo;s voices on balancing risks and benefits in decisions on tubal removal, Trusting the consultant, and Desiring equal healthcare.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe woman's knowledge about her internal reproductive organs\u003c/h2\u003e \u003cp\u003eA lack of knowledge about the anatomy and physiological functions of the female reproductive organs was identified as a barrier to participating in shared decision-making about Fallopian tube removal. Some women had difficulty distinguishing between the Fallopian tubes and ovaries and lacked knowledge about the physiology of menopause, including whether removing the uterus would trigger immediate menopause. Some felt ashamed of their lack of knowledge, which discouraged them from asking questions, despite their desire for answers. Instead, women sought information from alternative sources, such as the internet and friends.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I thought, \u0026lsquo;I really don\u0026rsquo;t understand.\u0026rsquo; It says Fallopian tubes and then ovaries. And I didn\u0026rsquo;t dare ask either, to come see the doctor and ask, \u0026lsquo;What does this mean?\u0026rsquo; Then they\u0026rsquo;ll think, \u0026lsquo;Don\u0026rsquo;t you know anything about your body?\u0026rsquo;\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;No, I thought, but like, that\u0026rsquo;s just it. \u0026lsquo;What will happen now, now I\u0026rsquo;m having my uterus taken out, will I end up going through menopause?\u0026rsquo;\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eWomen\u0026rsquo;s voices on balancing risks and benefits in decisions on tubal removal\u003c/h2\u003e \u003cp\u003eWomen described the decision to remove the Fallopian tubes as complex, influenced by varying levels of knowledge, personal experiences, and perceptions of risk. A lack of robust scientific evidence regarding the risks and benefits, such as the extent of the reduction in ovarian cancer risk or the likelihood of early menopause, was highlighted as a challenge.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They didn\u0026rsquo;t, like, say, \u0026lsquo;There\u0026rsquo;s a 100% chance you\u0026rsquo;ll reduce your risk of cancer.\u0026rsquo; It wasn\u0026rsquo;t like that, and there wasn\u0026rsquo;t a 100% chance you\u0026rsquo;d start menopause more quickly either\u0026hellip;or that\u0026rsquo;s how I understood it anyway when I read it, that it was \u0026lsquo;Maybe it\u0026rsquo;s like this\u0026rsquo; and \u0026lsquo;Maybe it\u0026rsquo;s like this.\u0026rsquo; So that\u0026rsquo;s why it was a bit like, \u0026lsquo;Hm, what do I think is most important?\u0026rsquo;\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think that if had gone down from 1\u0026ndash;0.5% I would definitely have done it or would have wanted to do it, you know...no, but you get what I mean, menopausal symptoms that is, like I said before, I\u0026rsquo;d much rather take them than cancer because I\u0026hellip;well, I don\u0026rsquo;t want that, if you know what I mean.\" (FGD5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor many, ovarian cancer was seen as particularly aggressive and frightening. Personal experiences with cancer often shaped decisions, leading to a strong desire to reduce risk whenever possible.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because I\u0026rsquo;ve had cancer in several parts of my body and it\u0026hellip;even if I\u0026rsquo;m alive and well, it\u0026rsquo;s...it\u0026rsquo;s a bloody great pressure weighing on the rest of my life. So if they can remove an organ in order to prevent the rest of that tissue from getting it, then, \u0026lsquo;Go for it,\u0026rsquo; that\u0026rsquo;s how I feel.\" (FGD3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn contrast, the risks of cardiovascular disease and osteoporosis linked to early menopause were perceived as more manageable through personal actions, such as maintaining a healthy lifestyle. However, many women were unaware of these associations when deciding on tubal removal.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When they talk about cardiovascular disease and osteoporosis, it\u0026rsquo;s cardiovascular disease that\u0026rsquo;s especially scary. It is, isn\u0026rsquo;t it? But I didn\u0026rsquo;t have a clue about that, that there was any risk at all. I would probably have thought about it and reconsidered and not been completely sure if I really should have had them removed if I\u0026rsquo;d known.\" (FGD4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSymptom relief was frequently prioritised, with hysterectomy seen as the primary solution. Tubal removal was regarded as an additional benefit rather than a main focus, particularly for women with severe symptoms.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As far as I\u0026rsquo;m concerned, it was mostly that I just wanted to stop bleeding and I wanted them to remove my entire uterus. Whether they should leave the Fallopian tubes or not wasn\u0026rsquo;t the primary issue for me.\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, age was a significant factor in decision-making. Women approaching menopause often felt that the risk of earlier menopause was less relevant.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If I\u0026rsquo;d have been younger, around 30, then I probably wouldn\u0026rsquo;t have had them removed, but I was 48, wasn\u0026rsquo;t I, so I don\u0026rsquo;t think it made much difference to me.\" (FGD4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere was broad agreement that the role of the Fallopian tubes was no longer relevant once the uterus was removed. Some women did not consider the Fallopian tubes to be healthy organs, as they were attached to a uterus they viewed as non-functional. The Fallopian tubes were not seen as having any particular significance in terms of gender identity or perception.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had my two children and I\u0026rsquo;m not going to have any more. The organ\u0026rsquo;s [the Fallopian tubes] function is, like, more or less over.\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTrusting the consultant\u003c/h2\u003e \u003cp\u003eThere was trust in the healthcare system and in the consulting gynaecologist to make the right decisions based on what would be best for her as an individual. However, the women also expressed scepticism towards the healthcare system to not have the time to make individually adapted decisions. Women wanted consultants to discuss individual risks for illness, balancing the potential advantages of the reduction in cancer risk against the potential risk of earlier menopause so decisions could be deeply influenced by their personal health priorities and experiences.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s more about maybe, even if they have just a little time for patients nowadays, they must find the time to discuss the medical\u0026hellip; background history: \u0026lsquo;What are your risks? What are your thoughts about this?\u0026rsquo;\u0026rdquo; (FGD3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWomen often trusted their surgeons to carefully re-evaluate the preventive procedure of OS during surgery, balancing the risks of complications against the potential benefit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDesiring equal healthcare\u003c/h2\u003e \u003cp\u003eThe participants emphasised the need for consistent guidance tailored to individual risk factors for early menopause and ovarian cancer. Participants wanted decisions about OS to be based on evidence rather than the hospital\u0026rsquo;s practices or the surgeon\u0026rsquo;s preferences. They also voiced concerns about the insufficient focus on women\u0026rsquo;s health issues and called for increased research in this field.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;And so I think it\u0026rsquo;s like a lottery who you see in that case or which healthcare region it is and then no, I would rather that it be the same, based on a joint decision or if there\u0026rsquo;s any scientific research or something, not just what some doctor randomly thinks.\u0026rdquo; (FGD4)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHealth after surgery\u003c/h2\u003e \u003cp\u003eThis category encapsulates the transformative and multifaceted experiences of women navigating life after hysterectomy, highlighting relief, lingering uncertainties, and the need for ongoing support. It consists of four subcategories: Postoperative care, information, and follow-up; Awareness of menopause; Living without a uterus; and Having regrets.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative care, information, and follow-up\u003c/h2\u003e \u003cp\u003eWomen experienced varying levels of support during postoperative care, ranging from indifferent and impersonal attention to compassionate and supportive care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Everybody needs a different amount of support. And after my operation, it was just about shutting the door to my room and \u0026lsquo;Alright, alright, I guess I was meant to cope on my own\u0026rsquo;...Everything has been very, very...It didn\u0026rsquo;t need to have gone so wrong.\u0026rdquo;(FGD3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome women reported uncertainty or forgetfulness about which organs were removed during surgery. Randomised patients were often unaware if their Fallopian tubes had been removed, leaving some uncomfortable with not knowing. Others, informed at the hospital, struggled to retain details, especially when receiving information in the post-operative ward.\u003c/p\u003e \u003cp\u003eThere was also a lack of clarity about expectations after surgery, particularly regarding menopausal status, with some unsure whether hysterectomy would result in menopause.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;But if you still have your ovaries, then OK, I won\u0026rsquo;t start the menopause then because it still produces eggs, but where do those eggs go?... It was more that kind of thought.\u0026rdquo;(FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMost women viewed the lack of postoperative follow-up negatively, emphasising the importance of assessing surgical outcomes and addressing risks associated with either removing or retaining the Fallopian tubes. Participants also highlighted the importance of a rehabilitative approach to minimise risks following surgery. They advocated for proactive measures, such as monitoring blood lipids and bone health, and providing vitamin D and calcium supplements. One participant explained:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;But it\u0026rsquo;s reasonable, if you know something, that you follow it up so that it doesn\u0026rsquo;t end up like, \u0026lsquo;Yes, but we knew that,\u0026rsquo; and then you get a fracture or whatever, like, and it turns out that they knew all along somehow that you could end up in that situation.\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAwareness of menopause\u003c/h2\u003e \u003cp\u003eMenopause was portrayed in various ways, ranging from a positive perspective of it as a natural and inevitable part of ageing that required little thought, to a more negative view, as a phase of life that was not something to look forward to. For some, the surgery heightened their awareness of menopausal changes. Others reflected on the inevitability of the process and how the procedure made them more attuned to their bodies. Some women reported believing that the surgery had not influenced their time to menopause, regardless of whether the Fallopian tubes were removed. For others, the absence of bleeding made it harder to discern whether vague symptoms were due to menopause or daily stress. However, experiencing hot flashes often made menopausal symptoms easier to identify.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;After my operation I was almost going around and waiting...I, like, felt in my body that \u0026lsquo;It\u0026rsquo;ll start now\u0026rsquo; and \u0026lsquo;It\u0026rsquo;ll start now\u0026rsquo; and I was, like, searching for symptoms.\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome women experienced only mild symptoms, if any, whereas others reported that menopause significantly impacted their daily lives. Symptoms of excessive sweating required frequent clothing changes and sleep disturbances led to daytime fatigue, but many expressed that they would rather endure menopausal symptoms than the issues they faced before the hysterectomy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Menopause is a part of our natural ageing process also and then you might not want to hurry the natural ageing process along by regulating our hormone balance in an unnatural way, like you do with an operation.\u0026rdquo; (FGD5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe need for menopause counselling and support was also emphasised. One woman in FGD1 described her experience living in a Swedish municipality offering free menopause counselling for women over a certain age, calling it \u003cem\u003e\"very beneficial.\"\u003c/em\u003e Some women reported difficulties seeking help for menopausal symptoms, often encountering dismissive attitudes that suggested these issues were simply part of being a woman. Others highlighted challenges in accessing menopausal hormone therapy at pharmacies, noting that such issues likely would not occur if the medication was for men.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think that we\u0026rsquo;ll all end up there eventually, but I think that what you\u0026rsquo;re telling me, it just makes you want to scream out loud. Because I think it\u0026rsquo;s terrible when they throw it in your face that, \u0026lsquo;Yes, but you just have to put up with it\u0026rsquo; or \u0026lsquo;No, that\u0026rsquo;s what it\u0026rsquo;s like to be a woman.\u0026rsquo;\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLiving without a uterus\u003c/h2\u003e \u003cp\u003eThe decision to remove the uterus was viewed as a significant and final step, symbolising the end of the childbearing phase, though few reported any special attachment to the uterus or Fallopian tubes in their perception of gender. Some women were initially hesitant, influenced by a desire to keep their bodies intact and concerns about feeling empty and losing their sense of femininity. None reported that these feelings persisted after the surgery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I know I had thoughts wondering if I was going to have an empty feeling. Because it\u0026rsquo;s also the most beautiful thing in my body that I\u0026rsquo;ve used, isn\u0026rsquo;t it, that\u0026rsquo;s my uterus in having my children, like. It hit me that, \u0026lsquo;But what if it\u0026rsquo;ll feel empty and feel\u0026hellip;\u0026rsquo; I went around thinking about that a bit, but it hasn\u0026rsquo;t been...it hasn\u0026rsquo;t crossed my mind since then.\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis concern also arose from women being informed that, after surgery, there was no need to seek further care from women's health services, as all their gynaecological organs had been removed. This left some questioning whether healthcare still recognised them as women.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They said, \u0026lsquo;Now that we\u0026rsquo;ve taken everything out, so if there\u0026rsquo;s a problem it\u0026rsquo;s not us you should come to see if you have any symptoms, it\u0026rsquo;s\u0026hellip;\u0026rsquo; I thought that was a bit strange, \u0026lsquo;Oh, ok, I see.\u0026rsquo; So I don\u0026rsquo;t belong to being a woman anymore or why shouldn\u0026rsquo;t I keep coming to the gynae department anymore? I guess I\u0026rsquo;ll have to go elsewhere and where should I go then?\u0026rdquo; (FGD3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWomen expressed fears that removing the uterus might make it harder to detect ovarian cancer. For some, monthly bleeding was seen as a sign that their gynaecological organs were functioning properly.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve always thought that\u0026hellip;well, when you\u0026rsquo;re on your period, well, it\u0026rsquo;s still, like, that your body works and things are alright.\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere was also concern about missing symptoms of ovarian cancer or other gynaecological conditions due to the lack of regular check-ups after a hysterectomy. Some women reflected on how Pap smears had provided a sense of reassurance, not only as a test for cervical cancer, but as a general health check for gynaecological wellbeing.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I\u0026rsquo;ve gone and had my Pap smears, and it, like, yes, it\u0026rsquo;s been like a little health checkup and so on.\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor others, the absence of regular follow-ups after surgery left them questioning whether they should proactively seek examinations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There aren\u0026rsquo;t so many regular follow-ups with gynae exams so...sometimes I think you should be checked up just to have them examined a bit and check that everything is OK. There\u0026rsquo;s nothing else that would be a good reason for me to go there and, like you said, well cancer could be growing for quite a while until you notice it or other people can see it.\u0026rdquo; (FGD2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe majority of women described their current lives as transformative, emphasising relief from excessive bleeding, pain, and the constant reliance on sanitary pads.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I finally recovered it was\u0026hellip;it was a new life, it was wonderful that it was gone, wasn\u0026rsquo;t it? So I was very pleased.\u0026rdquo; (FGD1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany also highlighted the freedom of no longer needing to take sick leave due to their periods.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That I\u0026rsquo;m so very happy not to have to bleed, because it\u0026rsquo;s more than just the blood. It\u0026rsquo;s all the pain, as well, all the cramps. I mean, I lay there all curled up and couldn\u0026rsquo;t even move several days each month.\u0026rdquo; (FGD3)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eHaving regrets\u003c/h2\u003e \u003cp\u003eSeveral women expressed regret over waiting too long to seek help for their bleeding issues, resulting in many years of suffering unnecessarily.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Perhaps I should have tried to get help sooner\u0026hellip;because if I\u0026rsquo;d known how well it would turn out, I would have done it much earlier.\u0026rdquo; (FGD4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome women expressed that they should have advocated more strongly for a hysterectomy, as they felt that all the attempted medical treatments only prolonged their suffering. Other women expressed regret for not following the gynaecologist\u0026rsquo;s recommendation for a hysterectomy earlier.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Maybe I feel somehow that somebody should have suggested this type of operation sooner. Because there were many, many years where I...lots of sick days just because I was on my period.\u0026rdquo; (FGD3)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the multifaceted experiences and reflections of women regarding their decisions about OS during benign hysterectomy, as well as their perceptions and experiences after surgery. The findings are organised into three key categories, each with four subcategories.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003eLack of strong opinions on OS and a willingness to contribute to research on women's health, seen as a chance to help other women, facilitated participation in the randomised study and leaving the decision to undergo OS to chance. Most women were unaware of OS as an option during a hysterectomy and, therefore, were highly dependent on the information provided by healthcare personnel. Insufficient study information, in terms of both limited details provided by healthcare professionals and lack of existing evidence on risks and benefits, was identified as a barrier to participation. Conversely, a strong desire to potentially reduce ovarian cancer risk or avoid earlier menopause often led to opting out of randomisation and choosing the preferred procedure. Our results are in line with a Cochrane review identifying key factors influencing the decision to participate in randomised trials, including the communication of trial information, personal influences, understanding of the risks and benefits, and a wish to contribute to research (24).\u003c/p\u003e \u003cp\u003eAge was identified as a factor that greatly influenced the decision on OS. The closer a woman perceived herself to be to menopause, the more willing she was to have her Fallopian tubes removed, as the downside of the intervention was then perceived to be reduced.\u003c/p\u003e \u003cp\u003eOur study highlights that patients having a hysterectomy often feel inadequately informed about the advantages and disadvantages of OS, constituting an obstacle for decision-making concerning tubal removal. This has also been reported in previous studies of women scheduled for a hysterectomy with or without OS (18) and in postoperative studies (17, 25). Most women could state a reduced risk of ovarian cancer as an advantage, but few were aware of the possible disadvantages of the procedure. This may be due to the lack of existing evidence on the preventive effect size and uncertainty of the long-term health risks after the procedure, constituting a barrier in OS counselling (17).\u003c/p\u003e \u003cp\u003eLimited knowledge of the link between early menopause and the risks of cardiovascular disease and osteoporosis was identified. This aligns with an Australian study on menopausal risk perception, which highlighted a significant gap between the perceived and actual risk of cardiovascular disease when entering menopause (26). However, our study found that women\u0026rsquo;s primary concern with OS was the risk of experiencing menopausal symptoms earlier. Women described other risk factors for cardiovascular disease, such as not smoking and maintaining a healthy lifestyle, as likely having a greater influence on these risks than having the Fallopian tubes removed. The study revealed a desire for individualised counselling, with time allocated to explore the patient's background risk for ovarian cancer and the risks associated with early menopause, which is in line with patient-centred care. Patient involvement is essential to providing patient-centred care, with shared decision-making as a cornerstone (27). Shared decision-making is complex and involves more than just discussing the risks and benefits of a treatment; it also includes individualised communication between the patient and consultant, addressing feelings, priorities, and preferences related to those risks and benefits (28). When clinical evidence of risks and benefits is limited, as in the case of OS (8), shared decision-making becomes even more complex, emphasising the importance of consultants to engage in collaborative conversations that explore the patient\u0026rsquo;s values and preferences concerning the uncertainty of the risks and benefits (29). Moreover, consultants must recognise their own biases and how these may influence patients' decisions, potentially steering them toward the consultant's personal preferences.\u003c/p\u003e \u003cp\u003eWomen expressed mixed emotions about menopause as a natural aspect of ageing given its wide range of symptoms. However, many welcomed the relief from period-related issues, finding menopausal symptoms preferable to the challenges they faced before undergoing hysterectomy. A lack of focus on women\u0026rsquo;s health during the menopause transition after surgery was noted, with a call for better health promotion actions, especially for those undergoing salpingectomy due to the potential risks accompanying the procedure. Rehabilitative approaches and menopause counselling were highly valued. In some countries, midlife health checks are reimbursed, with the aim of improving health and access among those with lower health literacy (30). As these checkups are performed at an age when women are generally approaching the menopausal transition, this is also an opportunity to discuss possible menopausal symptoms and increase knowledge of menopause (31).\u003c/p\u003e \u003cp\u003eConcerns were expressed about missing out on Pap smear testing after hysterectomy, reflecting that women value the reassurance of regular gynaecological check-ups. A misconception that the test served as a check-up for all gynaecological cancers was identified; this belief was also shared in a Swedish qualitative study (22) conducted in a similar setting. These concerns reveal a gap in information after hysterectomy, stressing the importance of clear guidance on cancer screening.\u003c/p\u003e \u003cp\u003eThe decision to remove the uterus was seen as final, marking the end of the childbearing phase. Though few women felt attached to the uterus, some initially feared feeling empty or less feminine after the hysterectomy, though these concerns faded post-surgery. However, previous studies noted such fears present preoperatively to persist after the procedure (32). Differences in hysterectomy rates across populations and variations in social and cultural constructs may explain the contrasting findings. Yet, none of the women in the present study indicated that the Fallopian tubes held any significance in their perception of gender, and there was consensus that the purpose of the organ was rendered irrelevant once the uterus was removed. Finally, women reflected on delays in seeking help for severe bleeding, prolonging unnecessary suffering. Some wished they had opted for a hysterectomy sooner or advocated more strongly for it. Regrets about agreeing to randomisation in the HOPPSA trial were also expressed, with participants feeling they missed out on the chance to reduce the risk of ovarian cancer.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA strength of this study is that it addressed the central concepts of trustworthiness, dependability, confirmability, transferability, and credibility throughout the whole process of the study (33). Recruitment of participants was conducted through purposive sampling, ensuring diversity, including variations in age, type of surgical intervention (hysterectomy with OS or hysterectomy only), and geographic location across Sweden, which strengthens the credibility of the study. Another strength is the wide variation in education level among participants. Including participants with diverse experiences enhances the likelihood of exploring the research question from multiple perspectives. However, recruitment was conducted through letters sent to eligible patients and it is possible that respondents were more likely to express satisfaction after surgery or have complaints compared to non-respondents. In addition, patients with limited health literacy may have opted not to participate. Furthermore, conducting all interviews exclusively in Swedish may have restricted the inclusion of perspectives from other cultural backgrounds.\u003c/p\u003e \u003cp\u003eThe transcripts were independently coded by members of the research team. The construction of subcategories and categories was carried out through triangulation until consensus was achieved, enhancing the study's dependability. To enhance the understanding of each subcategory and support interpretation and abstraction, quotes were included, strengthening the study's confirmability. The quotes were translated by a native English speaker with extensive experience in the field of gynaecology in collaboration with the first author to ensure correct interpretation during the translation.\u003c/p\u003e \u003cp\u003eThe research team consisted of consultants in gynaecology and obstetrics, two senior consultants in gynaecology and obstetrics, and a senior consultant midwife, all of whom have experience across various areas of women's health. This provides understanding and knowledge about the subjects discussed in the interviews, strengthening the credibility and offering deeper insight into women's experiences with hysterectomy. However, this can also constitute a limitation due to potential bias from preconceived notions.\u003c/p\u003e \u003cp\u003eA limitation of our study was the inability to conduct face-to-face meetings because patients were geographically spread across Sweden, which often restricted us to digital meetings. However, some women in the digital meetings expressed that they preferred this alternative because it did not require time to travel to and from the hospital for interviews, an issue reported as a potential barrier to participation in this study. In addition, participants in all FGDs, whether digital or face-to-face, expressed appreciation and comfort in sharing their opinions in both settings. This suggests that the meetings fostered an open atmosphere where participants could freely express their feelings, which supports the credibility of the results. The main findings of the study, the need for improved communication and personalised care to enhance shared decision-making regarding OS during hysterectomy, are likely to be a global health issue. Despite cultural differences in the perception of ovarian cancer risk, views on menopause, and variation in the prevalence of ovarian cancer (34), the vasomotor symptoms (35) and potential long-term health effects of the menopausal transition at a younger age may influence transferability to other settings.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the complexity of decision-making regarding OS during benign hysterectomy. Factors such as health illiteracy, personal priorities, past experiences, and the lack of robust evidence on OS risks and benefits significantly influence women's choices. These factors must be addressed during consultations to support informed decision-making aligned with patient-centred care principles. Given the limited clinical evidence on OS, shared decision-making becomes even more important.\u003c/p\u003e \u003cp\u003eThis study also emphasises the need for enhanced post-operative care and health promotion, including discussions on post-operative health expectations related to the menopausal transition. A major concern for women was the potential impact of OS on menopausal symptoms, stressing the need for further research on this topic.\u003c/p\u003e \u003cp\u003eThe findings of this study emphasise the need for and may contribute to the development of a decision aid tool to promote shared decision-making and improve OS counselling. Such a tool could enhance patient involvement, facilitate informed choices, and ultimately improve patient satisfaction with their surgical care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eDisclosure of interests\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research was supported by grants from the foundation of Hjalmar Svensson (grant number HJSV2024048), the Swedish Cancer Society (CAN 21 1408 PJ and CAN 21-848 PJ), and the Swedish state under the ALF-agreement (grant numbers ALFGBG-971191 and ALFGBG-1005815).\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the participating women for their time and effort in sharing their perceptions on the issues addressed in this study. Special thanks to Annette Nattland for transcribing all of the interviews, and to Joy Ellis for translating the quotes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eAll authors designed the study and contributed to the construction of the interview guide and the gathering of data. AD, MF, and HE analysed the data. AD wrote the first draft of the manuscript, which was\u0026nbsp;thereafter critically reviewed and revised by all authors. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Swedish Ethical Review Authority (Dnr: 2024-01592-02, 24April 2024). Oral and written consent were obtained prior to participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKurman RJ, Shih Ie M. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol. 2010;34(3):433-43.\u003c/li\u003e\n\u003cli\u003ePiek JM, van Diest PJ, Zweemer RP, Jansen JW, Poort-Keesom RJ, Menko FH, et al. Dysplastic changes in prophylactically removed Fallopian tubes of women predisposed to developing ovarian cancer. J Pathol. 2001;195(4):451-6.\u003c/li\u003e\n\u003cli\u003eMandelbaum RS, Adams CL, Yoshihara K, Nusbaum DJ, Matsuzaki S, Matsushima K, et al. The rapid adoption of opportunistic salpingectomy at the time of hysterectomy for benign gynecologic disease in the United States. Am J Obstet Gynecol. 2020;223(5):721 e1- e18.\u003c/li\u003e\n\u003cli\u003eRunnebaum IB, Kather A, Vorwergk J, Cruz JJ, Mothes AR, Beteta CR, et al. Ovarian cancer prevention by opportunistic salpingectomy is a new de facto standard in Germany. J Cancer Res Clin Oncol. 2023;149(10):6953-66.\u003c/li\u003e\n\u003cli\u003eKaur P, Rufin K, Finlayson SJ, Huntsman DG, Kwon JS, McAlpine JN, et al. Opportunistic Salpingectomy Between 2017 and 2020: A Descriptive Analysis. J Obstet Gynaecol Can. 2024;46(4):102278.\u003c/li\u003e\n\u003cli\u003eCollins E, Strandell A, Granasen G, Idahl A. Menopausal symptoms and surgical complications after opportunistic bilateral salpingectomy, a register-based cohort study. Am J Obstet Gynecol. 2019;220(1):85 e1- e10.\u003c/li\u003e\n\u003cli\u003eGelderblom ME, IntHout J, Dagovic L, Hermens R, Piek JMJ, de Hullu JA. The effect of opportunistic salpingectomy for primary prevention of ovarian cancer on ovarian reserve: a systematic review and meta-analysis. Maturitas. 2022;166:21-34.\u003c/li\u003e\n\u003cli\u003evan Lieshout LAM, Steenbeek MP, De Hullu JA, Vos MC, Houterman S, Wilkinson J, et al. Hysterectomy with opportunistic salpingectomy versus hysterectomy alone. Cochrane Database Syst Rev. 2019;8(8):CD012858.\u003c/li\u003e\n\u003cli\u003eDarelius A, Lycke M, Kindblom JM, Kristjansdottir B, Sundfeldt K, Strandell A. Efficacy of salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer: a systematic review. BJOG. 2017;124(6):880-9.\u003c/li\u003e\n\u003cli\u003eMishra GD, Davies MC, Hillman S, Chung HF, Roy S, Maclaran K, et al. Optimising health after early menopause. Lancet. 2024;403(10430):958-68.\u003c/li\u003e\n\u003cli\u003eIdahl A, Darelius A, Sundfeldt K, Palsson M, Strandell A. Hysterectomy and opportunistic salpingectomy (HOPPSA): study protocol for a register-based randomized controlled trial. Trials. 2019;20(1):10.\u003c/li\u003e\n\u003cli\u003eNtoumanoglou-Schuiki A, Tomasch G, Laky R, Taumberger N, Bjelic-Radisic V, Tamussino K. Opportunistic prophylactic salpingectomy for prevention of ovarian cancer: What do national societies advise? Eur J Obstet Gynecol Reprod Biol. 2018;225:110-2.\u003c/li\u003e\n\u003cli\u003eSteenbeek MP, van Lieshout LAM, Aarts JWM, Piek JMJ, Coppus S, Massuger L, et al. Factors influencing decision-making around opportunistic salpingectomy: a nationwide survey. J Gynecol Oncol. 2019;30(1):e2.\u003c/li\u003e\n\u003cli\u003eBritten N, Ekman I, Naldemirci O, Javinger M, Hedman H, Wolf A. Learning from Gothenburg model of person centred healthcare. BMJ. 2020;370:m2738.\u003c/li\u003e\n\u003cli\u003eWHO. Framework on integrated, people-centred health services: WHO secretariat 2016. http://apps.who.int/gb/ebwha/pdf_files/2016 [cited 2024 March 2nd].\u003c/li\u003e\n\u003cli\u003eReade CJ, Finlayson S, McAlpine J, Tone AA, Fung-Kee-Fung M, Ferguson SE. Risk-reducing salpingectomy in Canada: a survey of obstetrician-gynaecologists. J Obstet Gynaecol Can. 2013;35(7):627-34.\u003c/li\u003e\n\u003cli\u003eGelderblom ME, Van Lieshout LAM, Piek JMJ, De Hullu JA, Hermens R. Patients\u0026apos; and professionals\u0026apos; perspectives on implementation of opportunistic salpingectomy: a mixed-method study. BMC Health Serv Res. 2021;21(1):736.\u003c/li\u003e\n\u003cli\u003eCollins E, Lindqvist M, Mogren I, Idahl A. Bridging different realities - a qualitative study on patients\u0026apos; experiences of preoperative care for benign hysterectomy and opportunistic salpingectomy in Sweden. BMC Womens Health. 2020;20(1):198.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-51.\u003c/li\u003e\n\u003cli\u003eWilkinson S. Focus group methodology: a review. International Journal of Social Research Methodology. 1998;1 (3):181-203.\u003c/li\u003e\n\u003cli\u003eMalterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753-60.\u003c/li\u003e\n\u003cli\u003eSaunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-907.\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12.\u003c/li\u003e\n\u003cli\u003eHoughton C, Dowling M, Meskell P, Hunter A, Gardner H, Conway A, et al. Factors that impact on recruitment to randomised trials in health care: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;10(10):MR000045.\u003c/li\u003e\n\u003cli\u003eAdams JC, Conner M, Wong J, Knittel A, Louie M. Patient preferences regarding the cervix, ovaries, and fallopian tubes at the time of hysterectomy: a qualitative study. Women Health. 2024;64(10):783-92.\u003c/li\u003e\n\u003cli\u003eDeeks A, Zoungas S, Teede H. Risk perception in women: a focus on menopause. Menopause. 2008;15(2):304-9.\u003c/li\u003e\n\u003cli\u003eHedberg B, Wijk H, Andersson Gare B, Petersson C. Shared decision-making and person-centred care in Sweden: Exploring coproduction of health and social care services. Z Evid Fortbild Qual Gesundhwes. 2022;171:129-34.\u003c/li\u003e\n\u003cli\u003eElwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021;104(7):1591-5.\u003c/li\u003e\n\u003cli\u003ePoliti MC, Lewis CL, Frosch DL. Supporting shared decisions when clinical evidence is low. Med Care Res Rev. 2013;70(1 Suppl):113S-28S.\u003c/li\u003e\n\u003cli\u003eWilson LF, Dobson AJ, Mishra GD, Doust JA. Preventive health checks in Australian general practice for women during mid-life. Med J Aust. 2023;219(9):429-31.\u003c/li\u003e\n\u003cli\u003eGynaecologists TRAaNZCoOa. Menopause: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2025 [Available from: https://ranzcog.edu.au/wp-content/uploads/Menopause.pdf.\u003c/li\u003e\n\u003cli\u003eSilva Cde M, Vargens OM. Woman experiencing gynecologic surgery: coping with the changes imposed by surgery. Rev Lat Am Enfermagem. 2016;24:e2780.\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today. 2017;56:29-34.\u003c/li\u003e\n\u003cli\u003eCabasag CJ, Fagan PJ, Ferlay J, Vignat J, Laversanne M, Liu L, et al. Ovarian cancer today and tomorrow: A global assessment by world region and Human Development Index using GLOBOCAN 2020. Int J Cancer. 2022;151(9):1535-41.\u003c/li\u003e\n\u003cli\u003eKingsberg SA, Schulze-Rath R, Mulligan C, Moeller C, Caetano C, Bitzer J. Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review. Climacteric. 2023;26(6):537-49.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Opportunistic salpingectomy, hysterectomy, shared decision-making, qualitative, ovarian cancer, early menopause, focus group discussion","lastPublishedDoi":"10.21203/rs.3.rs-6210685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6210685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOpportunistic salpingectomy performed during benign hysterectomy to reduce ovarian cancer risk has uncertain long-term effects on ovarian function, potentially resulting in earlier menopause. As opportunistic salpingectomy is performed as a preventive intervention without a medical indication, it is essential that the decision to undergo the procedure be made through a shared decision-making process. This study explores women\u0026rsquo;s perceptions and experiences of opportunistic salpingectomy, factors influencing their decision to participate in a randomised trial, and the lasting impact of the procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative interview study with focus group discussions was conducted with women who had undergone hysterectomy with or without opportunistic salpingectomy 2\u0026ndash;7 years prior. Women were recruited from the HOPPSA (Hysterectomy and OPPortunistic SAlpingectomy) cohort through purposive sampling. HOPPSA is a randomised controlled trial in which women aged\u0026thinsp;\u0026lt;\u0026thinsp;55 years undergoing benign hysterectomy were randomised to hysterectomy with or without opportunistic salpingectomy. Focus group discussions guided by a semi-structured format were recorded digitally, transcribed verbatim, and analysed using qualitative manifest and latent content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty women (mean age 45.8 years, range 28\u0026ndash;53 years) with varying indications for hysterectomy participated in this study. Fifteen were randomised in HOPPSA, whereas five declined randomisation but joined the follow-up. The analysis identified three categories: Decision on whether to participate in the randomised trial, Deciding on opportunistic salpingectomy, and Health after surgery. Participation in HOPPSA stemmed from a desire to contribute to research or acceptance to let chance decide on tubal removal, though some participants later expressed regret. Limited information from healthcare personnel on the risks and benefits of opportunistic salpingectomy hindered shared decision-making. After surgery, women noted an inadequate focus on health during menopause.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDecision-making regarding opportunistic salpingectomy is complex and influenced by health illiteracy, personal priorities, and trust in healthcare. Findings highlight the need for personalised consultations on the preventive procedure and long-term support during the transition to menopause. When clinical evidence on risks and benefits is limited, such as for opportunistic salpingectomy, shared decision-making is crucial.\u003c/p\u003e","manuscriptTitle":"Hysterectomised women’s perceptions and experiences of the risks and benefits of opportunistic salpingectomy: A qualitative interview study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-22 08:32:03","doi":"10.21203/rs.3.rs-6210685/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-05-01T14:31:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T19:50:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-28T07:55:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311758697132280029049485803017735543391","date":"2025-04-27T17:35:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5283081731790261425069292529879259450","date":"2025-04-23T14:15:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130643908198553497432396026635580530204","date":"2025-04-21T14:33:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-21T03:27:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-16T10:01:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-25T04:46:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T14:27:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-03-24T14:26:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30bc0019-31ea-4b0c-a9d2-3c45046bc6a1","owner":[],"postedDate":"April 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-22T08:32:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-22 08:32:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6210685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6210685","identity":"rs-6210685","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}