Prophylactic oophorectomy in premenopausal women and long-term health

Sex-based differences in vascular function

Cardiovascular disease is the leading cause of morbidity and mortality for both men and women in the USA. However, there are differences between the sexes in age-dependent onset, severity, symptoms and outcomes. Basic research into the causes of sex-dependent differences in cardiovascular disease is ongoing and includes investigation into genetic variation in expression and distribution of receptors for the sex steroids; specificity of natural and synthetic ligands that activate the sex steroid receptors; and intracellular mechanisms that are activated by the receptors in all components of the vessel wall and blood elements, which integrate to regulate vascular tone, vascular repair and remodeling in health and disease. In this era of personalized medicine, basic research into mechanisms of sex differences in vascular function will result in improved prevention, detection and treatment of cardiovascular disease in both men and women.

Oophorectomy, menopause, estrogen treatment, and cognitive aging: clinical evidence for a window of opportunity

The neuroprotective effects of estrogen have been demonstrated consistently in cellular and animal studies but the evidence in women remains conflicted. We explored the window of opportunity hypothesis in relation to cognitive aging and dementia. In particular, we reviewed existing literature, reanalyzed some of our data, and combined results graphically. Current evidence suggests that estrogen may have beneficial, neutral, or detrimental effects on the brain depending on age at the time of treatment, type of menopause (natural versus medically or surgically induced), or stage of menopause. The comparison of women who underwent bilateral oophorectomy with referent women provided evidence for a sizeable neuroprotective effect of estrogen before age 50 years. Several case-control studies and cohort studies also showed neuroprotective effects in women who received estrogen treatment (ET) in the early postmenopausal stage (most commonly at ages 50-60 years). The majority of women in those observational studies had undergone natural menopause and were treated for the relief of menopausal symptoms. However, recent clinical trials by the Women's Health Initiative showed that women who initiated ET alone or in combination with a progestin in the late postmenopausal stage (ages 65-79 years) experienced an increased risk of dementia and cognitive decline regardless of the type of menopause. The current conflicting data can be explained by the window of opportunity hypothesis suggesting that the neuroprotective effects of estrogen depend on age at the time of administration, type of menopause, and stage of menopause. Therefore, women who underwent bilateral oophorectomy before the onset of menopause or women who experienced premature or early natural menopause should be considered for hormonal treatment until approximately age 51 years.

New strategies in ovarian cancer: uptake and experience of women at high risk of ovarian cancer who are considering risk-reducing salpingo-oophorectomy

Here, we review factors associated with uptake of risk-reducing salpingo-oophorectomy by women at increased hereditary risk for ovarian cancer, as well as quality of life issues following surgery. Forty-one research studies identified through PubMed and PsychInfo met inclusion criteria. Older age, having had children, a family history of ovarian cancer, a personal history of breast cancer, prophylactic mastectomy, and BRCA1/2 mutation carrier status increase the likelihood of undergoing surgery. Psychosocial variables predictive of surgery uptake include greater perceived risk of ovarian cancer and cancer-related anxiety. Most women report satisfaction with their decision to undergo surgery and both lower perceived ovarian cancer risk and less cancer-related anxiety as benefits. Hormonal deprivation is the main disadvantage reported, particularly by premenopausal women who are not on hormonal replacement therapy (HRT). The evidence is mixed about satisfaction with the level of information provided prior to surgery, although generally, women report receiving insufficient information about the pros and cons of HRT. These findings indicate that when designing decision aids, demographic, medical history, and psychosocial variables need to be addressed in order to facilitate quality decision making.

Cognitive functions in long-term survivors of ovarian cancer

BACKGROUND

Women diagnosed with ovarian cancer often undergo chemotherapy involving multiple agents. However, little is known about the incidence of cognitive adverse effects of chemotherapy in survivors of this disease. This cross-sectional study assessed neuropsychological functions in long-term survivors of ovarian cancer who were either in complete remission or with evidence of recurrent disease.

METHODS

Forty-eight women diagnosed with ovarian cancer 5 to 10 years prior to study enrollment underwent a brief neuropsychological evaluation; 22 patients were disease free and without history of recurrence (Group 1), and 26 patients had recurrent disease and were receiving treatment with chemotherapy or hormonal therapy (Group 2).

RESULTS

There were no statistically significant differences between the two patient groups on tests of attention, memory, and executive functions. Group mean cognitive test scores were within the average range on all tests; however 28% of patients met criteria for cognitive impairment, a significantly higher frequency (p=0.03) than reported in healthy populations.

CONCLUSIONS

In this study, neuropsychological test performance did not differ significantly between ovarian cancer survivors who were in remission and patients with recurrent disease and receiving treatment. Cognitive impairment was evident in a subset of patients, although group means test scores were within the average range. Additional research using prospective longitudinal designs is needed to clarify the contribution of disease, chemotherapy, hormonal therapy, and other risk factors to cognitive outcome in this clinical population.

Long-term deprivation of gonadal hormone accelerates brain aging in mice

OBJECTIVE

The purpose of this study was to assess the effect of long-term deprivation of gonadal hormone on brain aging in mice to develop a model of gonadectomy-accelerated brain aging.

METHODS

Male and female mice at 2 months old were orchiectomized (ORX) or ovarectomized (OVX) bilaterally or sham operated, and then they were fed for 10 months. The spatial learning and memory ability was tested using Morris Water Maze. The biomarkers of brain neuropathology were examined by Western blotting and immunohistochemistry.

RESULTS

Ovarectomy mildly impaired spatial learning and memory of mice, while the impairment in ORX-mice was not significant. The amount of Nissl bodies decreased in the hippocampus and cortex of gonadectomied mice. The expression of beta-amyloid (Aβ), beta-site APP cleaving enzyme 1 and phosphorylated-Tau increased in gonadectomied mice. Nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) decreased in the brain of OVX-mice, but neurotrophin-3 (NT-3) showed no change. We detected no decrease of NGF, BDNF or NT-3 in ORX-mice. TrkA expression decreased and p75(NTR) increased in the brain of gonadectomied mice. In all the above tests, there were no significant differences between young (2 months old) and sham operated (12 months old) mice. Alternations in the brain aging parameters were more obvious in OVX-mice than in ORX-mice.

CONCLUSION

Long-term gonadal hormone deprivation by young-age gonadectomy accelerated mouse brain aging, which could serve as a valuable mouse model to study brain aging and aging-related pathological changes.

Postmenopausal hormone therapy: an Endocrine Society scientific statement

OBJECTIVE

Our objective was to provide a scholarly review of the published literature on menopausal hormonal therapy (MHT), make scientifically valid assessments of the available data, and grade the level of evidence available for each clinically important endpoint. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The 12-member Scientific Statement Task Force of The Endocrine Society selected the leader of the statement development group (R.J.S.) and suggested experts with expertise in specific areas. In conjunction with the Task Force, lead authors (n = 25) and peer reviewers (n = 14) for each specific topic were selected. All discussions regarding content and grading of evidence occurred via teleconference or electronic and written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

Each expert conducted extensive literature searches of case control, cohort, and randomized controlled trials as well as meta-analyses, Cochrane reviews, and Position Statements from other professional societies in order to compile and evaluate available evidence. No unpublished data were used to draw conclusions from the evidence.

CONSENSUS PROCESS

A consensus was reached after several iterations. Each topic was considered separately, and a consensus was achieved as to content to be included and conclusions reached between the primary author and the peer reviewer specific to that topic. In a separate iteration, the quality of evidence was judged using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system in common use by The Endocrine Society for preparing clinical guidelines. The final iteration involved responses to four levels of additional review: 1) general comments offered by each of the 25 authors; 2) comments of the individual Task Force members; 3) critiques by the reviewers of the Journal of Clinical Endocrinology & Metabolism; and 4) suggestions offered by the Council and members of The Endocrine Society. The lead author compiled each individual topic into a coherent document and finalized the content for the final Statement. The writing process was analogous to preparation of a multiauthored textbook with input from individual authors and the textbook editors.

CONCLUSIONS

The major conclusions related to the overall benefits and risks of MHT expressed as the number of women per 1000 taking MHT for 5 yr who would experience benefit or harm. Primary areas of benefit included relief of hot flashes and symptoms of urogenital atrophy and prevention of fractures and diabetes. Risks included venothrombotic episodes, stroke, and cholecystitis. In the subgroup of women starting MHT between ages 50 and 59 or less than 10 yr after onset of menopause, congruent trends suggested additional benefit including reduction of overall mortality and coronary artery disease. In this subgroup, estrogen plus some progestogens increased the risk of breast cancer, whereas estrogen alone did not. Beneficial effects on colorectal and endometrial cancer and harmful effects on ovarian cancer occurred but affected only a small number of women. Data from the various Women's Health Initiative studies, which involved women of average age 63, cannot be appropriately applied to calculate risks and benefits of MHT in women starting shortly after menopause. At the present time, assessments of benefit and risk in these younger women are based on lower levels of evidence.

Evaluation of serum CA-125 levels for preoperative counseling in endometrioid endometrial cancer: a multi-center study

OBJECTIVE

To evaluate the role of serum CA-125 levels for preoperative counseling in endometrioid endometrial cancer (EEC).

METHODS

We reviewed 413 patients with EEC from 6 tertiary medical centers between July 1996 and June 2008. All patients were divided into (1) 4 categories of preoperative serum CA-125 levels: <18 U/mL (n=203); 18-35 U/mL (n=114); 36-70 U/mL (n=53); >70 U/mL (n=43) or (2) 3 categories: low-risk (n=240); intermediate-risk (n=99); high-risk diseases (n=74).

RESULTS

Receiver operative curves showed the best cut-off values of 16.2-40.8 U/mL for predicting prognostic factors with 53.4-84.2% of sensitivity, 43.9-81.7% of specificity, 48.8-82.1% of positive predictive value (PPV), 48.5-83.8% of negative predictive value (NPV) and 48.6-83.0% of accuracy. Especially, adnexal involvement was predicted with the highest accuracy (83.0%) at >or=40.8 U/mL. The best cut-off values for preoperative selection of intermediate- to high-risk, and high-risk diseases were 17.3 U/mL and 21.9 U/mL (62.4% and 68.9% of sensitivity; 54.6% and 64.3% of specificity; 57.9% and 64.2% of PPV; 59.2% and 67.4% of NPV, 58.5% and 65.8% of accuracy). Furthermore, >70 U/mL of preoperative serum CA-125 levels was a prognostic factor for poor progression-free and overall survivals.

CONCLUSIONS

Serum CA-125 levels may not be useful for predicting most of prognostic factors, and may not contribute to preoperative selection of patients with intermediate- or high-risk disease who need adjuvant radiotherapy in EEC. However, serum CA-125 levels may be helpful in preoperative counseling for young patients who want ovarian preservation, and >70 U/mL could be considered as a risk factor for poor survival.

Characterization of an animal model of postmenopausal cardiac hypertrophy and novel mechanisms responsible for cardiac decompensation using ovariectomized pressure-overloaded rats

OBJECTIVE

The development of animal models of cardiovascular disease are critical to define pathophysiological mechanisms and to advance diagnosis and therapy. The lack of a suitable animal model represents a failure to define the mechanisms responsible for postmenopausal myocardial hypertrophy in hypertension and adverse cardiac remodeling.

METHODS

In this review, we presented a rat model of postmenopausal myocardial hypertrophy, with particular focus on the similarities between the animal model and postmenopausal women regarding myocardial function as well as molecular and subcellular mechanisms. To elucidate the molecular mechanism of left ventricular (LV) hypertrophy and remodeling in postmenopausal women, we analyzed myocardial hypertrophy as well as cardiac function and hypertrophy-related protein expression in ovariectomized (OVX) and pressure overloaded (PO) rats.

RESULTS

The model is characterized by depletion of serum estrogen and increased heart-to-body weight and lung-to-body weight ratios. Moreover, the OVX-PO rats also show increased mean arterial blood pressure, LV end-diastolic pressure, LV developed pressure, and maximal rates of LV contraction and relaxation compared with the OVX group. Importantly, Akt activity was largely attenuated, and both endothelial nitric oxide synthase expression and activity were markedly reduced in the OVX-PO group. Finally, significant increased mortality was observed in the OVX-PO group after chronic isoproterenol administration.

CONCLUSIONS

Our results demonstrate that rats subject to OVX are unable to compensate for hypertrophy partly due to impaired Akt-endothelial nitric oxide synthase signaling along with deteriorated heart function and demonstrated increased mortality. In this review, we discussed the mechanisms of cardiac injury, which could play a critical role in postmenopausal hypertrophy, as well as the characteristics of the OVX-PO female rats as a model to test cardioprotective drugs in postmenopausal women.

Oophorectomy, menopause, estrogen, and cognitive aging: the timing hypothesis

BACKGROUND

The concept of neuroprotective effects of estrogen in women remains controversial.

OBJECTIVE

To explore the timing hypothesis in relation to cognitive aging and dementia.

METHODS

We reviewed existing literature, conducted some reanalyses, and combined results graphically.

RESULTS

Current evidence suggests that estrogen may have either protective effects or harmful effects on the brain depending on age, type of menopause (natural versus surgical), or stage of menopause. The comparison of women with ovarian conservation versus women who underwent bilateral oophorectomy provided evidence for a sizeable neuroprotective effect of estrogen in women in the premenopausal years (most commonly before age 50 years). Several case-control studies and cohort studies also showed a neuroprotective effect in women who received estrogen treatment in the early postmenopausal phase (most commonly at ages 50-60 years). However, recent clinical trials showed that women who initiated estrogen treatment in the late postmenopausal phase (ages 65-79 years) experienced an increased risk of dementia and cognitive decline.

CONCLUSION

The neuroprotective effects of estrogen depend on age, type of menopause, and stage of menopause (timing hypothesis).

MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization

OBJECTIVE

The purpose of this article is to describe the role of MR, CT, and PET/CT in the detection of ovarian cancer and the evaluation of adnexal lesions.

CONCLUSION

The goal of imaging in ovarian cancer detection is to expeditiously distinguish benign adnexal lesions from those requiring further pathologic evaluation for malignancy. For lesions indeterminate on ultrasound, MRI increases the specificity of imaging evaluation, thus decreasing benign resections. CT is useful in diagnosis and treatment planning of advanced cancer. Although (18)F-FDG-avid ovarian lesions in postmenopausal women are considered suspicious for malignancy, PET/CT is not recommended for primary cancer detection because of high false-positive rates.

Exercise for the management of side effects and quality of life among cancer survivors

Physical activity may play an important role in the rehabilitation of cancer survivors during and after treatment. Current research suggests that numerous beneficial outcomes are experienced in cancer survivors undergoing exercise interventions during or after cancer treatment. Exercise not only plays a role in managing side effects but also improves functional capacity and quality of life. The purpose of this article is to provide an overview of the oncology literature supporting the use of exercise as an effective intervention for improving cancer-related fatigue, other side effects, functional capacity, and quality of life among cancer survivors.

Estrogen attenuates ischemic oxidative damage via an estrogen receptor alpha-mediated inhibition of NADPH oxidase activation

The goal of this study was to elucidate the mechanisms of 17beta-estradiol (E(2)) antioxidant and neuroprotective actions in stroke. The results reveal a novel extranuclear receptor-mediated antioxidant mechanism for E(2) during stroke, as well as a hypersensitivity of the CA3/CA4 region to ischemic injury after prolonged hypoestrogenicity. E(2) neuroprotection was shown to involve a profound attenuation of NADPH oxidase activation and superoxide production in hippocampal CA1 pyramidal neurons after stroke, an effect mediated by extranuclear estrogen receptor alpha (ERalpha)-mediated nongenomic signaling, involving Akt activation and subsequent phosphorylation/inactivation of Rac1, a factor critical for activation of NOX2 NADPH oxidase. Intriguingly, E(2) nongenomic signaling, antioxidant action, and neuroprotection in the CA1 region were lost after long-term E(2) deprivation, and this loss was tissue specific because the uterus remained responsive to E(2). Correspondingly, a remarkable loss of ERalpha, but not ERbeta, was observed in the CA1 after long-term E(2) deprivation, with no change observed in the uterus. As a whole, the study reveals a novel, membrane-mediated antioxidant mechanism in neurons by E(2) provides support and mechanistic insights for a "critical period" of E(2) replacement in the hippocampus and demonstrates a heretofore unknown hypersensitivity of the CA3/CA4 to ischemic injury after prolonged hypoestrogenicity.

Modulating expression of brain heat shock proteins by estrogen in ovariectomized mice model of aging

Heat shock proteins (HSPs) serve as molecular chaperones and endogenous cytoprotective factors. Two of the well-studied HSPs, HSP70, and HSP27 can be significantly induced in many areas of brain by a variety of stressors. A decrease in expression of brain HSPs has been documented in aged brain. Estrogen is well known as a neuroprotective hormone, and it has been reported that estrogen can regulate HSP70 and HSP27 expression in neuronal cells. In this study, the relationship between estrogen and heat stress-induced brain HSPs expression in young and aged ovariectomized (OVX) mice was investigated. Our results show that heat stress-induced levels of HSP70 proteins and mRNA transcripts was significantly lower in brain of aged (12 month) OVX mice, compared with young (2 month) OVX mice group. Estrogen supplementation (17beta-estradiol 0.5mg/kg for 7 days) restored heat stress-induced brain HSP70 expression and attenuated heat stress-induced brain DNA fragmentation, caspase 3 activation and mitochondrial leakage of cytochrome c and AIF in OVX mice. These results suggest that estrogen deficiency during aging down-regulates heat stress-induced brain HSP70 expression, which reveals a previously unknown link between estrogen deficiency and stress response elements.

Sex/gender medicine. The biological basis for personalized care in cardiovascular medicine

Sex differences in morbidity and mortality associated with cardiovascular disease have been recognized by the medical community for decades. Investigation into the underlying biological basis of these differences was largely neglected by the scientific community until a report released by the Institute of Medicine in the United States in 2001 "Exploring the Biological Contributions to Human Health: Does Sex Matter?" Recommendations from this report included the need for more accurate use of the terms "sex" and "gender", better tools and resources to study the biological basis of sex differences, integration of findings from different levels of biological organization and continued synergy between basic and clinical researchers. Ten years after the Institute's report, this review evaluates some of the sex differences in cardiovascular disease, reviews new approaches to study sex differences and emphasizes areas where further research is required. In the era of personalized medicine, the study of the biological basis of sex differences promises to optimize preventive, diagnostic and therapeutic strategies for cardiovascular disease in men and women, but will require diligence by the scientific and medical communities to remember that sex does matter.

FINHYST 2006--national prospective 1-year survey of 5,279 hysterectomies

BACKGROUND

In Finland, the number of hysterectomies during one decade has decreased by 34%. The national prospective FINHYST study in 1996 showed abdominal hysterectomy (AH) as being most common: 58%. In Finland since 2002, vaginal hysterectomy (VH) has been most preferred, with laparoscopic hysterectomy (LH) surpassing AH in 2005.

METHODS

FINHYST 2006 is a national prospective hysterectomy study in which all hospitals collaborated from 1 January to 31 December 2006. Questionnaires, completed by gynaecologists, covered their experience, patient characteristics and surgical data.

RESULTS

The 5279 hysterectomies distributed by approaches were 44% VHs, 32% LHs and 24% AHs. Less than 2% were subtotal. The main indications for hysterectomy were myomas (33%), uterine prolapse (28%) and menorrhagia (21%). The main indication for VH was not related to uterine prolapse in 39%. Bilateral salpingo-ooforectomy was performed in 36% of AHs, 32% of LHs and 2% of VHs. Antibiotic prophylaxis was used in 97%, and thrombosis prophylaxis in 65%. Haemorrhage was least and operation time shortest with VH, and hospital stay and sick leave were shortest after LH.

CONCLUSIONS

In Finland, less invasive approaches comprise 76% of hysterectomies. This trend has resulted nationally in shortening of hospital stay and of convalescence time.

Increased cardiovascular mortality after early bilateral oophorectomy

OBJECTIVE

To investigate the mortality associated with cardiovascular diseases and the effect of estrogen treatment in women who underwent unilateral or bilateral oophorectomy before menopause.

DESIGN

We conducted a cohort study with long-term follow-up of women in Olmsted County, MN, who underwent either unilateral or bilateral oophorectomy before the onset of menopause from 1950 through 1987. Each member of the oophorectomy cohort was matched by age to a referent woman from the same population who had not undergone any oophorectomy. We studied the mortality associated with cardiovascular disease in a total of 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy, and 2,383 referent women.

RESULTS

Women who underwent unilateral oophorectomy experienced a reduced mortality associated with cardiovascular disease compared with referent women (hazard ratio [HR], 0.82; 95% CI, 0.67-0.99; P = 0.04). In contrast, women who underwent bilateral oophorectomy before age 45 years experienced an increased mortality associated with cardiovascular disease compared with referent women (HR, 1.44; 95% CI, 1.01-2.05; P = 0.04). Within this age stratum, the HR for mortality was significantly increased in women who were not treated with estrogen through age 45 years or longer (HR, 1.84; 95% CI, 1.27-2.68; P = 0.001) but not in women treated with estrogen (HR, 0.65; 95% CI, 0.30-1.41; P = 0.28; test of interaction, P = 0.01). Mortality was further increased after deaths associated with cerebrovascular causes were excluded.

CONCLUSIONS

Bilateral oophorectomy performed before age 45 years is associated with increased cardiovascular mortality, especially with cardiac mortality. However, estrogen treatment may reduce this risk.

Increased mortality for neurological and mental diseases following early bilateral oophorectomy

BACKGROUND

The effects of oophorectomy on brain aging remain uncertain.

METHODS

We conducted a cohort study with long-term follow-up of women in Olmsted County, Minn., USA, who underwent either unilateral or bilateral oophorectomy before the onset of menopause from 1950 through 1987. Each member of the oophorectomy cohort was matched by age to a referent woman from the same population who had not undergone any oophorectomy. We studied underlying and contributory causes of death in 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy, and 2,383 referent women.

RESULTS

Mortality for neurological or mental diseases was increased in women who underwent bilateral oophorectomy before age 45 years compared with referent women (hazard ratio = 5.24; 95% confidence interval = 2.02-13.6; p < 0.001). Within this age stratum, mortality was similar in women who were or were not treated with estrogen from the time of oophorectomy through age 45 years, and in women who had bilateral oophorectomy for prophylaxis or for treatment of a benign ovarian condition. Mortality was also increased in women who underwent unilateral oophorectomy before age 45 years without concurrent hysterectomy.

CONCLUSIONS

Bilateral oophorectomy performed before age 45 years is associated with increased mortality for neurological or mental diseases.

Long-term effects of bilateral oophorectomy on brain aging: unanswered questions from the Mayo Clinic Cohort Study of Oophorectomy and Aging

In the Mayo Clinic Cohort Study of Oophorectomy and Aging, women who had both ovaries removed before reaching natural menopause experienced a long-term increased risk of parkinsonism, cognitive impairment or dementia, and depressive and anxiety symptoms. Here, we discuss five possible mechanistic interpretations of the observed associations; first, the associations may be non-causal because they result from the confounding effect of genetic variants or of other risk factors; second, the associations may be mediated by an abrupt reduction in levels of circulating estrogen; third, the associations may be mediated by an abrupt reduction in levels of circulating progesterone or testosterone; fourth, the associations may be mediated by an increased release of gonadotropins by the pituitary gland; and fifth, genetic variants may modify the hormonal effects of bilateral oophorectomy through simple or more complex interactions. Results from other studies are cited as evidence for or against each possible mechanism. These putative causal mechanisms are probably intertwined, and their clarification is a research priority.