Lack of influence of simple premenopausal hysterectomy on bone mass and bone metabolism

Risk of osteoporosis and fracture after hysterectomies without oophorectomies: a systematic review and pooled analysis

The present study provides evidence that women who underwent hysterectomy without oophorectomies are at a higher risk of osteoporosis and bone fractures than the general population. Early interventions for these susceptible women may help to delay or reduce the risk of osteoporosis and bone fractures.

INTRODUCTION

Mounting studies have shown that patients with hysterectomy are at high risk of developing osteoporosis or bone fractures, but the evidence from all the relevant studies has not been previously synthesized. The present study aims to investigate whether women with hysterectomy without oophorectomies have a prominently higher prevalence of osteoporosis or fractures than healthy subjects.

METHODS

Four electronic databases were systematically searched to identify the eligible studies. The combined effect was assessed by calculating the relative risk (RR) with a 95% confidence interval (CI). More methodologies for this study were available in the PROSPERO (ID: CRD42021227255).

RESULTS

Finally, three observational studies offering osteoporosis cases and two retrospective studies reporting fracture cases were included. One eligible study has provided independent data from three groups of fractures. Synthetic results revealed that hysterectomy without oophorectomies was significantly associated with an increased risk of osteoporosis as compared to the general population (combined RR from three studies = 1.47, 95%CI 1.253 to 1.725, P < 0.001; heterogeneity, I² = 76.2%, P = 0.015). Consistently, the prevalence of fractures was also significantly higher in patients with hysterectomy without oophorectomies than in healthy controls (pooled RR from four studies = 2.333, 95%CI: 1.314 to 4.144, P = 0.004; heterogeneity, I² = 92.3%, P < 0.001).

CONCLUSIONS

This is the first study to quantify the association between hysterectomy without oophorectomies and osteoporosis/fracture risk through a meta-analysis and has subsequently confirmed its positive relationship. Additional large-sample rigorously prospective cohorts are still warranted to validate the present evidence.

Analyses of the association between cervical cancer and osteoporosis/osteoporotic fracture: a cross-sectional study using KoGES HEXA data

BACKGROUND

This study aimed to evaluate the association between cervical cancer and the occurrence of osteoporosis and osteoporotic fracture using data from the Korean Genome and Epidemiology Study (KoGES).

METHODS

In this national cohort study using KoGES health examination (HEXA) data, we extracted data for patients with cervical cancer (n = 493) and control participants (n = 77,571); we then analyzed the occurrence of osteoporosis and osteoporotic fracture at baseline from 2004 to 2013 and during follow-up from 2012 to 2016. A logistic regression model was used to analyze the odds ratios (ORs) and the 95% confidence intervals (CIs).

RESULTS

The ORs (95% CIs) for osteoporosis and osteoporotic fracture were 1.49 (95% CI 1.15-1.92, p = 0.03) and 1.06 (95% CI 0.82-1.38, p = 0.634), respectively, in the cervical cancer group. The ORs (95% CIs) for osteoporosis were 2.12 (95% CI 1.14-3.95, p = 0.018) in the ≤ 51-year-old group and 1.43 (95% CI 1.08-1.89, p = 0.011) in the ≥ 52-year-old group of cervical cancer patients.

CONCLUSION

We concluded that Korean women with cervical cancer had a higher risk of osteoporosis than healthy women, but the same finding was not observed for osteoporotic fracture.

Increased risk of osteoporosis with hysterectomy: A longitudinal follow-up study using a national sample cohort

BACKGROUND

Premenopausal hysterectomy is associated with a decreased ovarian reserve, follicular atresia, and subsequently reduced long-term estrogen secretion. Therefore, women who undergo hysterectomy will experience greater gradual bone mineral loss than women with an intact uterus and have an increased risk of osteoporosis.

OBJECTIVE

This study aimed to evaluate the association between hysterectomy without/with bilateral oophorectomy and the occurrence of osteoporosis using a national sample cohort from South Korea.

STUDY DESIGN

Using the national cohort study from the Korean National Health Insurance Service, we extracted data for patients who had undergone hysterectomy (n=9082) and for a 1:4 matched control group (n=36,328) and then analyzed the occurrence of osteoporosis. The patients were matched according to age, sex, income, region of residence, and medical history. A Cox proportional hazards model was used to analyze the hazard ratios and 95% confidence intervals. Subgroup analyses were performed based on age and bilateral oophorectomy status. The age of the participants was defined as the age at the time of hysterectomy.

RESULTS

The adjusted hazard ratio for osteoporosis was 1.45 (95% confidence interval, 1.37-1.53, P<.001) in the hysterectomy group. The adjusted hazard ratios for osteoporosis in the different age subgroups of this group were 1.84 (95% confidence interval, 1.61-2.10) for ages 40-44 years, 1.52 (95% confidence interval, 1.39-1.66) for ages 45-49 years, 1.44 (95% confidence interval, 1.28-1.62) for ages 50-54 years, 1.61 (95% confidence interval, 1.33-1.96, all P<.001) for ages 55-59 years, and 1.08 (95% confidence interval, 0.95-1.23, P=.223) for ages ≥60 years. The adjusted hazard ratios for osteoporosis according to hysterectomy/oophorectomy status were 1.43 (95% confidence interval, 1.34-1.51) in the hysterectomy without bilateral oophorectomy group and 1.57 (95% confidence interval, 1.37-1.79) in the hysterectomy with bilateral oophorectomy group.

CONCLUSION

The occurrence of osteoporosis was increased in patients who had undergone hysterectomy compared with that in matched control subjects regardless of bilateral oophorectomy status.

Bone mineral density in African&#x2013;American women with symptomatic uterine leiomyoma

OBJECTIVE

Uterine leiomyoma is associated with increased BMD in Caucasian women and is largely attributed to the state of hyperestrogenemia associated with disease. This relationship, however, has not been previously described in African-American women. We aim to assess BMD in African-American women with symptomatic uterine leiomyoma.

DESIGN

Case-control study.

MATERIALS & METHODS

29 African-American women with uterine leiomyoma signed an Institutional Review Board (IRB) approved consent form at a reproductive clinic of an inner city hospital in Brooklyn, NY, USA. BMD and T-score of lumbar spine was compared with a controlled group matched for age, race and BMI. BMD of lumbar spine was measured using Hologic QDR 4200 in both groups. Data are presented as mean ± SEM.

RESULTS

For the entire study population the mean age (years) was 42.07 ± 1.15, and the BMI (kg/m²) was 29.37 ± 0.93 in patients with uterine leiomyoma and 30.07 ± 1.06 for the control group (p = 0.07). There was a significant difference in the mean BMD (cm²) between the uterine leiomyoma group (1.17 ± 0.03) compared with control (1.05 ± 0.02 p < 0.01). The T-score for the uterine leiomyoma group was significantly higher compared with the control group (0.31 ± 0.25 and -0.74 ± 0.21 with p < 0.01). The prevalence of osteopenia (T-score <-1) was lower for the leiomyoma group when compared with controls, (p < 0.02).

CONCLUSION

Consistent with data from the white population with uterine leiomyoma, our data showed a significantly higher BMD in African-American women with uterine leiomyoma, compared with an age- and race-matched cohort. The implications of these findings remain to be investigated and further confirmed in future longitudinal studies.

MORBID ADHERENT PLACENTA: PREDICTION, DIAGNOSIS AND MANAGEMENT

Morbid adherent placenta (MAP), also known as placenta accreta, increta or percreta, is one of the main causes of maternal morbidity and mortality. Its incidence has noticeably increased in the last few decades, a fact directly related to the increase in caesarean sections. There is a close relation between iterative caesarean sections and MAP. This connection is of vital importance, since caesarean rates have risen worldwide, especially in the countries where there is the possibility of caesarean section on demand.

Influence of hysterectomy on long-term fracture risk

OBJECTIVE

To assess long-term fracture risk after hysterectomy, with or without oophorectomy.

DESIGN

Population-based, cohort study.

SETTING

Olmsted County, Minnesota.

PATIENT(S)

Women residing in Olmsted County (n = 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age- and sex-matched community controls.

INTERVENTION(S)

Observational study of the effect of hysterectomy for various indications on subsequent fractures.

MAIN OUTCOME MEASURE(S)

Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community.

RESULT(S)

Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98-1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98-1.15).

CONCLUSION(S)

Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention.

Fracture risk and bone density of peri- and early postmenopausal women with uterine leiomyomas

OBJECTIVES

Fracture risk and bone mineral density (BMD) among peri- and early postmenopausal women with leiomyomas requiring hysterectomy was evaluated.

METHODS

We counted fractures among women with or without leiomyomas using data from the Kuopio Osteoporosis Study. The study population consisted of 6086 women aged 47-56 years with never-use of hormone replacement therapy (HRT) responding to the baseline and 5-year follow-up inquiries. Part of the sample (n=1271) underwent bone densitometry.

RESULTS

Hysterectomy was carried out in 927 women, and 59% reported that this was attributable to leiomyomas. The hazard ratio (HR) was 0.68 (95% CI 0.49-0.94) for any and 0.73 (95% CI 0.43-1.26) for distal forearm fracture among women with leiomyomas compared to those without any. Among women postmenopausal at baseline, the corresponding HRs were 0.62 (95% CI 0.44-0.87) and 0.54 (95% CI 0.31-0.96); after adjusting for age, time since menopause weight, height and previous fracture 0.69 (95% CI 0.49-0.97) and 0.63 (95% CI 0.35-1.11). The baseline BMDs were 1.15 g/cm2 among hysterectomized leiomyoma and 1.12 g/cm2 (ns) among non-hysterectomized women at lumbar (L2-L4), and 0.94 and 0.93 g/cm2 (ns) at femoral sites. The follow-up lumbar BMDs were 1.13 and 1.09 g/cm2 (p<0.001) and the corresponding femoral values were 0.90 and 0.89 g/cm2 (ns), respectively. Among postmenopausal women, the corresponding baseline lumbar BMDs were 1.15 and 1.08 g/cm2 (p<0.001), femoral 0.93 and 0.90 g/cm2 (p=0.003); the follow-up lumbar BMDs 1.13 g/cm2 versus 1.07 g/cm2 (p<0.001); femoral BMDs 0.89 versus 0.87 (ns).

CONCLUSIONS

Peri- and early postmenopausal women with a history of leiomyomas seem to have better BMD and less fractures compared with those without leiomyomas. This may be mediated through higher estrogen levels leading to higher BMD and the growth of leiomyomas.

Menorrhagia: an update

Menorrhagia is defined as a 'complaint of heavy cyclical menstrual bleeding occurring over several consecutive cycles'. Objectively it is a total menstrual blood loss equal to or greater than 80 ml per menstruation. It is estimated that approximately 30% of women complain of menorrhagia. Excessive bleeding is the main presenting complaint in women referred to gynecologists and it accounts for two-thirds of all hysterectomies, and most of endoscopic endometrial destructive surgery. Thus, menorrhagia is an important healthcare problem. Its etiology, investigation, medical and surgical management are described. In approximately 50% of cases of menorrhagia no pathology is found at hysterectomy. Abnormal levels of prostaglandins or the fibrinolytic system in the endometrium have been implicated. Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid) and nonsteroidal anti-inflammatory agents (mefenamic acid). Over the past decade there has been increasing use of endometrial destructive techniques as an alternative to hysterectomy. Their further refinement and the advent of fibroid embolization has increased the options available to women.

[Pre-menopausal simple hysterectomy and post-menopausal female bone mineral density]

This study aimed to evaluate the bone mineral density (BMD) of post-menopausal women with previous pre-menopausal hysterectomy including bilateral ovarian conservation compared to a group of non-hysterectomized women with natural menopause. Data from a cross-sectional study of 30 pre-menopausally hysterectomized women evaluated in the post-menopause were compared with 102 naturally post-menopausal women, analyzing their respective bone densitometry, measuring the femoral and lumbar spinal BMD. Multiple regression analysis of the 132 women showed that age and body mass index (BMI) were heavily associated with femoral and lumbar spinal BMD, BMI directly associated, and age inversely associated with BMD. In addition, 30 hysterectomized women were matched by age and BMI to the 30 non-hysterectomized women, and bone densitometry did not show significant differences in BMD. These findings suggest that pre-menopausal hysterectomy with bilateral ovarian conservation does not appear to cause an additional reduction in bone mass when evaluated in the post-menopausal phase.

A general practice pilot audit study to assess advice and treatment offered to women following hysterectomy

BACKGROUND

Current evidence suggests that information and treatment offered to women post-hysterectomy to prevent osteoporosis are poor.

OBJECTIVES

To pilot a general practice audit protocol, to assess its ability to identify hysterectomized women and to offer appropriate information on fracture prevention.

METHOD

A pilot audit study was designed to assess advice offered to hysterectomized women aged 25-64 years. Data on ovarian status were evaluated. Women were recalled for counselling if there was no evidence of advice on fracture prevention and if they were not taking hormone replacement therapy (HRT). Change in HRT usage was used as the outcome measure to assess the impact of the audit.

RESULTS

Baseline data were collated for 5743 women. In 1456 (25%), both ovaries were removed and 4029 (70%) had one or both ovaries conserved; 258 (5%) had incomplete ovarian data. The average age at hysterectomy with both ovaries removed was 43.9 years, and with conservation of one or both ovaries was 40.5 years and 40.1 years, respectively. Some 2888 (50%) were ever-users of HRT (both ovaries removed 70%, one ovary removed 53%, both ovaries conserved 44%). A total of 2083 (36%) were known current users (both ovaries removed 53%, one ovary removed 40%, both ovaries conserved 30%). The mean duration of use in 2620 ever-users was 44 months. This was similar for all the women irrespective of ovarian status. Eighty per cent of those given HRT reported receiving some advice. Seventy-seven per cent of those not given HRT had not received advice. By the end of the audit, 424 had commenced HRT (20% increase). Current use rose to 44% (both ovaries removed 59%, one ovary conserved 46%, both ovaries conserved 39%). Sixty-three per cent of new users chose transdermal preparations.

CONCLUSIONS

The mean age at hysterectomy of between 40.1 and 43.9 years indicates the potential for early ovarian failure. Use of HRT is associated with availability of counselling. Uptake was better than anticipated, but HRT usage was still well below optimum. This audit fulfills its objectives but not without cost implications. Year by year it should achieve significantly improved management and health of hysterectomized women, and improved standards of patient care.

Hysterectomy with ovarian conservation: effect on bone mineral density

A cross-sectional study was undertaken in 58 consecutive women with premenopausal hysterectomy and ovarian conservation (Group 1) and 59 randomly selected women with natural menopause (Group 2) to determine the effect of hysterectomy on bone mineral density (BMD). Subjects were similar in age, height, weight, body mass index (BMI), exercise levels, family history of osteoporosis and smoking levels, but not years since hysterectomy or menopause (Group 1 = 14.9 +/- 10.8 years versus Group 2 = 9.8 +/- 8.7 years; p = 0.005), age at hysterectomy or menopause (Group 1 = 42.3 +/- 7.3 years versus Group 2 = 45.9 +/- 6.9 years; p = 0.008) or current alcohol consumption (Group 1 = 13.8% versus Group 2 = 39%; p = 0.002). Dual X-ray absorptiometry of the raw (unadjusted) lumbar spine and femoral neck BMD were similar for the 2 groups: lumbar spine = 0.947 +/- 0.179 g/cm2 (Group 1) versus 0.958 +/- 0.203 g/cm2 (Group 2) (p = 0.76) and femoral neck = 0.825 +/- 0.127 g/cm2 (Group 1) versus 0.815 +/- 0.146 g/cm2 (Group 2) (p = 0.71). Multivariate linear regression revealed that factors other than hysterectomy were associated with lumbar spine and femoral neck BMD. Thus, prior hysterectomy with ovarian conservation has no adverse effect on lumbar spine or femoral neck BMD.

The effect of hysterectomy and endometrial ablation on follicle stimulating hormone (FSH) levels up to 1 year after surgery

OBJECTIVES

In this study the hypothesis was tested, that in premenopausal patients FSH-levels would rise after 'simple hysterectomy'. As endometrial ablation is not supposed to compromise ovarian bloodflow, there would be no such change in ablated patients.

METHODS

Between January 1995 and April 1996, consecutive premenopausal patients with dysfunctional uterine bleeding who were scheduled for hysterectomy or endometrial ablation were asked to participate in the study. Bloodsamples were drawn before surgery, six weeks, six months and one year after surgery. FSH and oestradiol (E2) were assayed. In all patients data about length and weight were collected to calculate Body Mass Index (BMI). Every visit patients filled in a questionnaire, containing questions about typical climacteric complaints, combined in a five-point scale.

RESULTS

Except for a significant difference in preoperative FSH-level between both groups, there were no significant differences regarding age, Body Mass Index (BMI), oestradiol (E2) or the percentage of women with vasomotor complaints. Compared to the preoperative starting level, six weeks, six months and one year after surgery a significant rise in serum FSH in the hysterectomy group, as well as in the ablation group was found. However there was no significant difference in FSH increase between both groups. One third of the patients in both groups had typical climacteric complaints as flushing and nocturnal sweating.

CONCLUSIONS

Assaying serum FSH-levels before and after uterine surgery and comparing hysterectomized patients and patients after endometrial ablation, we found a significant rise in FSH-level up to one year after surgery in both groups postoperatively, indicating impaired ovarian function. There was no difference in FSH-levels between both groups. Therefore major uterine surgery (hysterectomy, ablation) may prelude an earlier onset of menopause.

Outcomes of hysterectomy

Recent randomized trials and prospective cohort studies have provided new information on the health outcomes of hysterectomy for nonmalignant conditions. These studies consistently have demonstrated a marked improvement in symptoms and quality of life during the early years after surgery. The long-term effects of premenopausal hysterectomy on ovarian function have not been established, but existing evidence suggests there is no adverse effect on risk for cardiovascular disease from hysterectomy alone. Epidemiologic studies have indicated that premenopausal hysterectomy with ovarian preservation is associated with a modest decrease in future risk for ovarian cancer and possibly breast cancer. There is no consistent evidence for adverse effects on bowel or bladder function. Hysterectomy does not cause long-term psychiatric morbidity, and psychological status generally improves. Studies of sexual function have shown varying results, with most suggesting improvement or no change in sexual function for the majority of women.

The menopause transition

New paradigms for the study of menopause will increase our understanding of whether symptoms, syndromes, and chronic diseases are associated with menopause. Rather than considering menopause as a discrete event, it has become clear that the menopause transition takes place over many years. Although this realization is central to our understanding of menopause, it is difficult to measure the temporal pattern of changes in hormones and their relation to concurrent or subsequent health-related events. The model of hormonal changes at the time of the transition has been expanded to include not only declines in estrogen but changes in a broader range of hormones, including the potential role of androgens. New models are attempting to account for the pattern and frequency of changes in hormone levels. Another level of complexity is contributed by the expansion of the menopause model to include comorbid medical and psychiatric conditions, environmental influences, and behaviors as covariates that influence the expression of menopause-related events. Although this more complicated paradigm makes the conduct of menopause research more challenging, it is also likely to elucidate previously confusing data, as the proper understanding of potentially complex exposures, effect modifiers, and confounders is more likely to provide clearer answers to critical research questions.

Effects of hysterectomy on bone in intact rats, ovariectomized rats, and ovariectomized rats treated with estrogen

To determine whether the uterus plays any role in mediating the ability of estrogen to conserve bone in the rat, eight groups of animals (n = 8) with their skeletons labeled with 45Ca were studied. Rats were ovariectomized (OVX), hysterectomized (Hyst), or given sham operations (Sham) and then pair-fed a low-hydroxyproline casein diet for 4 weeks. The groups were treated orally with 17 beta-estradiol (E2) or vehicle, and serial measurements of biochemical markers of bone breakdown were made in weeks 1, 2, and 4. The femur density was measured by dual-energy X-ray absorptiometry (DXA), and skeletal calcium and 45Ca content were determined chemically. Final total body calcium values (mg) in the eight treatment groups were (means +/- SD): Sham, 2573 +/- 179; Sham + E2, 2635 +/- 159; Hyst, 2537 +/- 151; Hyst + E2, 2410 +/- 151; OVX, 2189 +/- 146; OVX + E2, 2559 +/- 172; OVX/Hyst, 2138 +/- 132; and OVX/Hyst + E2, 2460 +/- 140. Ovariectomy raised biochemical markers of bone resorption (urinary 45Ca, hydroxyproline, and deoxypyridinoline), lowered DXA bone mineral density, and reduced total body calcium and 45Ca content in both Hyst and Sham-Hyst animals (p < 0.001), whereas E2 treatment prevented these changes. Hysterectomy did not impair the ability of E2 to conserve bone in OVX rats. Thus, we conclude that estrogen-mediated induction of growth factors from uterine tissue does not play an essential role in mediating the bone-conserving actions of estrogen in the rat.