Hysterectomy and oophorectomy are unrelated to bone loss in older women

A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited

OBJECTIVE

To perform an updated Markov modeling to assess the optimal age for bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy for benign indication.

METHODS

We performed a literature review that assessed hazard ratios (HRs) for mortality by disease, age, hysterectomy with or without BSO, and estrogen therapy use. Base mortality rates were derived from national vital statistics data. A Markov model from reported HRs predicted the proportion of the population staying alive to age 80 years by 1-year and 5-year age groups at time of surgery, from age 45 to 55 years. Those younger than age 50 years were modeled as either taking postoperative estrogen or not; those 50 and older were modeled as not receiving estrogen. Computations were performed with R 3.5.1, using Bayesian integration for HR uncertainty.

RESULTS

Performing salpingo-oophorectomy before age 50 years for those not taking estrogen yields a lower survival proportion to age 80 years than hysterectomy alone before age 50 years (52.8% [Bayesian CI 40.7-59.7] vs 63.5% [Bayesian CI 62.2-64.9]). At or after age 50 years, there were similar proportions of those living to age 80 years with hysterectomy alone (66.4%, Bayesian CI 65.0-67.6) compared with concurrent salpingo-oophorectomy (66.9%, Bayesian CI 64.4-69.0). Importantly, those taking estrogen when salpingo-oophorectomy was performed before age 50 years had similar proportions of cardiovascular disease, stroke, and people living to age 80 years as those undergoing hysterectomy alone or those undergoing hysterectomy and salpingo-oophorectomy at age 50 years and older.

CONCLUSION

This updated Markov model argues for the consideration of concurrent salpingo-oophorectomy for patients who are undergoing hysterectomy at age 50 and older and suggests that initiating estrogen in those who need salpingo-oophorectomy before age 50 years mitigates increased mortality risk.

Comparison of osteoporotic fracture risk in surgical and natural menopausal patients

Objectives

This study aims to compare the fracture risk calculated with Fracture Risk Assessment Tool (FRAX®) in patients with natural and surgical menopause.

Patients and methods

Between April 2019 and July 2019, 285 postmenopausal patients (mean age 57.3 years; range, 40 to 78 years) who were admitted to the menopause clinic were enrolled in this prospective cross-sectional study. Of these, 220 were in natural menopause and 65 were in surgical menopause. Demographic data, medical history, and International Physical Activity Questionnaire scores were collected through face-to-face interviews with the patients. Femoral neck and lumbar vertebrae (L1-L4) T-scores were evaluated using dual-energy X-ray absorptiometry. Fragility fracture risk was assessed using FRAX®.

Results

The groups were similar in terms of age, body mass index, duration of menopause, smoking, alcohol use, and history of fracture (p>0.05). The risk of major osteoporotic fracture and hip fracture calculated without adding bone mineral density (BMD) was similar between groups (p=0.417 and p=0.234). The risk of hip fracture calculated with the addition of BMD was higher in natural menopause patients (p=0.023). Lumbar vertebrae T-scores were similar between two groups regardless of age; femoral neck T-scores were higher in surgical menopause (T-score=-0.8) than natural menopause group (T-score=-1.25) aged under 60 years, whereas this difference disappeared after 60 years of age.

Conclusion

In our study, the fracture risk and the severity of osteoporosis were not different in surgical menopausal patients compared to the natural menopausal patients. Hip fracture risk calculated using BMD was lower in patients under 50 years of age in surgical menopausal patients. However, the fracture risks were similar in both groups after 50 years of age.

Pregnancy history and cognitive aging among older women: the Rancho Bernardo Study

OBJECTIVE

The aim of the study was to examine the association of pregnancy history with trajectories of cognitive function in older women.

METHODS

Participants were 1,025 women (mean age = 73.1 ± 9.6 y) enrolled in the Rancho Bernardo Study who attended a clinic visit between 1988 and 1992, when pregnancy history (ever pregnant, number of pregnancies, ages at first and last pregnancy) was recorded and cognitive function was assessed with a battery of four tests repeated up to 7 times through 2016. Linear mixed-effects regression models were used to examine the association between pregnancy history and longitudinal change in cognitive function.

RESULTS

Overall, 77% of women had at least one pregnancy; number of pregnancies ranged from 1 to 14 (mean = 2.9 ± 1.7). Ages at first and last pregnancy ranged from 16 to 44 years (mean = 24.9 ± 4.7) and 16 to 49 years (mean = 30.7 ± 5.5), respectively. Of 16 associations tested (4 pregnancy exposures by 4 cognitive tests), one was statistically significant without correction for multiple comparisons. Women who reported ever being pregnant recalled 0.12 fewer words on the Buschke Selective Reminding Test for every year increase in age than women who had never been pregnant (P = 0.05). No other significant associations of pregnancy history with cognitive decline were observed.

CONCLUSIONS

Our results show no clinically meaningful long-term influence of pregnancy history on age-related change in cognitive function. These reassuring findings suggest childbearing decisions and timing will not affect cognitive function in older age.

Rationale and design of a cohort study on primary ovarian insufficiency in female survivors of Hodgkin's lymphoma: influence on long-term adverse effects (SOPHIA)

INTRODUCTION

Hodgkin's lymphoma (HL) has become the prototype of a curable disease. However, many young survivors suffer from late adverse effects of treatment. Both chemotherapy (CT) and radiotherapy (RT) may induce primary ovarian insufficiency (POI), which has been associated with reduced bone mineral density (BMD), neurocognitive dysfunction and possibly cardiovascular disease (CVD). While the general assumption is that POI increases CVD risk, other hypotheses postulate reverse causality, suggesting that cardiovascular risk factors determine menopausal age or that biological ageing underlies both POI and CVD risk. None of these hypotheses are supported by convincing evidence. Furthermore, most studies on POI-associated conditions have been conducted in women with early natural or surgery-induced menopause with short follow-up times. In this study, we will examine the long-term effects of CT-induced and/or RT-induced POI on BMD, cardiovascular status, neurocognitive function and quality of life in female HL survivors.

METHODS AND ANALYSIS

This study will be performed within an existing Dutch cohort of HL survivors. Eligible women were treated for HL at ages 15-39 years in three large hospitals since 1965 and survived for ≥8 years after their diagnosis. Women visiting a survivorship care outpatient clinic will be invited for a neurocognitive, cardiovascular and BMD assessment, and asked to complete several questionnaires and to provide a blood sample. Using multivariable regression analyses, we will compare the outcomes of HL survivors who developed POI with those who did not. Cardiovascular status will also be compared with women with natural POI.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the Netherlands Cancer Institute and has been registered at 'Toetsingonline' from the Dutch Central Committee on Research involving Human Subjects (file no. NL44714.031.13). Results will be disseminated through peer-reviewed publications and will be incorporated in follow-up guidelines for HL survivors.

Menopause, Reproductive Life, Hormone Replacement Therapy, and Bone Phenotype at Age 60-64 Years: A British Birth Cohort

CONTEXT

Previous studies of menopausal age and length of reproductive life on bone are limited by retrospective reproductive histories, being cross-sectional, or lacking gold standard bone technologies or information on hormone replacement therapy (HRT) or surgical treatment.

OBJECTIVE

The objective of the study was to investigate age at menopause, length of reproductive life, and HRT use in relation to volumetric and areal bone mineral density (vBMD, aBMD), bone size, and strength in women aged 60-64 years.

DESIGN

This was a birth cohort study that followed up for 64 years with prospective measures of age at menarche and menopause and monthly HRT histories.

SETTING

The study was conducted in England, Scotland, and Wales.

PARTICIPANTS

Participants included 848 women with a known type of menopause and bone measures at 60-64 years.

MAIN OUTCOME MEASURES

Peripheral quantitative computed tomography measurements of the distal radius total and trabecular vBMD were measured. Diaphyseal radius total and medullary cross-sectional area, cortical vBMD, and polar strength strain index (SSI); dual-energy x-ray absorptiometry measurements of aBMD at the lumbar spine and total hip were also measured.

RESULTS

A 10-year increase in age at natural (but not surgical) menopause was associated with 8.2% (95% confidence interval [CI] 1.3%-15.1%, P = .02) greater trabecular vBMD and a 6.0% (95% CI 0.51%-11.5%, P = .03) greater total vBMD; findings were similar for length of reproductive life. A 10-year difference in HRT use was associated with a 6.0% (95% CI 2.6%-9.3%, P < .001) greater polar SSI and a 0.9% (95% CI 0.4%-1.5%, P = .001) greater cortical vBMD. These estimates changed little on adjustment. Estimates for aBMD were consistent with those for peripheral quantitative computed tomography.

CONCLUSIONS

The positive effects on trabecular vBMD of later natural menopause and longer reproductive life persisted into early old age. HRT use was associated with greater radius cortical vBMD and polar SSI and aBMD.

Bone mineral density and fractures after risk-reducing salpingo-oophorectomy in women at increased risk for breast and ovarian cancer

AIM

Risk-reducing salpingo-oophorectomy (RRSO) reduces ovarian cancer risk in BRCA mutation carriers. RRSO is assumed to decrease bone mineral density (BMD) and increase fracture risk more than natural menopause. We aimed to compare BMD and fracture incidence after premenopausal RRSO to general population data and identify risk factors for low BMD and fractures after RRSO.

METHODS

In 212 women with RRSO at premenopausal age, BMD was measured by dual energy X-ray absorptiometry. Fractures and risk factors were assessed by self-administered questionnaire. Fracture incidence after RRSO was compared to general practitioner data by using standardised incidence ratios (SIRs). Risk factors for low standardised BMD-scores and fractures were identified by regression analyses.

RESULTS

Median age at RRSO was 42years (range 35-65) and duration of follow-up 5years (2-8). Standardised lumbar spine (Z=0.01, p=0.870) and femoral neck BMD (Z=0.15, p=0.019) were not lower than population BMD. Higher age at time of RRSO and use of hormonal replacement therapy were associated with higher, and current smoking with lower standardised BMD-scores. Sixteen women reported 22 fractures. Fracture incidence was not higher than expected from the general population (all fractures: 25-44years: SIR 2.12 [95% confidence interval (CI) 0.85-4.37]; 45-64years: SIR 1.65 [95% CI 0.92-2.72]).

CONCLUSION

Five years after RRSO, BMD and fracture incidence were not different than expected from the general population. Based on these data it appears safe not to intensively screen for osteoporosis within five years after RRSO, although prospective research on the long-term effects of RRSO on bone is warranted.

Surgical menopause and nonvertebral fracture risk among older US women

OBJECTIVE

The aim of this study was to determine whether older postmenopausal women with a history of bilateral oophorectomy before natural menopause (surgical menopause) have a higher risk of nonvertebral postmenopausal fracture than women with natural menopause.

METHODS

We used 21 years of prospectively collected incident fracture data from the ongoing Study of Osteoporotic Fractures, a cohort study of community-dwelling women without previous bilateral hip fracture who were 65 years or older at enrollment, to determine the risk of hip, wrist, and any nonvertebral fracture. χ(2) and t tests were used to compare the two groups on important characteristics. Multivariable Cox proportional hazards regression models stratified by baseline oral estrogen use status were used to estimate the risk of fracture.

RESULTS

Baseline characteristics differed significantly among the 6,616 women within the Study of Osteoporotic Fractures who underwent either surgical (1,157) or natural (5,459) menopause, including mean age at menopause (44.3 ± 7.4 vs 48.9 ± 4.9 y, P < 0.001) and current use of oral estrogen (30.2% vs 6.5%, P < 0.001). Fracture rates were not significantly increased for surgical versus natural menopause, even among women who had never used oral estrogen (hip fracture: hazard ratio [HR], 0.87; 95% CI, 0.63-1.21; wrist fracture: HR, 1.10; 95% CI, 0.78-1.57; any nonvertebral fracture: HR, 1.11; 95% CI, 0.93-1.32).

CONCLUSIONS

These data provide some reassurance that the long-term risk of nonvertebral fracture is not substantially increased for postmenopausal women who experienced premenopausal bilateral oophorectomy, compared with postmenopausal women with intact ovaries, even in the absence of postmenopausal estrogen therapy.

Effect of bilateral oophorectomy on women's long-term health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced in order to prevent the subsequent development of ovarian cancer or other ovarian pathology that might require additional surgery. At present, bilateral oophorectomy is performed in 78% of women aged between 45 and 64 years having a hysterectomy, and a total of approximately 300,000 prophylactic oophorectomies are performed in the USA every year. Estrogen deficiency resulting from pre- and post-menopausal oophorectomies has been associated with higher risks of coronary heart disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression and anxiety in many studies. While ovarian cancer accounts for 14,800 deaths per year in the USA, coronary heart disease accounts for 350,000 deaths per year. In addition, 100,000 cases of dementia may be attributable annually to prior bilateral oophorectomy. At present, observational studies suggest that bilateral oophorectomy may do more harm than good. In women who are not at high risk of developing ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Bilateral oophorectomy versus ovarian conservation: effects on long-term women's health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced to prevent the subsequent development of ovarian cancer. Currently, bilateral oophorectomy is performed in 55% of all U.S. women having a hysterectomy, with approximately 300,000 prophylactic oophorectomies performed every year. Observational studies show that estrogen deficiency, resulting from premenopausal or postmenopausal oophorectomy, is associated with higher risks of coronary artery disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression, and anxiety. These studies suggest that bilateral oophorectomy may do more harm than good. In women not at high risk for development of ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Relationship of Bone Densitometry and Bone Resorption Markers With Menopausal Type and Duration

Objective: Menopause age and bone mineral density are positively related and there is a rapid bone loss in the early post-menopausal period. A ratio of 30% of post-menopausal women are affected from osteoporosis developing due to bone loss and this causes 40% risk of fracture in a 50- year old woman.

Materials and Methods: In this sudy, serum osteocalcin and urine deoxypridinoline levels were analyzed in 102 postmenapausal and 48 healthy premenopausal controls who presented to gynecology outpatient clinic. Bone densitometry was obtained from all postmenopausal women. Postmenopausal patients were further divided into four groups according to time since menopause:<5 years, 5-9 years, 10-19 years and >20 years.

Results: Mean (SD) age in 48 premenopausal women was 47.7 (3.7) while it was 56.5 (6.8) in 102 post-menopausal women. 34 out of 102 post-menopausal women had surgical menopause due to bilateral oopheroctomy+hysterectomy while the remaining had natural menopause. No significant difference was found in bone-turnover markers between women with surgical and natural menopause.

Conclusion: Although there was not a statistically significant difference between bone-turnover markers, bone mineral density stays lower in surgical menopausal patients and this difference disappear only after about 20 years. Also bone turnover markers are usually high up to five years after surgical menopause and return to normal levels after then. Thus, our study suggested that oopheroctomy does not cause additional risk to hysterectomy. We also suggest that there is not a long-term relationship between serum bone turnover markers or bone density and the etiology of menopause. (Turk J Rheumatol 2010; 25: 29-33)

Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis

BACKGROUND

Bone mineral density is known to decrease rapidly after the menopause. There is limited evidence about the separate contributions of a woman's age, menopausal status and age at menopause to the incidence of hip fracture.

METHODS AND FINDINGS

Over one million middle-aged women joined the UK Million Women Study in 1996-2001 providing information on their menopausal status, age at menopause, and other factors, which was updated, where possible, 3 y later. All women were registered with the UK National Health Service (NHS) and were routinely linked to information on cause-specific admissions to NHS hospitals. 561,609 women who had never used hormone replacement therapy and who provided complete information on menopausal variables (at baseline 25% were pre/perimenopausal and 75% postmenopausal) were followed up for a total of 3.4 million woman-years (an average 6.2 y per woman). During follow-up 1,676 (0.3%) were admitted to hospital with a first incident hip fracture. Among women aged 50-54 y the relative risk (RR) of hip fracture risk was significantly higher in postmenopausal than premenopausal women (adjusted RR 2.22, 95% confidence interval [CI] 1.22-4.04; p = 0.009); there were too few premenopausal women aged 55 y and over for valid comparisons. Among postmenopausal women, hip fracture incidence increased steeply with age (p<0.001), with rates being about seven times higher at age 70-74 y than at 50-54 y (incidence rates of 0.82 versus 0.11 per 100 women over 5 y). Among postmenopausal women of a given age there was no significant difference in hip fracture incidence between women whose menopause was due to bilateral oophorectomy compared to a natural menopause (adjusted RR 1.20, 95% CI 0.94-1.55; p = 0.15), and age at menopause had little, if any, effect on hip fracture incidence.

CONCLUSIONS

At around the time of the menopause, hip fracture incidence is about twice as high in postmenopausal than in premenopausal women, but this effect is short lived. Among postmenopausal women, age is by far the main determinant of hip fracture incidence and, for women of a given age, their age at menopause has, at most, a weak additional effect. Please see later in the article for the Editors' Summary.

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.

Effect of early menopause on bone mineral density and fractures

OBJECTIVE

To review the data on the effect of early menopause on bone. Do women undergoing early menopause develop lower bone mineral density at an earlier age and do they have a higher incidence of osteoporotic fractures? Is there a difference on bone between women who undergo early natural menopause compared to women who have early menopause after oophorectomy?

RESULTS

The earlier in life that menopause occurs, the lower the bone density will be later in life. Low bone density is associated with a higher fracture rate, and several studies show a relationship between early menopause, oophorectomy, and an increase in osteoporotic fractures.

CONCLUSIONS

Early menopause is a risk factor for osteoporosis. Women with an early menopause should have bone density testing performed within 10 years of menopause so that osteopenia or osteoporosis will be diagnosed early and appropriate anti-resorptive therapy initiated.

Randomized controlled trial of the effect of hysterectomy or LNG-IUS use on bone mineral density: a five-year follow-up

A 72-year-old female with scirrhous-type advanced gastric cancer was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (80 mg/m(2)/day) was orally administered for 3 weeks and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. Partial response (PR) was obtained after the first course, and total gastrectomy was performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and a few regional lymph node metastases (3/67). The patient has now been in good health without a recurrence for 1 year and 9 months after surgery.

The post-menopausal ovary displays a unique pattern of steroidogenic enzyme expression

BACKGROUND

While menopause results in the loss of cyclic steroid production, evidence exists for persistent, albeit reduced, ovarian androgen production. In order to continue to synthesize ovarian androgens, the steroidogenic enzymes necessary for androgen biosynthesis must be present. Few studies have selectively analysed some of the steroidogenic enzymes present in the post-menopausal ovary (PMO), and a comprehensive study of this matter has never been undertaken.

METHODS

RNA and protein were obtained from PMO, pre-menopausal ovarian stroma, corpora lutea (CL), ovarian follicles, placenta, and myometrium. Oligonucleotide microarray analysis was performed to compare the gene expression profiles of PMO with pre-menopausal ovarian stroma. Real-time RT-PCR was performed for LH/HCG receptor (LHCGR), steroidogenic acute regulatory (StAR), cholesterol side-chain cleavage (CYP11A), 3beta-hydroxysteroid dehydrogenase type I (HSD3B1) and type II (HSD3B2, 3betaHSD), 17a-hydroxylase (CYP17), cytochrome b5 (CytB5), and aromatase (CYP19). Western blot analysis was performed for StAR, CYP11A, CYP17,and 3betaHSD.

RESULTS

The PMO and pre-menopausal ovarian stroma had a similar pattern of steroidogenic enzyme expression. The PMO had persistent, but reduced, levels of LHCGR and most steroidogenic enzymes. CYP19 and HSD3B2 mRNA were greatly reduced in PMO in comparison with CL (50-fold and 2000-fold less respectively). HSD3B2 was not detectable in PMO by western analysis.

CONCLUSIONS

This study supports the idea that the PMO retains some steroidogenic capacity. However, based on steroidogenic enzyme expression, the PMO has a unique pattern of steroidogenic enzyme expression that favors Delta5 steroid formation over Delta4 steroid formation.

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.