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

Osteoporosis and Fracture Risk Following Benign Hysterectomy Among Female Patients in Korea

IMPORTANCE

Prior research about the association between hysterectomy and osteoporosis risk had limitations.

OBJECTIVE

To assess osteoporosis and fracture risk among female patients who underwent hysterectomy due to benign conditions.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, female patients aged 40 to 59 years with benign hysterectomy between 2003 and 2011 were selected from Korean National Health Insurance Data and matched by 1:1 propensity score with female patients who had health checkups and indicated that they had not had a hysterectomy. A Cox proportional hazard model was used to analyze osteoporosis and fracture risk, with participants monitored until December 31, 2020. Data analysis was performed from July 16, 2022, to January 12, 2023.

EXPOSURES

Hysterectomy with or without adnexal surgical procedure.

MAIN OUTCOMES AND MEASURES

The primary outcome was the risk of osteoporosis. Secondary outcomes included the risk of vertebral fracture, hip fracture, other fractures, and total fracture.

RESULTS

The study population included 25 910 patients; the median (IQR) age was 47 (44-50) years, and median (IQR) follow-up period was 10.9 (9.4-12.7) years. In the stratified-extended Cox proportional analysis, female patients who underwent hysterectomy without an adnexal surgical procedure were associated with a higher risk of osteoporosis within 7 years compared with female patients who did not undergo hysterectomy (hazard ratio [HR], 1.28 [95% CI, 1.19-1.37]); the analysis was divided into 7 years due to a violation of the Cox assumption, and the risk did not differ after 7 years (HR, 0.99 [95% CI, 0.93-1.06]). However, the hysterectomy group with an adnexal surgical procedure had an association with higher risk of osteoporosis compared with the nonhysterectomy group both within 7 years of study entry (HR, 1.56 [95% CI, 1.33-1.82]) and after 7 years (HR, 1.20 [95% CI, 1.04-1.40]). In the hysterectomy group without an adnexal surgical procedure, the risks of vertebral fracture, hip fracture, and total fracture were similar to those in the nonhysterectomy group. Similar trends were observed in the hysterectomy group with an adnexal surgical procedure.

CONCLUSIONS AND RELEVANCE

Hysterectomy without an adnexal surgical procedure was associated with an increased osteoporosis risk within 7 years, but not afterwards, compared with the nonhysterectomy group. Hysterectomy was not associated with vertebral and hip fractures.

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.

Increased risk of depression before and after unilateral or bilateral oophorectomy: A self-controlled case series study using a nationwide cohort in South Korea

BACKGROUND

There is insufficient evidence of the association between oophorectomy and depression.

METHODS

A nationwide medical records database of South Korea was used to investigate incidence rate ratios (IRRs) of major depressive disorder before and after oophorectomy (n = 36,284) using a self-controlled case series design. Outcomes before and after hysterectomy (n = 25,415) were identified to compare with those around oophorectomy.

RESULTS

In all oophorectomy and hysterectomy groups, the risk of depression was increased before and after surgery, peaking immediately before or after the operation, with no significant difference in the pattern of the results according to type of surgery. In the bilateral oophorectomy group, the IRR was increased between 2-3 months before the surgery, peaking immediately before surgery at 1.39 (95% CI: 1.30-1.49, p < .0001), and remained heightened for one-year postexposure. Subgroup analyses performed according to ovarian cancer, age group, and hormone replacement therapy produced results similar to those of the main outcome.

LIMITATIONS

Because we used claims data, the detailed clinical information related to oophorectomy is lacking. There is possibility that time-varying confounder besides age and season might have affected the results CONCLUSIONS: The risk of depression increased before and after oophorectomy. The increase in risk of depression started before oophorectomy and peaked immediately before or after the operation, but no significant differences between unilateral and bilateral surgery and cancer and noncancer or among age groups were noted.

Does Saving Uterus Save Ovaries?

Ovarian function after hysterectomy is a subject of much controversy since many years. There is increasing awareness among gynecologists that the ovaries need to be spared at hysterectomy for benign conditions. However the awareness is limited, and many practitioners believe in removal of ovaries at hysterectomy. Removal of ovaries will save lives of patients at risk of developing ovarian cancer. But it will be unnecessary for low-risk women and will in fact endanger their lives by increasing cardiac risks. Recent data suggest that ovarian epithelial cancer arises from tubal epithelium, which adds new option of performing only salpingectomy and sparing ovaries, which will serve dual purpose of preventing ovarian cancer and continuing productive function of ovaries. Reproductive function is lost with hysterectomy. But it may be worth looking at impact of hysterectomy on productive function of ovaries. This editorial will focus on this issue and look at evidence on effects of other gynecological procedures on ovarian function.

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.

Ovarian Changes After Abdominal Hysterectomy for Benign Conditions

OBJECTIVES

To investigate any change in the ovaries, including early follicular serum follicle-stimulating hormone (FSH) level, total ovarian volume, total antral follicle count, and ovarian stromal blood flow, in patients who had undergone abdominal hysterectomy for benign conditions.

METHODS

Fifteen women with abdominal hysterectomy and conservation of ovaries for benign conditions and who were between 29 and 44 years old were recruited to undergo three-dimensional ultrasound examination with power Doppler to assess total ovarian volume, total antral follicle count, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of ovarian stromal blood flow. Serum FSH, estradiol, and progesterone levels were checked on the same day. The results of the assessments were considered taken during the early follicular phase if the estradiol and progesterone levels were basal. Fifteen age-matched healthy women underwent the same assessments on the second day of menstruation.

RESULTS

Women with hysterectomy had significantly elevated serum FSH level and lower ovarian stromal blood flow indices, including VI, FI, and VFI, as compared with healthy women. The total antral follicle count and the total ovarian volume were similar between the two groups.

CONCLUSION

These changes may suggest altered ovarian function after hysterectomy.

Prior hysterectomy and oophorectomy and incident venous thrombosis risk among postmenopausal women: a population-based, case-control study

OBJECTIVE

Hysterectomy and bilateral salpingo-oophorectomy (BSO) are associated with changes in endogenous hormone levels, yet the risk of venous thrombosis (VT) associated with hysterectomy and BSO is incompletely characterized. This study evaluated the risk of incident VT among postmenopausal women associated with combined prior hysterectomy/oophorectomy status and current use of hormone therapy (HT).

METHODS

In a case-control study, we identified incident VT cases (n = 1,623) among postmenopausal Group Health Cooperative enrollees without reproductive cancer, defining their "index date" as their VT diagnosis date (1995-2010). Matched controls had not experienced a prior VT (n = 4,480). Multiple logistic regression models estimated adjusted relative risks for VT associated with combinations of prior hysterectomy/oophorectomy status and HT use at the index date.

RESULTS

Compared with women with an intact uterus who were not using HT, there was no suggestion of greater VT risk in women with prior hysterectomy without BSO, whether they were (adjusted odds ratio [aOR] = 0.80 [95% CI: 0.57, 1.12]) or were not using HT (aOR = 1.09 [95% CI: 0.89, 1.35]). Women with prior hysterectomy and BSO who were using HT were not at a greater VT risk (OR = 1.00 [95% CI: 0.78, 1.27]), but there was evidence of a 25% greater risk associated with prior hysterectomy with BSO and no current HT use (OR = 1.25 [95% CI: 1.05, 1.49]).

CONCLUSIONS

Collectively, these and prior data do not suggest a substantial impact of hysterectomy, with or without BSO, on the risk of VT among postmenopausal women.

Ovarian function and ovarian blood supply following premenopausal abdominal hysterectomy

INTRODUCTION

The issue of conserving the ovaries at hysterectomy in premenopausal women with benign gynecologic disease has been the subject of considerable controversy. Some clinicians prefer prophylactic oophorectomy in premenopausal women during hysterectomy to prevent future development of malignant changes in conserved ovaries. Other clinicians prefer to conserve apparently normal ovaries, because bilateral oophorectomy in premenopausal women results in an abrupt imbalance, sudden onset of menopausal symptoms, decreased libido, increased cardiovascular risk and osteoporosis.

MATERIAL AND METHODS

Two hundred and twenty multipara women (who had completed their families), with benign uterine pathology were included in this prospective study for abdominal hysterectomy with bilateral ovarian preservation. Pre-operative vaginal ultrasound, Doppler studies, diagnostic hysteroscopy and endometrial biopsy were done followed by laboratory studies including Anti-mullerian hormone (AMH), follicle stimulating hormone (FSH) and estradiol for all studied women. Doppler studies, AMH, FSH and estradiol were repeated 6 and 12 months post-operative for assessment of the ovarian function and ovarian blood supply after hysterectomy.

RESULTS

Pre-operative AMH, FSH and estradiol of the studied women were statistically insignificant compared to AMH, FSH and estradiol 6 and 12 months post-operative. Twelve months post-operative right and left ovarian volumes (6.92 ± 0.18 and 6.85 ± 0.19 cm(3), respectively) were significantly larger than pre-operative right and left ovarian volumes (6.19 ± 0.22 and 5.86 ± 0.23 cm(3), respectively), and, 12 months post-operative right and left ovarian pulsatility indices (2.92 ± 0.15 and 2.96 ± 0.16 cm/s, respectively) were significantly lower than pre-operative right and left ovarian pulsatility indices (3.45 ± 0.19 and 3.36 ± 0.2 cm/s, respectively). Eight (3.6%) cases of the studied women developed an ovarian cyst 6 months after hysterectomy, 3 were spontaneously resolved and the remaining 5 (2.27%) cases underwent exploratory laparotomy.

CONCLUSIONS

There is no evidence of ovarian dysfunction affecting conserved ovaries one year after hysterectomy in premenopausal women as evident by AMH, FSH and estradiol. Furthermore, an increased ovarian volume and reduced ovarian pulsatility indices indicate a possible increase in ovarian blood supply, and preserved non-compromised ovarian function.

Examination of the ovarian reserve after generation of unilateral rudimentary uterine horns in rats

Objective. The purpose of this experimental rat model study is to evaluate the changes in the ovarian environment after excision of the rudimentary horn. Methods. Ten female Wistar albino rats were used in this study. One cm of right uterine horn length was excised in the first operation. Two months after the first operation, all animals were sacrificed to obtain ovaries for histological examination. Mann-Whitney U test and Student's t-test were used for statistical analysis purposes. Statistical significance was defined as P < 0.005. Results. The number of primordial follicles (P = 0.415), primary follicles (P = 0.959), preantral follicles (P = 0.645), antral follicles (P = 0.328), and Graafian follicles (P = 0.721) was decreased and the number of atretic follicles (P = 0.374) increased in the right ovarian side. Howeve,r this difference was not found to be statistically significant. Conclusion. The results of this experimental rat model study suggest that the excision of rudimentary horn could have negative effects on ipsilateral ovarian functions.

Analysis of uterine and ovarian arterial blood flow and ovarian hormone levels prior to and after hysteroscopic endometrial resection

The objective of this study was to evaluate the effect of hysteroscopic endometrial ablation on the ovarian and uterine artery blood flow and on follicle stimulating hormone (FSH) and oestradiol (E2) levels. A total of 26 consecutive women with abnormal uterine bleeding refractory to medical treatment had undergone hysteroscopic electrosurgical transcervical resection of the endometrium (TCRE). Ultrasonographic measurement of ovarian volumes and colour Doppler flow assessment of the uterine and ovarian arteries were performed on all patients before surgery (group 1) and 1 week (group 2) and 6 months (group 3) after surgery. Blood samples were also collected for determination of FSH and E2 levels, 4 weeks before and 1 month after surgery. No statistically significant change was observed between preoperative and postoperative (1st week and 3rd month) volumes of the ovaries. The mean pulsatility index (PI) of the uterine and ovarian artery did not show statistically significant differences between postoperative 1st week and 3rd month measurements of uterine and ovarian artery PI. The increase in serum levels of FSH and E2 after endometrial resection did not reach statistical significance. Although, women may present with climacteric complaints of hot flushes and nocturnal sweating after endometrial resection, this is probably a psychological response to hypomenorrhoea and amenorrhoea, as no statistically significant changes in FSH and E2 levels and uterine/ovarian blood flow were demonstrated in the early postoperative period.

Effect of hysterectomy with ovarian preservation on ovarian function

OBJECTIVE

To prospectively estimate the risk for earlier ovarian failure among women undergoing hysterectomy with ovarian preservation, as compared with women of similar age without hysterectomy.

METHODS

A prospective cohort study was conducted among women aged 30 to 47 years undergoing hysterectomy without bilateral oophorectomy (n=406) and women with intact uteri (n=465). Blood samples and questionnaire data were obtained at baseline and annually for up to 5 years. Hazard ratios (HR) for ovarian failure, defined as follicle-stimulating hormone levels 40 international units/L or higher, were calculated using Cox proportional hazards models.

RESULTS

Ovarian failure occurred among 60 of the women with hysterectomy and 46 of the women in the control group. Women undergoing hysterectomy were at nearly a twofold increased risk for ovarian failure as compared with women with intact uteri (HR 1.92, 95% confidence interval [CI] 1.29-2.86). The proportional hazards model further estimated that 14.8% of women with hysterectomies experienced ovarian failure after 4 years of follow-up compared with 8.0% of the women in the control group. Risk for ovarian failure was greater for women who had a unilateral oophorectomy along with their hysterectomy (HR 2.93, 95% CI 1.57-5.49), but also it was significantly increased for women who retained both ovaries (HR 1.74, 95% CI 1.14-2.65).

CONCLUSION

Increased risk of earlier ovarian failure is a possible consequence of premenopausal hysterectomy. Although it is unresolved whether it is the surgery itself or the underlying condition leading to hysterectomy that is the cause of earlier ovarian failure, physicians and patients should take into account this possible sequela when considering options for treatment of benign conditions of the uterus.

LEVEL OF EVIDENCE

II.

The effect of total abdominal hysterectomy on serum anti-Müllerian hormone levels: a pilot study

OBJECTIVE

To evaluate the effect of hysterectomy on levels of serum anti-Müllerian hormone (AMH), an indicator of ovarian reserve.

METHOD

Twenty-two premenopausal women between 40 and 50 years of age who underwent total abdominal hysterectomy for uterine leiomyoma were enrolled to the patient group and unaffected women in a similar age range constituted the control group. Samples were collected preoperatively and at the 4th month postoperatively from the patients and two times at 4 months apart from the controls. Serum AMH levels were detected with enzyme-linked immunosorbent assay and compared within each group and between groups.

RESULTS

Baseline serum AMH values were similar (1.46 ± 2.02 ng/ml for the hysterectomy group and 1.53 ± 1.82 ng/ml for the control group, p = 0.73). Serum AMH levels at month 4 decreased to 0.62 ± 0.9 ng/ml and 1.26 ± 1.78 ng/ml for hysterectomy patients and controls, respectively (p = 0.001 and < 0.001, respectively). Although the percentage median decrease was higher in hysterectomized women (58.9% vs. 28.5%), this was statistically insignificant (p = 0.26).

CONCLUSION

Although not statistically significant, our study demonstrated that total abdominal hysterectomy causes 30% more loss of ovarian reserve in addition to the effects of aging. Further research on larger populations is needed to confirm our results and to apply them in clinical practice.

Breast cancer risk and ovariectomy, hysterectomy, and tubal sterilization in the women's contraceptive and reproductive experiences study

Removal or impairment of ovaries before menopause may affect a woman's breast cancer risk by altering her cumulative exposure to ovarian hormones. The Women's Contraceptive and Reproductive Experiences Study, a population-based, multicenter case-control study of incident invasive breast cancer, recruited women aged 35-64 years (4,490 cases and 4,611 controls) who provided data on ovariectomy, hysterectomy, and tubal sterilization during in-person interviews. Controls were frequency-matched to cases by age, race, and study site. Unconditional logistic regression analysis was used. Women who had not undergone premenopausal reproductive surgery were the referent group. Bilateral ovariectomy was associated with reduced breast cancer risk overall (odds ratio (OR) = 0.59, 95% confidence interval (CI): 0.50, 0.69) and among women <45 years of age (ORs ranged from 0.31 to 0.52), but not among those who were older at surgery. It was also associated with a reduced risk for estrogen and progesterone receptor-positive tumors (OR = 0.63, 95% CI: 0.52, 0.75) but not receptor-negative tumors. Hysterectomy with ovarian conservation (OR = 0.83, 95% CI: 0.72, 0.96) and hysterectomy with partial ovary removal (OR = 0.73, 95% CI: 0.59, 0.91) were also associated with lower risk. No association with breast cancer risk was observed with tubal sterilization only or partial ovariectomy without hysterectomy. Reproductive organ surgeries may alter ovarian hormone levels, thereby affecting breast cancer risk.

Change in the ovarian environment after hysterectomy as assessed by ovarian arterial blood flow indices and serum anti-Müllerian hormone levels

OBJECTIVE

The aim of this prospective study was to evaluate the changes in the ovarian environment after hysterectomy based on ovarian arterial blood flow indices and serum anti-Müllerian hormone (AMH) levels.

STUDY DESIGN

Ovarian arterial blood flow indices (pulsatile and resistance indices) by Doppler ultrasonography and serum AMH levels were measured at baseline and 1 week, 1 month, and 3 months after hysterectomy in 32 women ranging in age from 38 to 49 years, or at the time of screening in 21 age-matched controls. The study subjects underwent hysterectomy with conservation of both ovaries for benign diseases of the uterus (laparoscopy-assisted vaginal hysterectomy [LAVH], n=26; and total abdominal hysterectomy [TAH], n=6). The study subjects and controls were analyzed using a t-test or one-way analysis of variance.

RESULTS

No differences existed in demographic profiles, ovarian arterial blood flow indices, and serum AMH levels at baseline between the hysterectomy and control groups. Ovarian arterial blood flow indices did not change before and after surgery, and there were no serial changes in the mean levels of serum AMH at each time point (1.80+/-1.81 ng/mL [pre-operatively], 1.69+/-1.62 ng/mL [1 week post-hysterectomy], 1.42+/-1.34 ng/mL [1 month post-hysterectomy], and 1.52+/-1.72 ng/mL [3 months post-hysterectomy]; p=0.805). In addition, no significant differences in ovarian arterial blood flow indices and serum AMH levels existed between the LAVH and TAH groups.

CONCLUSION

This preliminary study suggests that hysterectomy does not affect the ovarian environment for up to 3 months post-operatively, as assessed by ovarian arterial blood flow indices and serum AMH levels.

The effect of hysterectomy on ovarian blood supply and endocrine function

OBJECTIVE

To evaluate the effect of hysterectomy on ovarian blood supply by color Doppler ultrasonography and the relationship between ovarian blood supply and ovarian function.

METHODS

Fifty patients undergoing hysterectomy due to uterine myoma were recruited as the study group. Forty patients who received myomectomy served as the control group. The following ovarian arterial parameters were measured before operation, on day 5, 1 and 3 months after operation: peak systolic flow velocity (Vmax) and pulsatility index (PI). Blood samples were taken at the time of each Doppler scan for subsequent hormone analysis: serum estradiol, progesterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH).

RESULTS

In the study group, Vmax, FSH and LH levels were significantly higher, while PI, estradiol and progesterone levels were significantly lower, on day 5 compared to pre-operation and to those of the control group. One and 3 months postoperatively, PI, FSH and LH levels were significantly higher, while Vmax, estradiol and progesterone levels were significantly lower, compared to pre-operation and to those of the control group. Vmax and PI were significantly correlated with FSH (r = 0.440, p = 0.015; and r = -0.361, p = 0.043, respectively) on day 5 postoperatively, but not with estradiol, progesterone and LH. Vmax was significantly correlated with estradiol and progesterone (r = 0.417, p = 0.045; and r = 0.808, p < 0.001, respectively) 1 and 3 months postoperatively, but not with LH and FSH. There were no correlations between PI and the hormone parameters 1 and 3 months postoperatively.

CONCLUSIONS

Hysterectomy may impair ovarian blood supply and function. There is good correlation between Doppler parameters and endocrine parameters.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial

OBJECTIVE

To compare among women with menorrhagia the effect of hysterectomy or levonorgestrel-releasing intrauterine system (LNG-IUS) on sexual functioning.

DESIGN

A randomised controlled trial.

SETTING

Five university hospitals in Finland.

SAMPLE

A total of 236 women, aged 35-49 years.

METHODS

Of the women, 117 were treated by hysterectomy and 119 by LNG-IUS.

MAIN OUTCOME MEASURES

Sexual functioning was evaluated by modified McCoy sexual scale at baseline and at 6 months, 12 months, and 5 years after initiation of treatment (hysterectomy or application of LNG-IUS).

RESULTS

Among women treated by hysterectomy, sexual satisfaction increased and sexual problems decreased. Among LNG-IUS users, satisfaction with partner decreased. In addition to treatment modality (P = 0.02), estrogen therapy (P = 0.01), smoking (P = 0.001), night sweats (P = 0.03), vaginal dryness (P = 0.04), hot flushes (P = 0.01), and having someone to ask for advice (P = 0.03) and to share worries (P = 0.01) explained changes in sexual functioning.

CONCLUSIONS

Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG-IUS does not have such a positive effect.

A comparison of different methods for including 'age at menopause' in analyses of the association between hormone replacement therapy use and breast cancer

BACKGROUND AND METHODOLOGY

Late 'age at menopause' is a recognised risk factor for postmenopausal breast cancer and is also associated with decreased use of hormone replacement therapy (HRT). When investigating the association between HRT use and breast cancer risk it is therefore necessary to adjust for the potential confounder, 'age at menopause'. 'Age at menopause', however, cannot be determined for women with a hysterectomy and ovarian conservation. Using data on 13 357 postmenopausal women in whom 396 cases of invasive breast cancer were diagnosed during 9 years of follow-up from the Melbourne Collaborative Cohort Study, we compared the estimates of relative risk of HRT use for breast cancer for three different methods of dealing with missing data: complete-case analysis, single imputation and multiple imputation.

RESULTS

'Age at menopause' was missing for 17% of the data. Both HRT use and 'age at menopause' were significant risk factors for breast cancer, although 'age at menopause' only marginally confounded the estimates of risk for HRT. Women with 'age at menopause' missing did not represent a random sample of the population. Complete-case analyses resulted in higher estimates of the risk associated with HRT use compared with the different methods of imputation.

DISCUSSION AND CONCLUSIONS

We recommend that analyses investigating the association between HRT and breast cancer should present the results in two ways: excluding women with 'age at menopause' missing and including the women using multiple imputation. For both methods, estimates of risk, with and without the adjustment of 'age at menopause', should be given.

La chirurgie tubaire et utérine a-t-elle un effet délétère sur la fonction ovarienne?

Changes in menstrual pattern after tubal sterilisation have been reported for more than 50 years. Hence all tubal surgeries have been suspected of altering the ovarian reserve, by damage to the ovarian blood vessels. Recent studies showed that tubal surgery has no significant adverse effect on doppler flow indice and hormonal markers. Hysterectomy and uterine artery embolization seem to decrease ovarian reserve in perimenopausal women. Uterine artery embolization does not seem to have adverse effects on normally functioning ovaries.

Fresh human orthotopic ovarian cortex transplantation: long-term results

BACKGROUND

Ovarian orthotopic transplantation in patients with premature ovarian failure is reported to result in full-term pregnancies. Ischaemia and freezing/thawing are potentially injurious for tissues. This study was designed to analyse the effect of ischaemia on long-term ovarian function in humans.

METHODS

Prospective case-control study. Subjects were 12 premenopausal women undergoing hysterectomy and fresh orthotopic transplantation of the entire ovarian cortex plus a control group of five patients undergoing hysterectomy only. Follow-up lasted 2 years. Serum FSH and anti-Müllerian hormone (AMH) were recorded, and ovulatory cycles were determined by vaginal ultrasound and serum progesterone levels.

RESULTS

Follow-up showed that ovulation was restored in 11 of the 12 patients who received grafts over the duration of the study (9.3 +/- 1.73 ovulations versus 12.0 +/- 0.86 in controls, NS), and 9 of 12 patients remained ovulatory after 2 years. We identified four patterns of FSH secretion during the study, 5 of 12 (41.7%) women having the same pattern as controls. There was a trend for serum AMH levels 7 days after surgery (0.16 +/- 0.02 microg/l) to be lower than pre-surgery levels (0.38 +/- 0.09 microg/l, P = 0.07) and higher in women whose FSH patterns suggested normal ovarian function, but the results did not reach significance. After transplantation, FSH correlated more closely (r = -0.639, P = 0.02) with normal ovarian function than AMH (r = 0.465, P = 0.12).

CONCLUSIONS

Fresh orthotopic ovarian cortex transplantation is a viable procedure. It maintains normal ovarian function after 2 years in 75% of cases and preserves ovarian function against ischaemia in 41.7% of patients.

A Prospective Comparison of the Impact of Uterine Artery Embolization, Myomectomy, and Hysterectomy on Ovarian Function

PURPOSE

To prospectively compare uterine artery embolization (UAE) versus myomectomy and hysterectomy with regard to ovarian function as measured by postprocedure follicle-stimulating hormone (FSH) levels and symptoms.

MATERIALS AND METHODS

Fifty-five patients were prospectively enrolled in the study: 33 patients who underwent UAE, seven who underwent myomectomy, and 15 who underwent hysterectomy. Patients had serum FSH and estradiol levels measured on the third day of the menstrual cycle before their procedure and at regular follow-up visits for as long as 6 months. At these intervals, patients were also surveyed regarding menopausal symptoms.

RESULTS

Although a mild transient increase in mean FSH level after UAE was noted at 3 months, there were no statistically significant differences among the three groups in mean FSH levels at 1 month, 3 months, or 6 months of follow-up. Menopausal symptoms arose in the UAE and hysterectomy groups, but there was no statistically significant difference or permanent effect in either group.

CONCLUSION

There is no significant difference in impact on ovarian function after UAE, hysterectomy, or myomectomy at follow-up for a maximum of 6 months.

Hypertension is associated with an increased risk for hysterectomy: a Danish cohort study

OBJECTIVE

To assess whether hypertension is a risk factor for hysterectomy, endometrial resection, and myomectomy.

STUDY DESIGN

Self-report questionnaires were collected from 81% of 1959 Danish women aged 30 or 40 years selected at random in 1976-1991, in four different cohort studies. Baseline data included standardized information about cardiovascular diseases, hypertension, use of medicine, gynecologic history, social background, and life style factors. Weight, height and blood pressure were measured. The women were followed via central registers to assess the incidence of hysterectomy, endometrial resection, and myomectomy performed for benign diagnoses. Cox regression analyses were used to control for confounding.

RESULTS

The average time to follow-up was 15 years, and 135 operations performed for benign diagnoses were identified. Women with a history of hypertension had a double risk of having an operation compared to women without hypertension, independent of confounders.

CONCLUSION

Hypertension seems to be a risk factor for hysterectomy performed for benign diagnoses, and thus contributes to women undergoing hysterectomy having an increased risk of cardiovascular diseases. It might be relevant to pay increased attention to the blood pressure in candidates for hysterectomy, as optimal antihypertensive treatment could decrease their otherwise increased risk of cardiovascular disease years after hysterectomy.

The hysterectomized woman

OBJECTIVE

To delineate the health profile of hysterectomized women and to assess whether women who have undergone hysterectomy have a different health profile even before surgery.

MATERIAL AND METHODS

The WHILA project covers all women (n = 10,766) aged 50-60, living in the Lund area and are based on questionnaires and personal interviews tied to laboratory examinations.

RESULTS

6917 women (64.2%) had complete questionnaires and laboratory tests, 800 were hysterectomized (11.6%). Logistic regression analysis revealed that hysterectomized women had more "dizziness" 1.40 (1.19-1.66), "nervous problems" 1.29 (1.07-1.56), "backache" 1.37 (1.16-1.62), "joint problems" 1.29 (1.09-1.52), "eye problem" 1.20 (1.02-1.42) and "headache" 1.17 (1.00-1.37). For both somatic (5.22 versus 4.49 mean value, p < 0.001) and psychological (4.19 versus 3.86 mean value, p = 0.002) symptoms, the number was higher in hysterectomized women. Logistic regression analysis revealed that among hysterectomized women university education was less common odds ratios 0.73 (95% confidence interval 0.58-0.91) as well as working full time 0.76 (0.62-0.93). A higher body weight at the age 25, 1.01 (1.001-1.02) as well as a weight gain of more than 5 kg during the last 5 years 1.27 (1.07-1.50), elevation of serum triglycerides 1.29 (1.16-1.44), high-density (HDL) 1.44 (1.14-1.80) and low-density lipoprotein (LDL) cholesterol 1.11 (1.02-1.21) as well as the bone density 1.08 (1.00-1.17). Hysterectomized women had a lower age at giving first birth (p < 0.001), shorter interval between menstrual periods (p < or = 0.001) and less frequent amenorrhic episodes (p < 0.05). The hysterectomized women used IUD to a lesser extent (p < 0.05) but used hormone therapy (HT) (p < 0.001) and utilized health care services (p < 0.001) more often.

CONCLUSIONS

Long after surgery, several somatic and psychological symptoms were still more common in hysterectomized women. A low frequency of amenorrhic episodes and lower age at giving first birth, concomitant with a higher body weight already at age 25 may imply that women who end up hysterectomized have a specific health profile long before as well as long after surgery.

Effects of three different sterilization methods on utero-ovarian Doppler blood flow and serum levels of ovarian hormones

OBJECTIVE

The aim of the study was to assess pre-operative and post-operative serum levels of ovarian hormones and changes in utero-ovarian arterial blood flow by Doppler ultrasonography in women in whom one of three different sterilization methods was applied.

STUDY DESIGN

The Pomeroy method of tubal ligation, fimbriectomy, or laparoscopic bipolar coagulation were applied in 42 patients. Serum levels of sex hormones were checked, and utero-ovarian arterial Doppler measurements were performed pre-operatively and post-operatively. The presence or absence of dysmenorrhea was noted before and after the operations.

RESULTS

We detected a significant increase in the average uterine arterial resistivity index (RI) and both ovarian arterial pulsatility index (PI) values in the Pomeroy method group (p<0.05). There was a significant increase in dysmenorrhea complaints in the total number of patients (p<0.05), particularly in the fimbriectomy group.

CONCLUSION

The significant increase in uterine arterial Doppler measurements with the Pomeroy method may be due to the removal of a larger tubal segment. Even though the increase is not statistically significant, fimbriectomy should not be applied in young women, because it may increase dysmenorrhea and the procedure is not reversible.

Transfer pathways between the ovaries and the uterus in the cebus monkeys (Cebus apella)

The aim of this work was to study, in the Cebus apella monkey, the developmental changes in the microanatomy of the utero-ovarian ligament (UOL) and whether their vascular and neural elements might be involved in the transfer of signals between the ovaries and uterus. Sections including uterus, UOL, and ovary obtained from two foetuses, two prepubertal, and four cycling monkeys, two of them treated with a neuron-axonal tracer, diamidino yellow (DY) into the corpus luteum (CL) and the remaining two into the endometrium, were analyzed for the expression of neurofilament protein (NFP) and tracer distribution. Eight regularly cycling females were used to investigate the transfer to the CL of pulses of prostaglandin F(2alpha) (PGF(2alpha)) (n=4) or its vehicle (n=4) given intra-uterus. A convoluted artery, in conjunction with various vein channels, passed over the UOL allowing for a direct communication between uterus and ovaries. The artery acquired prominence during adulthood, in a manner well suited with the ovarian status. Immunohistochemical analysis revealed that NFP expression by the oocyte and by the endometrial epithelial cells was a highly conserved feature during development, whereas the appearance of NFP fibers in the ovaries, UOL, and uterus was a late event in the ontogenesis, likely regulated by the hormonal environment. Neurons, as an obvious source for these NFP fibers, were not recognized at any developmental stage, although some neuron-like cells were observed within the CL. The pattern displayed by the tracer DY, further suggested a reciprocal axonal transport among endometrial cells and follicular and luteal cells of both ovaries and between the ovaries themselves. The functionality of the utero-ovarian connection was assessed after injecting PGF(2alpha) intra-uterus. A short exposition to PGF(2alpha) pulses was required for lowering ovarian and peripheral progesterone concentrations causing luteolysis, indicating that transport mechanism operating between uterus and ovary must be very efficient. The results suggest that the vessels and axons contained in the UOL of the Capuchin monkeys might be two combined key pathways underlying the reciprocal transfer of signals controlling utero-ovarian homeostasis.

Effects of hysterectomy on ovarian morphology and serum FSH level in rats

OBJECTIVE

To investigate the effects of hysterectomy with ovarian conservation on ovarian histology and FSH plasma level.

METHODS

Fifty female Wistar albino rats (30 for hysterectomy and 20 sham operated for control) were used after two complete estrous cycles. Six months after hysterectomy, the blood samples were collected from both the groups to test FSH plasma level and all animals were sacrificed by decapitation to obtain ovaries for histological examination.

RESULTS

Histologic study showed that ovaries from control group exhibited many follicles in various stages of development including primary, secondary and tertiary follicles. There were one or two secondary and tertiary follicles but no primary follicle in each histological section of the 6 months after hysterectomy. The ovaries showed that the cortex of ovary completely covered by corpora lutea, and there were many cystic follicles and atretic follicles with few normal follicles. Theca interna is absent in cysts and most of the mural granulose cell population has been depleted. Serum FSH levels showed significantly increase in hysterectomized group compared control after 6 months operation.

CONCLUSIONS

The results of present study support previous studies and suggest that hysterectomy with ovarian conservation in young patients could preserve a woman's normal hormonal milieu. The uterus could have controlling on ovulation and hysterectomy might accelerate to initiate of early menopause.

The association of hysterectomy and menopause: a prospective cohort study

OBJECTIVE

To determine whether or not hysterectomy leads to an earlier onset of the menopause.

DESIGN

A prospective cohort study.

SETTING

Gynaecology service of large urban hospital.

POPULATION

Premenopausal women with and without hysterectomy.

METHODS

Multivariate survival analysis techniques were used to adjust for differences in initial follicle stimulating hormone (FSH) levels, body mass index, smoking and unilateral oophorectomy between the groups.

MAIN OUTCOME MEASURES

FSH levels were measured for five years following hysterectomy and compared with the comparison group. Menopause was defined as a single FSH measurement of at least 40 IU/L.

RESULTS

Two hundred and fifty-seven women undergoing hysterectomy were compared with 259 women who had not undergone a hysterectomy. Fifty-three women (20.6%) in the hysterectomy group and 19 women (7.3%) in the comparison group reached menopause over the five years of the study. Women in the hysterectomy group with a pre-operative FSH <10 IU/L reached menopause 3.7 years (95% CI 1.5-6.0 years) earlier than women in the comparison group independent of BMI, smoking and unilateral oophorectomy. Twenty-eight women in the hysterectomy group had unilateral oophorectomy and 10 (35.7%) of these women reached menopause over the five years of follow up. Women in the hysterectomy group with unilateral oophorectomy reached menopause 4.4 years (95% CI 0.6, 7.9 years) earlier than women with both ovaries in the hysterectomy group independent of baseline FSH, BMI and smoking.

CONCLUSIONS

Hysterectomy is associated with an earlier onset of menopause. Hysterectomy with unilateral oophorectomy is associated with an even earlier onset of the menopause in this study.

Effect of total abdominal hysterectomy on ovarian blood supply in women of reproductive age

OBJECTIVE

The purpose of this study was to evaluate the effect of total abdominal hysterectomy on ovarian blood supply using transvaginal color Doppler ultrasonography in women of reproductive age.

METHODS

This prospective study included 61 women aged 40 years or younger who were divided into 2 groups: group 1, comprising 31 patients who underwent total abdominal hysterectomy (TAH); and group 2, comprising 30 women with no abnormalities. Inclusion criteria included normal ovarian function at baseline, with basal follicle-stimulating hormone levels of less than 15 mUI/mL, normal body weight, no tobacco use, and no history of laparotomy or ovarian disease. Ovarian arterial blood supply by determination of the pulsatility index (PI) on Doppler analysis and ovarian volume on transvaginal ultrasonography were assessed at baseline and at 6 and 12 postoperative months. The Student t test, profile analysis, and Friedman and Mann-Whitney tests were used in the statistical analysis of data.

RESULTS

Statistical analysis of baseline data revealed that both groups were homogeneous. At months 6 and 12, greater ovarian volumes and lower PI values were observed in patients who underwent TAH (P < .05). By the end of the study, in 8 of the 31 patients who underwent TAH (25.5%), benign ovarian cysts were observed. In the control group, all the parameters studied remained unchanged.

CONCLUSIONS

The reduced PI values observed on Doppler ultrasonography suggested a decrease in the resistance flow in the ovarian arteries in women of reproductive age who underwent TAH.

Long-Term Treatment of Menorrhagia With Levonorgestrel Intrauterine System Versus Endometrial Resection

OBJECTIVE

The purpose of this study was to compare the long-term efficacy of the levonorgestrel intrauterine system and transcervical resection of the endometrium in the treatment of menorrhagia.

METHODS

This study was an open, randomized 3-year trial. Patients with menorrhagia were assigned randomly to either the levonorgestrel intrauterine system (n = 30) or endometrial resection (n = 29). Pictorial blood loss assessment charts were used to measure menstrual blood loss. A pictorial blood-loss assessment chart score exceeding 75 (representing menstrual blood loss >/=60 mL) was used to diagnosis the patient as having menorrhagia. Discontinuations and cases requiring repeat operations were evaluated.

RESULTS

Pictorial blood loss scores decreased from a baseline median of 261.5 (range, 60-1503) to 7 (range, 0-101; P < .001) for the levonorgestrel intrauterine system and from 311 (range, 81-2506) to 4 (range, 0-182; P < .001) for transcervical resection of the endometrium. Nineteen women of 30 using the levonorgestrel intrauterine system completed the 3-year follow-up compared with 22 of 29 for transcervical resection of the endometrium.

CONCLUSION

Both treatments efficiently reduced menstrual bleeding. The high continuation rate suggests that the levonorgestrel intrauterine system is comparable with transcervical resection of the endometrium.

Comparison of ovarian cyst formation in women using the levonorgestrel-releasing intrauterine system vs. hysterectomy

OBJECTIVE

To analyze the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on ovarian cyst formation, endometrial thickness and the size of uterus and uterine fibroids by ultrasonography.

SUBJECTS AND METHODS

This was a prospective, randomized trial comparing the LNG-IUS and hysterectomy in 236 women (age range 35-49 years) referred for menorrhagia. Transvaginal ultrasound examination was used to study the presence of ovarian cysts, uterine size, endometrial thickness, and the size of the uterus and uterine fibroids during a 12-month follow-up period.

RESULTS

At baseline examination, 12 ovarian cysts were detected, eight in the LNG-IUS group and four in the hysterectomy group. During the follow-up period, 14 new cysts had emerged at 6 months and 14 new cysts had emerged at 12 months in the LNG-IUS group, whereas the corresponding figures in the hysterectomy group were three and eight, respectively. All but one of the 14 new cysts (94.1%) detected at 6 months in the LNG-IUS group resolved spontaneously, whereas two out of the eight cysts detected at the baseline examination persisted for 12 months. Three cysts were removed at operation. The relative risk of the occurrence of ovarian cysts was significantly higher in women with LNG-IUS, compared with women who underwent hysterectomy. LNG-IUS did not affect the size of the uterus or uterine fibroids, but it was associated with a decrease in endometrial thickness. The occurrence of cysts did not correlate with age or follicle stimulating hormone levels, but a weak positive correlation between the occurrence of cysts and the presence of irregular bleeding was observed.

CONCLUSIONS

LNG-IUS use in the treatment of menorrhagia was associated with the development of ovarian cysts, but these were symptomless and showed a high rate of spontaneous resolution. LNG-IUS did not affect the size of the uterus or the size of uterine fibroids, but decreased the thickness of the endometrium.

The perimenopause: definitions, demography, and physiology

The perimenopausal years should serve to remind patients and clinicians that this is a time for education. Certainly preventive health care education is important throughout life, but at the time of midlife, a review of the major health issues can be especially rewarding. The failure to respond appropriately (by either clinician or patient) easily leads to a loss of the patient from a practice, but equally, if not more importantly, is the probability that the loss of a patient from a practice means that another woman has lost her involvement in a preventive health care program. Contrary to popular opinion, the menopause is not a signal of impending decline, but rather a wonderful phenomenon that can signal the start of something positive, a good health program.

The effect of surgical sterilization on ovarian function: a rat model

OBJECTIVE

To evaluate the effects of various methods of sterilization on ovarian function, in a rat model.

STUDY DESIGN

Forty-eight female Whistar albino rats weighing 200-250g are divided equally into four groups. All rats underwent laparotomy, while no specific intervention was made to the first group. Bilateral tubal ligation by Pomeroy's technique, unipolar and bipolar cautery was done to the second, third and fourth groups, respectively. All rats were then individually caged and fed on demand for 6 months. Afterwards, the rats were sacrificed and underwent bilateral oophorectomy. A pathologist blinded to the groups made histological examination by counting number of healthy tertiary follicles and corpora lutea in each ovary. The results of the groups were statistically compared by one-way ANOVA using post-hoc Bonferroni correction.

RESULTS

Rats in group 1 had significantly higher number of healthy tertiary follicles than every other group. Rats in group 1 also had significantly more corpora lutea than those in group 3.

CONCLUSION

Tubal ligation may affect ovarian function, which in turn may reflect to ovarian histology in rats.

Assignment to menopausal status and estimation of age at menopause for women with missing or invalid data--a probabilistic approach with weighting factors in a large-scale epidemiological study

OBJECTIVE

Gynaecologic surgeries and hormone medication increasingly interfere with the concept of determining menopausal status based on self-reported data about the last menstrual period-an approach frequently applied in epidemiological studies. This analysis compared different approaches of menopausal status determination, including a probabilistic approach that was developed to reduce misclassification of menopausal status.

METHODS

Interview and questionnaire data relating to hormone status from about 16,000 German women were used to determine menopausal status using different approaches: menses based, age based, self-assessment based, and a probabilistic approach.

RESULTS

Applying strict menses-based criteria, 29.1% of the women were found to be with undetermined menopausal status. The probabilistic approach was applied to determine menopausal status and age at menopause for these women. The proposed approach uses the current age of the women with undetermined menopausal status, and the relative age-dependent frequencies of pre- or postmenopausal status among those with natural menopausal status to calculate weighting factors, which represent the probabilities of being pre- and postmenopausal of each woman previously undetermined. Correspondingly, the missing age at menopause was estimated with the same probabilistic approach. Applying various approaches to determine menopausal status, the ratio of pre- to postmenopausal women differed considerably, ranging from 1.03 to 1.61. In addition, considerable differences were observed with respect to the number of missing values for both menopausal status and age at menopause.

CONCLUSION

The probabilistic approach allowed to estimate menopausal status and age at menopause with the advantage that all available information from the entire study population and from the individual is used.

Is there evidence for preferential delivery of ovarian estradiol to the endometrium?

OBJECTIVE

To determine the direction of delivery of E(2) in the female pelvis by assessing the ratio of endometrial to serum E(2) in women whose ovaries were stimulated to produce E(2) with women who received exogenous E(2).

DESIGN

Prospective comparative study.

SETTING

University-based ART program.

PATIENT(S)

Oocyte donors and recipients of donor oocytes.

INTERVENTION(S)

Micronized E(2) administered by the oral or vaginal route and oocyte donation.

MAIN OUTCOME MEASURE(S)

Serum and endometrial levels of E(2).

RESULT(S)

Serum E(2) levels were significantly higher in women who underwent controlled ovarian hyperstimulation (COH) and women receiving exogenous E(2) by the vaginal route than in those who received oral E(2). Levels of E(2) in endometrial tissue were similar in women who underwent COH and those receiving oral E(2). Endometrial E(2) levels in women who underwent vaginal administration were significantly higher than those in the oral E(2) or COH groups. The ratio of endometrial to serum E(2) was highest in women who underwent vaginal E(2) and lowest in those undergoing COH.

CONCLUSION(S)

Vaginal administration of micronized E(2) results in preferential absorption of E(2) into the endometrium, consistent with a "uterine first pass" effect. Since endogenous E(2) produced the smallest ratio of E(2) between the endometrium and serum, E(2) produced by the ovaries is not preferentially delivered to the uterus.