Hysterectomy with ovarian conservation: effect on bone mineral density

Relationship between myomectomy and risk of osteoporosis or fracture: A population-based cohort study

Myomectomy, a surgery to remove multiple leiomyomas from the uterus, is a treatment option for uterine fibroids (UF) in premenopausal patients. Osteoporosis and bone fractures are known to be strongly associated with menopausal status or hormonal changes. However, no studies have discussed the association between myomectomy and osteoporosis or fractures. This study investigated the risk of osteoporosis or fractures (vertebrae, hip, and others) in Korean patients who had undergone myomectomy without bilateral oophorectomy. We used data from the 10-year claims database of the Korean National Health Insurance from January 2009 to December 2020. Data for patients who had undergone myomectomy without oophorectomy (n = 211,969) and the control group (n = 450,124) who were randomly selected from the database were extracted. The incidence and hazard ratios (HRs) of osteoporosis or fracture between the myomectomy patients and the control group were calculated. A Cox proportional hazards model was used to analyze hazard ratios and 95% confidence intervals (CI). Subgroup analyses were performed based on age. The adjusted hazard ratios for osteoporosis and total fractures were 0.934 (95% CI: 0.916-0.954, P<0.001) and 0.919 (95% CI: 0.896-0.941, P<0.001), respectively, in the myomectomy group. The adjusted hazard ratios according to fracture site were 0.857 (95% CI: 0.799-0.92, P<0.001) for vertebral fractures, 0.706 (95% CI: 0.48-1.037, P = 0.076) for hip fractures, and 0.919 (95% CI: 0.896-0.943, P<0.001) for other fractures. In conclusion, patients who have undergone myomectomy might have a decreased risk of osteoporosis or 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.

Hysterectomies are associated with an increased risk of osteoporosis and bone fracture: A population-based cohort study

AIM

This study investigated the risk of osteoporosis or bone fractures (vertebrae, hip and others) in hysterectomized women in Taiwan.

MATERIALS AND METHODS

This is a retrospective population-based cohort study from 2000 to 2013. Women aged ≥30 years who underwent hysterectomy between 2000 and 2012 were included in this study. The comparison group was randomly selected from the database with a 1:4 matching with age and index year. Incidence rate and hazard ratios of osteoporosis and bone fracture between hysterectomized women and the comparison group were calculated. Cox proportional hazard regressions were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

We identified 9,189 hysterectomized women and 33,942 age-matched women without a hysterectomy. All women were followed for a median time of about 7 years. The adjusted hazard ratio (aHR) of subsequent osteoporosis or bone fracture was higher in the hysterectomy women (2.26, 95% confidence interval [CI] = 2.09-2.44) than in the comparison group. In the subgroup analysis, oophorectomy and estrogen therapy increase the risk of osteoporosis or fracture in both groups. Regarding the fracture site, the aHR of vertebral fracture (4.92, 95% CI = 3.78-6.40) was higher in the hysterectomized women than in the comparison group. As follow-up time increasing, the aHR of vertebral fracture in hysterectomized women were 4.33 (95% CI = 2.99-6.28), 3.89 (95% CI = 2.60-5.82) and 5.42 (95% CI = 2.66-11.01) for <5, 5-9 and ≥9 years of follow-up, respectively.

CONCLUSIONS

In conclusion, we found that hysterectomized women might be associated with increased risks of developing osteoporosis or bone 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.

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)

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.

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.

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.

Hysterectomy and oophorectomy are unrelated to bone loss in older women

OBJECTIVE

The relation of hysterectomy and oophorectomy to change in bone mineral density (BMD) was examined in older women using and not using estrogen replacement therapy (ERT).

METHODS

Women aged 60-80 years from the Rancho Bernardo Study attended clinic visits in 1988-1991 and 1992-1995 when hysterectomy and oophorectomy were ascertained, ERT use was validated and spine and hip BMD was assessed at both visits with DEXA. Women were either current ERT users or nonusers at both visits.

RESULTS

Among these 447 women, average age was 71 (S.D.=9.0); average years postmenopause was 24.7 (S.D.=10.9). Overall, 122 had a hysterectomy with ovarian conservation and 91 had a hysterectomy with bilateral oophorectomy; 41% reported current ERT use for an average duration of 19.1 years (S.D.=10.8). Hysterectomized women were 2.3 times more likely to report ERT use than intact women (P<0.001). Comparisons adjusted for age, obesity, and age at menopause but not for ERT use showed hysterectomized women had less bone loss per year at the hip than intact women (P<0.05). However, this difference was explained by ERT; after adjustment for ERT, mean hip bone loss per year was -0.57% for intact women, -0.42% for hysterectomized women with ovarian conservation and -0.32% for bilaterally oophorectomized women (P's>0.10). There were no differences by hysterectomy or oophorectomy in bone loss at the spine or femoral neck. For all sites, women using ERT had higher BMD at both visits than nonusers (P's<0.001). Stratification by ERT showed that within users and nonusers, there were no differences in BMD or bone loss at any site by hysterectomy or oophorectomy.

CONCLUSIONS

There are no long term effects of hysterectomy and bilateral oophorectomy on bone loss. Women who use ERT have better BMD than nonusers.