Uterine Disorders
Ovarian Failure After Pre-menopausal Hysterectomy Patricia G Moorman
Associate Professor, Department of Community and Family Medicine, Duke University Medical Center
Abstract
Hysterectomy is the most common non-obstetrical surgery among women, and up to one-quarter of women will have a hysterectomy before natural cessation of menses. It has been hypothesised for many years that women undergoing pre-menopausal hysterectomy are at increased risk of earlier ovarian failure. Numerous studies dating back several decades have evaluated ovarian function after hysterectomy; however, many of them had important limitations, including small sample sizes, inadequate control groups, short duration of follow-up or menopause classification based only on symptoms. Recent large, prospective cohorts that compare women with hysterectomy with healthy controls provide compelling evidence of the increased risk of earlier ovarian failure after hysterectomy. It remains unresolved whether the increased risk is attributable to the surgery itself or to the underlying condition that was the indication for the hysterectomy. Further research addressing ovarian reserve in women undergoing hysterectomy may provide useful information for clinicians and patients as they evaluate treatment options for benign conditions of the uterus.
Keywords Hysterectomy, ovarian failure, menopause, follicle-stimulating hormone, anti-Müllerian hormone
Disclosure: The author has no conflicts of interest to declare. Acknowledgements: This work was supported in part by a grant from the United States National Institutes of Health, National Institute on Aging (R01 AG020162). Received: 13 January 2012 Accepted: 30 January 2012 Citation: European Obstetrics & Gynaecology, 2012;7(1):35–8 Correspondence: Patricia G Moorman, Associate Professor, Department of Community and Family Medicine, Duke University Medical Center, DUMC Box 2715, 2424 Erwin Road, Suite 602, Durham, NC 27705, US. E:
patricia.moorman@
duke.edu
Hysterectomy is the most frequent non-obstetrical surgical procedure among women in the US, with approximately 600,000 procedures performed annually.1
consequences, including the well-documented increased risk of osteoporosis, cardiovascular disease and all-cause mortality.11–15
Rates are markedly higher in the US (510 per
100,000 women) than in Europe, Canada and Australia (approximately 200–350 per 100,000 women).1–4
Although many countries have
observed declines in hysterectomy rates over the past few decades, it is still one of the most common surgeries performed on women in developed countries, and a substantial proportion of women will undergo hysterectomy during their lifetime.5,6
In the US, it is estimated
that 25 % of women will have a hysterectomy by the age of 50, and the lifetime risk of having a hysterectomy is approximately 40 %.5,7
Despite
the increasing use of alternative treatments – such as uterine artery embolisation, endometrial ablation or progestin-releasing intra-uterine devices for leiomyomas or dysfunctional uterine bleeding – the number of women undergoing hysterectomy each year remains high, and the long-term outcomes after surgery, including risk of ovarian failure, are an important consideration.
The majority of hysterectomies are performed on pre-menopausal women, with the highest rates among women aged 40–44 years.1,8 The ovaries are left intact in most pre-menopausal women undergoing hysterectomy for benign conditions, because of evidence that the physical and psychological benefits of retaining the ovaries outweigh the possible risk of ovarian pathology, including cancer.9,10
While
it is clear that ovarian function continues in the majority of pre-menopausal women after hysterectomy, there has long been concern that ovarian failure occurs earlier among women with hysterectomy. Earlier menopause, in turn, has serious health
© TOUCH BRIEFINGS 2012
Other
Thus, the risk of early ovarian failure is an important factor when evaluating the overall benefits and risks of hysterectomy.
possible adverse effects of earlier ovarian failure include increased risk of cognitive dysfunction, physical limitations and Parkinson’s disease.16–18
Studies of Ovarian Failure After Hysterectomy The long-term effect of hysterectomy on ovarian function has been investigated in studies dating back several decades. Overall, the conclusions of the investigations are mixed, with some studies reporting that hysterectomy is associated with a significantly increased risk of earlier ovarian failure while others conclude that there is no evidence of a significant effect of hysterectomy on ovarian function. However, the quality of the investigations is highly variable, and considerations of study design, control group, method of assessment of ovarian function, duration of follow-up and sample size are important for interpreting the overall literature on the topic.
Some of the earliest studies relied on the subjective assessment of ovarian failure based on patient-reported symptoms or clinical evaluation.19–21
In addition to the obvious concern about misclassification of menopausal status based solely on symptoms, these studies employed cross-sectional or retrospective study designs that could further obscure the determination of age at menopause.
Other studies have used biochemical parameters, such as serum follicle stimulating hormone (FSH) or urinary pregnanediol, to assess
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