Clinical pearls:
- Women who underwent ovarian sparing hysterectomy have a greater decrease in levels of antimüllerian hormone as compared to women with intact reproductive organs and this decrease is independent of baseline levels.
- These women on an average achieve menopause 1.9 years earlier than those with no surgery.
- The highest number of hysterectomies are performed on women aged 40-44 making them susceptible to premature menopause and increasing their risk for CVD, osteoporosis and psychological problems.
The decision
to spare the ovaries or remove it during hysterectomy is often very difficult
to make in everyday gynecology practice. The potential benefit of removing the
ovaries for eliminating the risk of ovarian cancer has to be balanced against
the cardiovascular and anti-osteoporotic benefits gained by sparing them.
Prophylactic
Oophorectomy along with hysterectomy in low risk women results in early death,
fatal and nonfatal cardiac disease, osteoporosis and neurologic complications.[1]
A study results showed that for women who have a hysterectomy with ovarian
conservation at ages 50 to 54 with being at average risks for chronic diseases,
the chances of surviving to age 80 was 62.46% vs 53.88% if ovaries were not
spared. [2]
This 8.5%
difference was advocated to far less women dying because of CVD (15.95% vs.
7.57%) and hip fracture (4.96% vs. 3.38%) far exceeding the mortality of .47% women
dying because of ovarian cancer in patients whom ovaries were left behind at
the time of benign hysterectomy.
But, recent
research and evidence indicate that women who underwent ovarian sparing hysterectomy
entered menopause very quickly as compared to women with intact reproductive organs.[3]
[4]
A recent Prospective
Research on Ovarian Function study (PROOF) published in May, 2016 issue of
obstetrics and gynecology compared the levels of antimüllerian hormone in women
undergoing hysterectomy before and after the surgery.
PROOF is a
prospective cohort study of large ethnically divert women who underwent ovarian
sparing hysterectomy and racially and age matched controls conducted between
2004-2007 and followed through 2009.
Median Baseline
levels of antimüllerian were comparable in both the groups before the study subjects
underwent hysterectomy, but at a median of 366 days’ follow up post
hysterectomy, the study group has almost twice decrease in antimüllerian
hormone levels (−40.7% compared with −20.9%; P<.001) and were
more likely to have nondetectable levels (12.8% compared with 4.7%; P=.02)
compared with the referent group.
These large
decrease could be explained by assuming that hysterectomy disrupts the blood flow
to ovaries or removes the paracrine /endocrine stimulus from the uterus
hastening the ovarian senescence due to follicular depletion.
It was also
observed that black women were more predisposed to decrease in antimüllerian
hormone as compared to white women. This finding is comparable to previous
other related studies which concluded that reproductive aging varies according
to race and ethnicity and black women have lower baseline antimüllerian levels
and also show greater percentage decline.
The study
had limitation of only studying a subset of cohort, but was done to eliminate other
confounding factors.
To conclude,
women who underwent hysterectomy with ovaries left intact, have a greater decrease
in levels of antimüllerian hormone as compared to women with intact reproductive
organs and this decrease is independent of baseline levels.
If
hysterectomy is leading to decreased ovarian reserve and earlier menopause,
then this has very important public health ramifications. Hysterectomy is the most
common surgery in gynecology worldwide and second most common operation
performed in US with approximately 600,000 hysterectomies are performed each
year.
The highest
number of Hysterectomies are performed on women aged 40-44 making them
susceptible to premature menopause and increasing their risk for CVD, osteoporosis
and psychological problems.
[1]Keshavarz
H, Hillis H, Kieke BA, Marchbanks P. Hysterectomy surveillance—United States,
1994–1999. Atlanta (GA): Centers for Disease Control and Prevention; 2002.
Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm.
[2] http://www.pharllc.com/wp-content/uploads/2013/03/Parker-Contemp-Obstet-Gynecol-2006.pdf
accessed on June 29, 2016.
[3] Ahn EH, Bai SW, Song CH, Kim JY, Jeong KA, Kim
SK, et al.. Effect of hysterectomy on conserved ovarian function. Yonsei Med J
2002;43:53–8.
[4] Farquhar CM, Sadler L, Harvey SA, Stewart
AW. The association of hysterectomy and menopause: a prospective cohort study.
BJOG 2005;112:956–62
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