Ovarian conservation
at hysterectomy does not reduce the risk of future cardiometabolic diseases
reports the results of large prospective cohort study published in Menopause,
the journal of The North American Menopause Society (NAMS).
This is one
of the few studies that focuses on long term effect of hysterectomy with
ovarian conservation. Earlier studies have documented strong evidence between increased
incidence of cardiovascular diseases(CVD) and other chronic diseases after hysterectomy
with bilateral oophorectomy.
The risk was
especially increased if the hysterectomy was carried out before the age of 35.
Using
Epidemiological project record, the researchers identified 2094 women who underwent
hysterectomy with ovarian conservation between 1980 and 2002. Each woman was
age matched with a control residing in the same county and who have neither
undergone hysterectomy nor bilateral oophorectomy.
Cox
proportional hazard models and Kaplan-Meier analysis was used to calculate hazards
ratios and absolute risk after taking into consideration 20 risks factors and
other potential confounders.
The two cohort
were followed up for a period of 22 years, and women who have undergone
hysterectomy were at increased risk of obesity, hyperlipidemia, hypertension,
cardiac arrhythmias and coronary artery diseases.
Women who
had hysterectomy under the age of 35 years were at nearly 5 times increased risk
of congestive heart failure and 2.5 times increased risks of coronary artery
disease.
Dr. JoAnn
Pinkerton, NAMS executive director said in a NAMS press release, “These study
results suggest that alternative uterine-preserving treatments may need to be
considered more often in lieu of hysterectomies, especially in benign
situations. For those women having hysterectomy, hormone therapy should be
considered for added protection, because ovarian function appears to be
impaired by the surgery.”
History of
preeclampsia in first pregnancy doubles the risk for Major Cardiac Event (MACEs)
subsequently later in life for mothers, the risk is 2.8 times if the
preeclamptic pregnancy resulted in SGA and/or preterm delivery. If the
preeclampsia recurs in subsequent pregnancy the risk is 2.2 times while if it
is combined again with in SGA and/or preterm delivery the risk increases nearly
5 times compared with women without preeclampsia according to new research study
published in March issue of Journal of American Medical Association( JAMA).[1]
In this large
register based prospective follow up study, the researchers linked the data
from Medical Birth Registry of Norway(MBRN) with Cardiovascular Disease in
Norway 1994–2009 (CVDNOR) project and the Norwegian Cause of Death Registry.
Of 708 614 women
registered with MBRN from 1980–2009, 506 350 women between 16-49 years of age
with parity <5 met the study inclusion criteria’s. The exposure of interest was preeclampsia defined
according to the criteria by American Congress of Obstetrician and
Gynecologists (ACOG).
The outcome of interest in the study was nonfatal acute
myocardial infarction or coronary death, CVD or all-cause mortality.
Further the
analyses was stratified by parity, assessing whether the exposure and outcome
differed according to number of children born. Women with more than 1 births
were grouped as no preeclampsia (control), women with preeclampsia in first pregnancy, women with preeclampsia in subsequent pregnancy or preeclampsia in later but not
first pregnancy.
The
incidence of preeclampsia was 6% (29 917) in at least one pregnancy with 75% of
these preeclamptic pregnancy (21 635) being the first pregnancy. Preeclamptic
women were 2 times more likely to have a child born with SGA and 3 times more
like to have a preterm labor as compared to women with no preeclampsia.
Women with only
preeclampsia had 1.6 times increased risk of all-cause mortality which further
increased to 3.7 with a child born with SGA and 2.8 times with preterm delivery
as compared to women without preeclampsia.
After adjusting
for confounders, the risk of MACE was highest in preeclamptic women who had
SGA/ preterm delivery (4.7 times) and the risk was highest if preeclampsia occurs
in first 2 pregnancy with SGA/ preterm birth.
During follow up 1275 (0.3%) women experienced MACEs
and 468 (0.1%) mothers died due to CVD and 5411 (1.1%) due to any cause with majority
of cardiac events occurred after the age of 50 years.
The study
provide evidence to monitor these high-risk women who are at increased risk for
coronary artery disease in future.
Michael Greger,
MD, FACLM is a
physician, New York Times bestselling author, and internationally recognized professional
speaker on a number of important public health issues. Dr. Greger has lectured
at the Conference on World Affairs, the National Institutes of Health, and the
International Bird Flu Summit, among countless other symposia
and institutions; testified before Congress; has appeared on shows such as The
Colbert Report and The Dr. Oz Show; and was invited as an expert witness in
defense of Oprah Winfrey at the infamous "meat defamation" trial.[1]
His website is NutritionFacts.org, which has got a collection of videos and articles
about healthy plant based diet.
The topic of his presentation was How
not to die: The role of diet in preventing, arresting and reversing our top 15
killers. The presentation was based upon his latest book How not to Die, which became an
instant New York Times Best Seller.
The book is available on Amazon and
other sites in kindle, audio CD, paperback and hardcover.
Photo courtesy: Amazon
The presentation begins with a
personal note about Dr.Greger’s grandmother, who was diagnosed with end stage
heart disease at age 65 and was sent home to await death as Drs. Said that
nothing could be done to improve her condition.
She was confined to wheelchair and was in a really bad shape. She was
rescued by Nathan Pritikin, one of our early lifestyle medicine pioneers.
She was put on a completely different
diet of lots of fruits and vegetables, and the outcome is a history.
Not only she defied death, but lived a
healthy life for another 31 years --- till the age of 96, and enjoyed her 6
grandchildren and great grandchildren.
This incidence inspired Dr. Greger to choose
medicine and later specialize and dedicate his life to life style changes and
prevention and cure of diseases.
He maintains his non-profit website
solely dedicated to nutrition, diet and cure of diseases through healthy plant
based diet- NutritionFacts.org.
The 15 most common cause of diseases
worldwide are Heart disease, Cancer, Hypertension, smoking and COPD, Stroke,
Diabetes, kidney failures, respiratory infection, suicide, blood septicemia,
parkinsonism.
Talking about heart disease Dr. Greger
said “Heart disease is a choice like dental cavities.”Coronary
heart disease; atherosclerosis; hardening of the arteries, begins in childhood. By
age 10, the arteries of nearly all kids raised on the standard American diet
already have fatty streaks—the first stage of the disease.[2]
When
researchers took people with heart disease and put them on the kind of
plant-based diet followed by those populations that didn’t suffer from heart
disease, their hope was to slow the disease process down—maybe even stop it.
But instead, something miraculous happened.
The disease
started to reverse, to get better. As soon as patients stopped eating an
artery-clogging diet, their arteries started opening up. Their bodies
were able to start dissolving some of the plaque away. Even in some cases of
severe triple vessel heart disease, arteries opened up without drugs, without
surgery—suggesting their bodies wanted to heal all along, but were just never
given the chance. This improvement in blood flow to the heart is after just
three weeks of eating healthy.
Similarly,
he has put out reasons and evidence for each of the 15 diseases he described
that can be prevented, or reversed with diet.
The complete lecture can be heard
here.
He has a famous list of daily dozen
that should be consumed daily to add years to your life.
This is the list by Dr.Michael Greger as told to Daily Mail, UK.[3]
1Cruciferous
vegetables, such as broccoli, brussels sprouts, cabbage, cauliflower, kale,
spring greens, radishes, turnip tops, watercress
One serving a day: A serving is half a
cup chopped or quarter of a cup of broccoli or brussels sprouts.
2 Greens
including spring greens, kale, young salad greens, sorrel, spinach, swiss chard
Two servings a day: A serving is
one cup raw or half a cup cooked.
Two servings a
day: A serving is one cup raw leafy vegetables; half a cup raw or cooked
non-leafy vegetables; half a cup vegetable juice; a quarter of a cup dried
mushrooms
Three servings a
day: That's a quarter of a cup of hummus or bean dip; half a cup of cooked
beans, split peas, lentils or tofu; or a full cup of fresh peas or sprouted
lentils.
5 Berries: Any
small edible fruit, including grapes, raisins, blackberries, cherries,
raspberries and strawberries
One serving a
day: A serving is half a cup of fresh or frozen, or quarter of a cup of dried.
A recent paper
published in the BMJranks Medical error as the third leading cause of death
after heart disease and cancer.
CDC compiles
the annual list of the most common cause of deaths in USA, based on death
certificates filled out by physicians, funeral directors, medical examiners,
and coroners.
The health
care provider fills the certificates using an International Classification of
Disease (ICD) code to the cause of death, and unfortunately no ICD-10 code
exists at present for human and system factors.
According to
an article published in Journal of patient safety, premature deaths associated
with preventable harm to patients was estimated at more than 400,000 per year
costing the nation a colossal $1 trillion each year.
There's also
the 10,000 serious complications cases resulting from medical errors that occur
each day, beside the 1000 death each day.
"Medicine
today invests heavily in information technology, yet the promised improvement
in patient safety and productivity frankly have not been realized," said
Peter Pronovost, MD, senior vice president for Patient Safety and Quality and
director of the Armstrong Institute for Patient Safety and Quality at Johns
Hopkins.
According to
authors although human error is inevitable, but steps can certainly be taken to
reduce its frequency and severity. They suggest making error made and lesson
learnt more visible instead of conducting closed door mortality meetings, so
that healthcare staff is more aware of such complications.But all
these requires a robust data which is difficult in the absence of standardized collection and reporting at the national
level.
The death
certificate can be changed to include an extra column requiring to address
whether a preventable complication have contributed to the cause of death.
Increasing
trained healthcare staff to rescue patients and limiting human error by always
following set protocols in handling an emergency situation.
Beside USA, medical
errors are also leading cause of deaths in Canada and UK. About 117 other
countries in the world also code the cause of death using ICD codes, using it
as an indicator of health status. ICD-10 also has limited codes to capture the
cause of mortality.
The authors
suggest that when a medical error occurs, the physiological cause of death
along with the error leading to it should be captured.
At the same
time the statistics relating to medical error death should be shared nationally
and internationally as other research is shared, creating a common platform to
heightened awareness.
Hysterectomy is the second most common surgery performed
in US after cesarean section. According
to CDC data approximately 600,000 hysterectomies are performed each year. A
nationwide study further reported that unilateral or bilateral
oophorectomy was performed in 68 percent of women at the time of abdominal
hysterectomy, 60 percent at laparoscopic hysterectomy, and 26 percent at
vaginal hysterectomy.
Women have an option of undergoing elective
oophorectomy (EO) along with benign hysterectomy to reduce the risk of ovarian
cancer, thereby reducing a chance of second surgery coupled with decreased perceived
anxiety of breast and ovarian cancer
subsequently.But there are negative side effects of this surgical
induced menopause such as death, total cancer mortality, osteoporosis,
cognitive decline, decreased sexual drive and increased cardiac mishap support
conservation of ovarian function.
There is considerable debated going on between EO and
ovarian conservation, with strong statements are put forward in favor of each. Currently
ACOG recommends “strong consideration should be made for retaining normal
ovaries in premenopausal women who are not at increased genetic risk of ovarian
cancer. [However,] given the risk of ovarian cancer in postmenopausal women,
ovarian removal at the time of hysterectomy should be considered for these
women.”
Arguments in favor of ovarian conservation:
EO is detrimental for the overall health of women and
decreases the life expectancy due to coronary artery disease. In a landmark
study by Parker et al using Surveillance, Epidemiology, and End Results (SEER)
database, the National center for Health Statistics, the Women’s Health
Initiative, and the National Inpatient Sample it was seen that there is no
clear cut benefit of EO at any age and women died early due to associate
morbidity.
The neuroprotective benefits of estrogen were seen in
multiple studies and was further supported by declining cognitive functions
specially in women undergoing EO under 50 yrs.
EO leads to increase in hip fracture due to decrease
in BMD as estrogen levels plummet. This was specifically seen in the light of
mass discontinuation of hormone replacement therapy among postmenopausal women when
results of Women’s Health Initiation trial published.
A decrease in sexual desire and function, resulting in
quality of life issues and conflict in interpersonal relationship, depression
was seen after oophorectomy.
Arguments in favor of EO:
Ovarian cancer is the fifth leading cause of death
among women in US with estimated 22,280 new cases and 14,240 deaths in 2016. A woman’s lifetime risk of ovarian cancer is 1 in 70
or 1.4% with no known effective screening method that could diagnose it at very
early stage. Researchers haveestimated that 1000 new cases of ovarian
cancer could be avoided if EO is performed in women undergoing hysterectomy in
women 40 years and older.
In women at high risk for ovarian cancer (especially
with familial history or genetic predisposition, BRCA1 or BRCA2 mutations)
risk-reducing oophorectomy (RRO) reduced cancer specific mortality.
In general population RRO is an ideal treatment for
the prevention of ovarian cancer in women who have known risk factors like being
white, never having been pregnant, late age of menopause, and a long estimate
number of years of ovulation in absence of effective screening strategies.
EO leads to avoiding the risk of second surgery after
hysterectomy due to adnexal disease or masses.
Effective replacement therapy available to prevent
osteoporosis, cardiac and sexual dysfunctions is being put as a valid argument
in support of EO, specifically after the beneficial results of hormone therapy from
Women’s Health Initiative studies.
A recentstudy by Trabuco et al published in the May
issue of Obstetrics and Gynecology has concluded that even if ovaries are
spared at the time of hysterectomy, it affects the ovarian reserve as evident
by declining levels of Antimüllerian hormone. The study also reported that women
undergoing hysterectomy became menopausal 1.9 years earlier than referent patient who has not undergone any surgery.
Despite all these arguments studies have recently
documented that of all the hysterectomies performed for benign reason 36%-38% were
deemed unnecessary and histologically normal.
So, the decision for EO should be made according to
each woman’s individual genetic test results and her risk for developing ovarian
malignancy. Age at the time of benign hysterectomy is an important decisive
factor. In 2010, recommendations from the Society of Gynecologic Oncologists
state “Ovarian conservation before menopause may be especially important in
patients with a personal or strong family history of cardiovascular or
neurological disease. Conversely, women at high risk of ovarian cancer should
undergo risk-reducing bilateral salpingo-oophorectomy.”
A women’s risk of cardiovascular disease, dementia,
osteoporosis, and family history must be taken into account before decisions for
EO or ovarian conservation are made in woman considering hysterectomy.
