Hysterectomy and ovarian function: levels of follicle stimulating hormone and incidence of menopausal symptoms are not affected by hysterectomy in women under age 45 years

Gynecological surgery in adulthood imparts cognitive and brain changes in rats: A focus on hysterectomy at short-, moderate-, and long-term intervals after surgery

Premenopausal hysterectomy is associated with a greater relative risk of dementia. We previously demonstrated cognitive impairments in adult rats six weeks after hysterectomy with ovarian conservation compared with intact sham-controls and other gynecological surgery variations. Here, we investigated whether hysterectomy-induced cognitive impairments are transient or persistent. Adult rats received sham-control, ovariectomy (Ovx), hysterectomy, or Ovx-hysterectomy surgery. Spatial working memory, reference memory, and anxiety-like behavior were tested either six-weeks post-surgery, in adulthood; seven-months post-surgery, in early middle-age; or twelve-months post-surgery, in late middle-age. Hysterectomy in adulthood yielded spatial working memory deficits at short-, moderate-, and long-term post-surgery intervals. Serum hormone levels did not differ between ovary-intact, but differed from Ovx, groups. Hysterectomy had no significant impact on healthy ovarian follicle or corpora lutea counts for any post-surgery timepoint compared with intact sham-controls. Frontal cortex, dorsal hippocampus, and entorhinal cortex were assessed for activity-dependent markers. In entorhinal cortex, there were alterations in FOSB and ΔFOSB expression during the early middle-age timepoint, and phosphorylated ERK1/2 levels at the adult timepoint. Collectively, results suggest a primary role for the uterus in regulating cognition, and that memory-related neural pathways may be modified following gynecological surgery. This is the first preclinical report of long-term effects of hysterectomy with and without ovarian conservation on cognition, endocrine, ovarian, and brain assessments, initiating a comprehensive framework of gynecological surgery effects. Translationally, findings underscore critical needs to decipher how gynecological surgeries, especially those involving the uterus, impact the brain and its functions, the ovaries, and overall aging from a systems perspective.

Effect of hysterectomy on ovarian function: a systematic review and meta-analysis

BACKGROUND

Hysterectomy is one of the most frequently gynecologic surgeries performed in premenopausal women. Many premenopausal patients are unwilling to undergo hysterectomy due to the probable decreased ovarian function. The aim of this study is to determine the effect of hysterectomy on ovarian function.

METHODS

A meta-analysis has been reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and the A Measurement Tool to Assess Systematic Reviews (AMSTAR) guidelines. We mainly searched the Embase, PubMed and Web of Science databases for eligible studies. The outcomes were the levels of common indicators of ovarian function, such as anti-müllerian hormone (AMH), follicle stimulating hormone (FSH), inhibin B, estradiol (E2) and luteinizing hormone (LH). The evidence was synthesized using meta-analysis via fixed or random effect model according to heterogeneity. Subgroup analyses were performed to examine the potential sources of heterogeneity.

RESULTS

The 14 included studies were conducted between 1989 and 2021, involving a total of 1,457 premenopausal women with 760 and 697 in the hysterectomy and control group, respectively. We found that hysterectomy damage ovarian function compared to the control group, with lower AMH level [Weighted mean difference (WMD) = -0.56, 95% confidence interval (95% CI): -0.72 to -0.39, P = 0.000], higher FSH levels (WMD = 2.96, 95% CI: 1.47 to 4.44, P = 0.000), lower inhibin B levels (WMD = -14.34, 95% CI: -24.69 to -3.99, P = 0.000) and higher LH levels (WMD = 4.07, 95% CI: 1.78 to 6.37, P = 0.000). In addition, E2 levels have a decreasing trend (WMD = -17.13, 95% CI: -35.10 to 0.85, P = 0.631) in the hysterectomy group but were not statistically significant.

CONCLUSION

Hysterectomy has a negative impact on ovarian function, especially in female patients over 40 years old. So, the older patients should closely monitor their ovarian function for early diagnosis and treatment of menopausal symptoms.

The effects of hysterectomy with bilateral salpingectomy on ovarian reserve

OBJECTIVE

To determine whether ovarian reserve is compromised after hysterectomy with bilateral salpingectomy.

METHODS

A prospective longitudinal study was conducted among 84 women who underwent hysterectomy with bilateral salpingectomy at a tertiary medical center in Beijing, China, between August 2, 2015, and January 15, 2017. Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured to assess ovarian function before undergoing the procedure (baseline) and at weeks 1 and 6 after surgery (postoperative period).

RESULTS

The median age was 41.61 ± 0.62 years. Age negatively correlated with the serum AMH level at baseline (P<0.001), as well as with preoperative-to-postoperative changes in the concentration of this hormone (P<0.001). Serum AMH levels were lower in the postoperative period versus the preoperative period (P<0.001). By contrast, serum FSH levels were higher in the postoperative period than in the preoperative period (P<0.001). Moreover, no correlation was found with body mass index.

CONCLUSIONS

Hysterectomy with bilateral salpingectomy compromised ovarian reserve, with the damage being most severe among younger patients.

Hysterectomy Uniquely Impacts Spatial Memory in a Rat Model: A Role for the Nonpregnant Uterus in Cognitive Processes

Approximately one-third of women experience hysterectomy, or the surgical removal of the uterus, by 60 years of age, with most surgeries occurring prior to the onset of natural menopause. The ovaries are retained in about half of these surgeries, whereas for the other half hysterectomy occurs concurrently with oophorectomy. The dogma is that the nonpregnant uterus is dormant. There have been no preclinical assessments of surgical variations in menopause, including hysterectomy, with and without ovarian conservation, on potential endocrine and cognitive changes. We present a novel rat model of hysterectomy alongside sham, ovariectomy (Ovx), and Ovx-hysterectomy groups to assess effects of surgical menopause variations. Rats without ovaries learned the working memory domain of a complex cognitive task faster than did those with ovaries. Moreover, uterus removal alone had a unique detrimental impact on the ability to handle a high-demand working memory load. The addition of Ovx, that is, Ovx-hysterectomy, prevented this hysterectomy-induced memory deficit. Performance did not differ amongst groups in reference memory-only tasks, suggesting that the working memory domain is particularly sensitive to variations in surgical menopause. Following uterus removal, ovarian histology and estrous cycle monitoring demonstrated that ovaries continued to function, and serum assays indicated altered ovarian hormone and gonadotropin profiles by 2 months after surgery. These results underscore the critical need to further study the contribution of the uterus to the female phenotype, including effects of hysterectomy with and without ovarian conservation, on the trajectory of brain and endocrine aging to decipher the impact of common variations in gynecological surgery in women. Moreover, findings demonstrate that the nonpregnant uterus is not dormant, and indicate that there is an ovarian-uterus-brain system that becomes interrupted when the reproductive tract has been disrupted, leading to alterations in brain functioning.

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.

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.

Blood pressure and bone mineral density in premenopausal and postmenopausal women

INTRODUCTION

Previous studies regarding the associations between blood pressure (BP) and bone mineral density (BMD) have shown conflicting results. However, menopausal status and pharmacotherapy may modify this relationship. The objective of this study was to explore the association between systolic BP (SBP) and diastolic BP (DBP) and BMD in pre- and postmenopausal women, and to assess the extent to which this association is mediated by menopausal status and pharmacotherapy.

METHODS

A cross-sectional study was conducted using a sample of 4,058 pre- and postmenopausal women aged 40 years or older (N = 991 and 3,067, respectively), who participated in NHANES III. BMD measurement of the femur neck was used as the primary outcome measure. Regression models were used to examine the association between SBP or DBP and BMD.

RESULTS

The unadjusted models for systolic and diastolic BP were positively and significantly associated with femoral BMD in premenopausal women (p = 0.0039 and p = 0.0065, respectively) as well as in postmenopausal women (p < 0.0001 for both SBP and DBP). After adjusting for covariates in the multivariate models, the association between BP and BMD in postmenopausal women no longer prevailed. In premenopausal women, the association between SBP or DBP and BMD was modified by hormone therapy (p = 0.0278 and p = 0.0025, respectively). Once the stratum-specific adjusted models by hormone therapy use were examined, the association between SBP or DBP and BMD was no longer significant.

CONCLUSIONS

The study results suggest that there is no link between BP and BMD in pre- and postmenopausal women.

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.

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.

Does hysterectomy affect ovarian function? Histopathologic evaluation and serum FSH, inhibin A, and inhibin B levels in an experimental rat model

OBJECTIVE

To evaluate the effects of hysterectomy with ovarian conservation on ovarian histology, and FSH, inhibin A, and inhibin B plasma levels.

STUDY DESIGN

Forty-five female Wistar albino rats were used in this study and randomly divided into two groups: hysterectomy (n=30) and sham-operated (n=15). Blood samples were collected before and after (50 and 100 days) abdominal hysterectomy from both groups to measure plasma levels of FSH, inhibin A, and inhibin B. All animals were sacrificed by decapitation to obtain ovaries for histological examination. For statistical analyses, Mann-Whitney U, Chi-square, Wilcoxon matched pairs signed rank sum tests, and two-sided variance analysis were used and statistical significance was defined as p<0.05.

RESULTS

There was no difference in hormonal variables between groups when the time interval was considered completely [p>0.05 (for FSH p=0.962; for inhibin A p=0.321; for inhibin B p=0.476)]. In the hysterectomy group, the inhibin B level at postoperative day 50 was significantly lower than the control group (p=0.007) and at postoperative day 100, inhibin A concentrations were increased significantly when compared with the levels at both baseline and postoperative day 50 (p<0.001). Histopathologic evaluation of ovaries 100 days after hysterectomy showed that ovaries from the hysterectomy group had significantly fewer primary (p=0.01), preantral (p<0.001), and antral follicles (p<0.001), and significantly more corpora lutea (p<0.001), atretic (p=0.02), and cystic follicles (p=0.003).

CONCLUSION

The results of this experimental rat model suggest that hysterectomy may affect ovarian function.

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.

A comparison of estradiol levels between women with a hysterectomy and ovarian conservation and women with an intact uterus

OBJECTIVES

To compare the distribution of estradiol levels between women with a hysterectomy and ovarian conservation and women with an intact uterus.

METHODS

A large cross-sectional study of women aged between 40 and 69 years, residing in Melbourne, Australia. Estradiol levels were available for 152 women with a hysterectomy and ovarian conservation and 1423 women with an intact uterus. All of the women were 'never-users' of hormone replacement therapy.

RESULTS

For women under 55 years of age, we observed that those with a hysterectomy and ovarian conservation had slightly higher estradiol levels compared with those with an intact uterus after adjustment for age, body mass index, smoking status and alcohol intake (ratio of geometric means of estradiol levels = 1.24; 95% confidence interval = 1.00-1.53). For women who were 55 years or greater, the distribution of estradiol levels varied little by hysterectomy status.

CONCLUSIONS

Our data do not suggest that women with hysterectomy and ovarian conservation have markedly different estradiol levels compared to women with an intact uterus.