Age-specific hysterectomy and oophorectomy prevalence rates and the risks for cancer of the reproductive system

Improving clinical outcomes through attention to sex and hormones in research

Biological sex, fluctuations in sex steroid hormones throughout life and gender as a social construct all influence every aspect of health and disease. Yet, for decades, most basic and clinical studies have included only male individuals. As modern health care moves towards personalized medicine, it is clear that considering sex and hormonal status in basic and clinical studies will bring precision to the development of novel therapeutics and treatment paradigms. To this end, funding, regulatory and policy agencies now require inclusion of female animals and women in basic and clinical studies. However, inclusion of female animals and women often does not mean that information regarding potential hormonal interactions with pharmacological treatments or clinical outcomes is available. All sex steroid hormones can interact with receptors for drug targets, metabolism and transport. Genetic variation in receptors or in enzymatic function might contribute to sex differences in therapeutic efficacy and adverse drug reactions. Outcomes from clinical trials are often not reported by sex, and, if the data are available, they are not translated into clinical practice guidelines. This Review will provide a historical perspective for the current state of research related to hormone trials and provide concrete strategies that, if implemented, will improve the health of all people.

Surgical menopause in association with cognitive function and risk of dementia: A systematic review and meta-analysis

INTRODUCTION

Experimental and epidemiological studies suggest female sex hormones to have long-lasting neuroprotective and anti-ageing properties. Surgically-induced menopause leads to a premature cessation of exposure to female sex hormones and could thus impact late-life cognitive function. Yet, evidence remains controversial.

METHODS

We systematically reviewed literature for articles investigating the association of surgical menopause (defined as bilateral oophorectomy before the onset of menopause) with risk of dementia, cognitive performance, cognitive decline, and Alzheimer's disease neuropathological indices later in life. We evaluated study quality with the Newcastle-Ottawa scale and performed random-effects meta-analyses.

RESULTS

We identified 11 eligible studies (N = 18,867). Although surgical menopause at any age was not associated with risk of dementia (4 studies; HR: 1.16, 95%CI: 0.96-1.43), early surgical menopause (≤45 years of age) was associated with a statistically significantly higher risk (2 studies; HR: 1.70, 95%CI: 1.07-2.69). Surgical menopause at any age was associated with faster decline in verbal memory, semantic memory, and processing speed, whereas early surgical menopause was further associated with faster global cognitive decline. No heterogeneity was noted. Among women undergoing surgical menopause, a younger age at surgery was associated with faster decline in global cognition, semantic and episodic memory, worse performance in verbal fluency and executive function, and accumulation of Alzheimer's neuropathology.

CONCLUSIONS

Current evidence is limited, but suggests surgical menopause induced by bilateral oophorectomy at ≤45 years of age to be associated with higher risk of dementia and cognitive decline. Additional large-scale cohort studies are necessary to replicate these findings.

Sex hormones and stroke: Beyond estrogens

Stroke risk and poor stroke outcomes in postmenopausal women have usually beeen attributed to decreased levels of estrogen. However, two lines of evidence suggest that this hormone may not be solely responsible for elevated stroke risk in this population. First, the increased risk for CVD and stroke occurs much earlier than menopause at a time when estrogen levels are not yet reduced. Second, estrogen therapy has not successfully reduced stroke risk in all studies. Other sex hormones may therefore also contribute to stroke risk. Prior to menopause, levels of the gonadotrophin Follicle Stimulating Hormone (FSH) are elevated while levels of the gonadal peptide inhibin are lowered, indicating an overall decrease in ovarian reserve. Similarly, reduced estrogen levels at menopause significantly increase the ratio of androgens to estrogens. In view of the evidence that androgens may be unfavorable for CVD and stroke, this elevated ratio of testosterone to estrogen may also contribute to the postmenopause-associated stroke risk. This review synthesizes evidence from different clinical populations including natural menopause, surgical menopause, women on chemotherapy, and preclinical stroke models to dissect the role of ovarian hormones and stroke risk and outcomes.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review

OBJECTIVE

To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy.

DATA SOURCES

MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries.

METHODS OF STUDY SELECTION

Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14-0.7% compared with 0.02-0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04-1.92). Coronary heart disease (HR 1.26, 95% CI 1.04-1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27-2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results.

CONCLUSION

Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.

Efficacy of Raloxifene Hydrochloride for the Prevention of Health Care Problems in Patients Who Undergo Surgery for Endometrial Cancer: A Multicenter Randomized Clinical Trial

Objective

Removal of the ovaries is common during surgery for endometrial cancer. However, because loss of the ovaries can cause several health problems in patients, strategies for the prevention of such problems need to be established. Hence, we decided to conduct a multicenter randomized clinical trial to assess the effect of raloxifene on bone mineral density (BMD), bone metabolism, and the lipid profile of patients who had undergone surgery for patients with endometrial cancer.

Materials and Methods

Patients with endometrial cancer were enrolled after treatment. The participants were randomized into 2 groups: group 1 included 39 women who received alfacalcidol (1 μg/d) alone and group 2 included 37 women who received alfacalcidol and the test drug, raloxifene hydrochloride, at a dose of 60 mg/d. The BMD of lumbar spine and femoral neck, serum bone markers, as well as lipid profile parameters were evaluated at enrollment as well as 6, 12, and 24 months after the enrollment. The primary efficacy end point was the percentage change from baseline to 24 months in lumbar spine (L2-L4) and femoral neck BMD.

Results

Sixty-four women completed the 24-month study. At 24 months, the lumbar and femoral neck BMDs were significantly increased in group 2 compared with group 1 (3.5% vs −0.8% and 2.3% vs −2.8%, respectively). In group 2, low-density lipoprotein-cholesterol levels were significantly reduced by 13.6% and serum N-terminal telopeptide of type I collagen as well as bone-specific alkaline phosphatase values were significantly reduced by 16.7% and 25.7%, respectively. The patients who received adjuvant therapy for endometrial cancer showed a significantly higher response to raloxifene (5.8% vs 1.9%). Recurrence was detected in 2 (2.6%) patients in group 1. No severe adverse events were noted in any patient during the study period.

Conclusions

Raloxifene exerts positive effects on BMD, bone metabolism, and lipid profile parameters and could provide an improved therapeutic option for patients with endometrial cancer.

Age at surgical menopause influences cognitive decline and Alzheimer pathology in older women

OBJECTIVE

To determine the association between age at surgical menopause and both cognitive decline and Alzheimer disease (AD) pathology in 2 longitudinal cohorts.

METHODS

Female subjects from 2 longitudinal studies of cognitive decline (Religious Orders Study and Rush Memory and Aging Project) were included (total n = 1,884). The primary analysis examined the association between age at surgical menopause and decline in a global cognition score. Secondary analyses examined additional outcomes: 1) decline in 5 cognitive subdomains and 2) a global measure of the burden of AD pathology. In exploratory analyses, we examined the effect of hormone replacement therapy (HRT). We adjusted all models for age, education, smoking, and cohort and stratified by surgical vs natural menopause.

RESULTS

For the 32% of subjects with surgical menopause, earlier age at menopause was associated with faster decline in global cognition (p = 0.0007), specifically episodic memory (p = 0.0003) and semantic memory (p = 0.002). Earlier age at menopause was also associated with increased AD neuropathology (p = 0.038), in particular neuritic plaques (p = 0.013). HRT use for at least 10 years, when administered within a 5-year perimenopausal window, was associated with decreased decline in global cognition. No associations were seen in women who had natural menopause.

CONCLUSIONS

Early age at surgical menopause was associated with cognitive decline and AD neuropathology. Ongoing studies should clarify the potential effect of HRT on this relationship.

Prophylactic adnexectomy along with vaginal hysterectomy for benign pathology

OBJECTIVE

This study was designed to evaluate the safety and feasibility of prophylactic adnexectomy during vaginal hysterectomy for benign pathology.

METHODS

We retrospectively reviewed medical records of all patients who underwent vaginal hysterectomy (VH) between 2008 and 2010. Clinical comparison of patients who underwent VH with adnexectomy (n = 92) and VH only (n = 686) was performed. Clinical characteristics (age, parity, body mass index, and previous pelvic surgery), surgical outcomes (uterine weight, operative time, estimated blood loss, pelvic adhesion, hemoglobin change and hospital stay) and intra- and postoperative complications (transfusion, bladder injury and fever) were evaluated.

RESULTS

Clinical characteristics except for age (45.44 years for VH only vs. 47.15 years for VH with adnexectomy, P = 0.007) were not different between the two groups. Similarly, surgical outcomes and complication rates were not different between the two groups.

CONCLUSION

Prophylactic bilateral adnexectomy can be performed safely during VH.

Impact of surgical menopause on lipid and bone metabolism

OBJECTIVE

To clarify the effects of ovariectomy on lipid and bone metabolism.

METHODS

This study was a prospective study with a longitudinal design within 1 year after surgery. Sixty-two premenopausal women were recruited and divided into two groups: group M (preservation of ovary, n=27) and group BSO (bilateral ovariectomy, n=35). Serum lipid levels, urinary N-telopeptide of type I collagen (NTx) and bone mineral density (BMD) were measured. We also examined the number of postoperative episodes requiring pharmacological intervention.

RESULTS

There was a significant elevation in the level of low density lipoprotein cholesterol in group BSO from 6 to 12 months compared with the baseline level; the level did not change in group M. The NTx level significantly increased from 6 to 12 months, and the BMD was significantly decreased by as much as 6.7% at 12 months in group BSO; these variables did not change in group M. The effect of lipid and bone metabolism in group BSO was observed when the ages of the two groups were matched. Carbohydrate metabolism and arterial stiffness, measured by pulse wave velocity, did not change throughout the study period in either group. No subjects in group M required medication expect for two patients whose ovarian function was diminished by postoperative radiation and by natural menopause. Eleven women received medication in group BSO: nine for climacteric disorders using hormone therapy (25.7%), and two for dyslipidemia using statins (5.7%).

CONCLUSIONS

Bilateral ovariectomy seems to cause dyslipidemia and serious loss of bone mineral density within only 1 year, and patients who lose ovarian function may require careful medical care.

Characterization of an animal model of postmenopausal cardiac hypertrophy and novel mechanisms responsible for cardiac decompensation using ovariectomized pressure-overloaded rats

OBJECTIVE

The development of animal models of cardiovascular disease are critical to define pathophysiological mechanisms and to advance diagnosis and therapy. The lack of a suitable animal model represents a failure to define the mechanisms responsible for postmenopausal myocardial hypertrophy in hypertension and adverse cardiac remodeling.

METHODS

In this review, we presented a rat model of postmenopausal myocardial hypertrophy, with particular focus on the similarities between the animal model and postmenopausal women regarding myocardial function as well as molecular and subcellular mechanisms. To elucidate the molecular mechanism of left ventricular (LV) hypertrophy and remodeling in postmenopausal women, we analyzed myocardial hypertrophy as well as cardiac function and hypertrophy-related protein expression in ovariectomized (OVX) and pressure overloaded (PO) rats.

RESULTS

The model is characterized by depletion of serum estrogen and increased heart-to-body weight and lung-to-body weight ratios. Moreover, the OVX-PO rats also show increased mean arterial blood pressure, LV end-diastolic pressure, LV developed pressure, and maximal rates of LV contraction and relaxation compared with the OVX group. Importantly, Akt activity was largely attenuated, and both endothelial nitric oxide synthase expression and activity were markedly reduced in the OVX-PO group. Finally, significant increased mortality was observed in the OVX-PO group after chronic isoproterenol administration.

CONCLUSIONS

Our results demonstrate that rats subject to OVX are unable to compensate for hypertrophy partly due to impaired Akt-endothelial nitric oxide synthase signaling along with deteriorated heart function and demonstrated increased mortality. In this review, we discussed the mechanisms of cardiac injury, which could play a critical role in postmenopausal hypertrophy, as well as the characteristics of the OVX-PO female rats as a model to test cardioprotective drugs in postmenopausal women.

Increased cardiovascular mortality after early bilateral oophorectomy

OBJECTIVE

To investigate the mortality associated with cardiovascular diseases and the effect of estrogen treatment in women who underwent unilateral or bilateral oophorectomy before menopause.

DESIGN

We conducted a cohort study with long-term follow-up of women in Olmsted County, MN, who underwent either unilateral or bilateral oophorectomy before the onset of menopause from 1950 through 1987. Each member of the oophorectomy cohort was matched by age to a referent woman from the same population who had not undergone any oophorectomy. We studied the mortality associated with cardiovascular disease in a total of 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy, and 2,383 referent women.

RESULTS

Women who underwent unilateral oophorectomy experienced a reduced mortality associated with cardiovascular disease compared with referent women (hazard ratio [HR], 0.82; 95% CI, 0.67-0.99; P = 0.04). In contrast, women who underwent bilateral oophorectomy before age 45 years experienced an increased mortality associated with cardiovascular disease compared with referent women (HR, 1.44; 95% CI, 1.01-2.05; P = 0.04). Within this age stratum, the HR for mortality was significantly increased in women who were not treated with estrogen through age 45 years or longer (HR, 1.84; 95% CI, 1.27-2.68; P = 0.001) but not in women treated with estrogen (HR, 0.65; 95% CI, 0.30-1.41; P = 0.28; test of interaction, P = 0.01). Mortality was further increased after deaths associated with cerebrovascular causes were excluded.

CONCLUSIONS

Bilateral oophorectomy performed before age 45 years is associated with increased cardiovascular mortality, especially with cardiac mortality. However, estrogen treatment may reduce this risk.

Prophylactic oophorectomy in premenopausal women and long-term health

OBJECTIVE

To review the data on long-term outcomes in women who underwent prophylactic bilateral oophorectomy, a common surgical procedure that has more than doubled in frequency since the 1960s.

STUDY DESIGN

Literature review of the published data on the consequences of prophylactic bilateral oophorectomy. Special emphasis was given to the Mayo Clinic Cohort Study of Oophorectomy and Aging. Main outcome measures Overall mortality, cardiovascular disease, cognitive impairment and dementia, parkinsonism, osteoporosis, psychological wellbeing and sexual function.

RESULTS

There is a growing body of evidence suggesting that the premature loss of ovarian function caused by bilateral oophorectomy performed before natural menopause is associated with several negative outcomes. In particular, studies have revealed an increased risk of premature death, cardiovascular disease, cognitive impairment or dementia, parkinsonism, osteoporosis and bone fractures, decline in psychological wellbeing and decline in sexual function. The effects involve different organs (e.g. heart, bone, or brain), and different functions within organs (e.g. cognitive, motor, or emotional brain functions). Estrogen treatment may prevent some but not all of these negative outcomes.

CONCLUSION

The potential adverse effects of prophylactic bilateral oophorectomy on heart health, neurological health, bone health and quality of life should be carefully weighed against its potential benefits for cancer risk reduction in women at average risk of ovarian cancer.

Hysterectomy prevalence and cardiovascular disease risk factors in American Indian women

OBJECTIVES

We investigated hysterectomy prevalence and associated demographic and reproductive factors among American Indian women. The association between hysterectomy and cardiovascular disease (CVD) risk factors was also examined.

METHODS

Data were from 2689 American Indian women who participated in the first examination of the Strong Heart Study from 1989 to 1992. Odds ratios were estimated for factors related to hysterectomy adjusting for other covariates. The association between hysterectomy and CVD risk factors was examined among 1726 eligible women using analysis of covariance.

RESULTS

Hysterectomy prevalence ranged from 24% to 34% across differing age groups and the percent with oophorectomy among those with a hysterectomy ranged from 43% to 63%. Geographic area, more prior pregnancy losses, more education, and less speaking of the native language were associated with increased hysterectomy prevalence. After adjustment for age, the women who had a hysterectomy with intact ovaries had higher total cholesterol and low-density lipoprotein cholesterol levels than those with a natural menopause.

CONCLUSIONS

American Indian women have comparable hysterectomy prevalence as non-Hispanic white women. Education and native language speaking related to hysterectomy in this population. Hysterectomy alone may relate to unfavorable changes of lipid profile.

The role of prophylactic oophorectomy in the avoidance of ovarian cancer

OBJECTIVE

To determine the role of prophylactic oophorectomy at elective hysterectomy in the avoidance of ovarian cancer.

METHOD

A survey was performed of all members of the Society of Gynecologic Oncologists and all obstetrician-gynecologists in the State of Connecticut.

RESULT

Seventy-nine percent of gynecologic oncologists and 72% of obstetrician-gynecologists surveyed reported 0-1% of women would be saved from ovarian cancer if one ovary was removed at elective hysterectomy at age 45 years. If both ovaries were removed, 8.4% and 32.1% of these physicians respectively responded that 95-100% of women could be saved from ovarian cancer. Approximately 50% responded that macroscopic appearance and frozen section studies at surgery were helpful in deciding whether to remove ovaries at hysterectomy. A literature review suggested that 12% of ovarian cancers might be avoided if women undergo prophylactic oophorectomy at elective hysterectomy.

CONCLUSION

There is a lack of well-designed epidemiologic studies evaluating risk factors for ovarian cancer and the role of prophylactic oophorectomy at elective hysterectomy.

Prevalence of hysterectomy in Ireland

OBJECTIVES

To assess factors influencing the prevalence of hysterectomy in Ireland.

METHODS

Analysis of results of a questionnaire completed by a population-based cohort of 17735 women aged 50-65 years attending for breast screening.

RESULTS

Prevalence of hysterectomy was 22.2%, was increased in proportion to parity and was higher in younger women, those who had previously used oral contraception and those who had private health insurance; peak age at operation was 45-49 years.

CONCLUSION

The relatively high prevalence parity reflects contraceptive practices and utilization of health service resources.

Cancer of the corpus uteri in white and black women in Michigan, 1985-1994: an analysis of trends in incidence and mortality and their relation to histologic subtype and stage

BACKGROUND

Cancer of the corpus uteri occurs more commonly among white women in the U.S., yet survival is poorer for black women. This study examined whether this trend has changed and also examined the relation of age and histologic subtype to differences in stage.

METHODS

This retrospective cohort study assessed incidence trends, mortality trends, and the relation of age and histologic subtype to stage for 12,079 incident cases and 2325 deaths registered between 1985 and 1994 in Michigan. Rate ratios compared incidence and mortality. Odds ratios quantified the contribution of age and histologic subtype to differences in risk for advanced stage, using Mantel-Haenszel univariate techniques and multivariate logistic regression.

RESULTS

The overall incidence rate was 21.99 per 100,000, and the overall mortality rate was 3.82 per 100,000. Black women had a 40% lower risk (rate ratio [RR] =0.60) of developing cancer of the corpus uteri but had a 54% greater risk (RR=1.54) of dying from cancer of the corpus uteri. Black women were at greater risk of being diagnosed with either sarcoma or more aggressive adenocarcinoma. However, after adjustment for age and histologic subtype, black women still had an increased risk for advanced stage disease (2.63, 95% confidence interval=2.19-3.16).

CONCLUSIONS

The disparity between white and black women persists in incidence and mortality trends for cancer of the corpus uteri. The greater frequency of more aggressive histologic subtypes experienced by black women accounts for only 10% of their excess risk for more advanced stage disease.

Development and validation of the Menorrhagia Outcomes Questionnaire

OBJECTIVE

To develop and evaluate the acceptability, reliability and validity of a short, patient-based questionnaire for assessing the outcomes of surgical treatment for menorrhagia due to benign disease.

DESIGN

A psychometric study by postal survey.

SETTING

Five hospitals in southeast England.

SAMPLE

One hundred and eleven women undergoing hysterectomy for menorrhagia due to benign disease.

METHODS

Data from a long research questionnaire used in the North West Thames Hysterectomy Study were analysed using standard psychometric methods to identify the subset of items which were the most scientifically sound indicators of outcome. The Menorrhagia Outcomes questionnaire is a 26-item questionnaire which covers symptoms, post-operative complications, quality of life, and women's satisfaction with outcome. The questionnaire was field tested for acceptability, reliability and validity by postal survey.

RESULTS

The Menorrhagia Outcomes Questionnaire was found to be highly acceptable to women and showed excellent internal consistency, test-retest reliability, criterion and construct validity.

CONCLUSION

The Menorrhagia Outcomes Questionnaire is a practical and scientifically sound measure of outcome from the woman's perspective following surgical treatment for menorrhagia due to benign disease. It takes less than five minutes to complete, is appropriate for use with different surgical treatments for menorrhagia (eg. hysterectomy, endometrial resection, laser ablation) and is feasible for routine monitoring of large numbers of women by postal survey. Most importantly, this questionnaire has been shown to perform well from a scientific point view, having met standard psychometric criteria for reliability and validity.

Is incidental prophylactic oophorectomy an acceptable means to reduce the incidence of ovarian cancer?

BACKGROUND

According to previous reports, the lifetime risk of developing ovarian carcinoma is 1.4%. This figure varies with age from 6.6 per 100,000 among women aged 35 to 39 years up to 55.1 per 100,000 among women aged 75 to 79 years. Prophylactic oophorectomy remains a modality to decrease the incidence of ovarian cancer. What proportion of women diagnosed with an ovarian malignancy had a preceding laparotomy at which time a prophylactic oophorectomy could have been performed?

METHODS

We reviewed the new ovarian cancer diagnoses seen in patients between August 1988 and August 1993 at the Ottawa Regional Cancer Foundation. Four hundred and four patients were identified. These patients were analyzed for preceding abdominal surgery, age, time to disease progression, time to death, time to death from other causes, and average follow-up. The previous abdominal surgeries were divided into: (1) major gynecological surgery; and (2) general surgery procedures, which were further divided into laparotomy and pelvic surgery (group A surgeries) and general surgery that included other abdominal surgeries (ie, appendectomy, cholecystectomy) where access to the pelvis could be more difficult (group B surgeries).

RESULTS

A total of 270 abdominal surgeries was performed, prior to the diagnosis of ovarian cancer. The group was stratified according to the timing of the surgery (< or =40 years, 41 to 45 years, 46 to 50 years, >50 years). Based on these data, and on the grouping of general gynecologic surgeries plus the general surgical procedures of group A, 10.9% of ovarian cancers would have been prevented if prophylactic oophorectomy had been performed in patients who had surgery over 40 years of age; over 45 years this was 6.7%, over 50 years it was 4%. If one adds all major surgeries, including general surgery groups A and B, the results were 26.9% over 40 years of age, 20% over 45, and 16.6% over 50.

CONCLUSION

We found that, depending on the age of the patient, prophylactic oophorectomy results in a 4% to 10.9% reduction in the incidence of ovarian carcinoma. This increases to 16.6% to 26.9% if one considers general surgery procedures in which access could be more difficult. Although we are not advocating the frequent use of this procedure, we recommend that surgeons routinely discuss this option before surgery with their postmenopausal female patients over 49 years of age. Given that the decision for prophylactic oophorectomy is multifaceted, we feel that a risk scoring for ovarian cancer and a discussion of the risk and benefit ratio should be undertaken. The ultimate goal is to heighten patient awareness of the risk factors to ensure that an informed decision is made concerning this consistently lethal disease.

Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study

OBJECTIVE

To describe the indications for total abdominal hysterectomy for women with nonmalignant disease and to determine the immediate (initial ten days) and medium term outcome.

DESIGN

A prospective cohort study.

SETTING

Three district general hospitals in shire counties, two in outer London and one London teaching hospital.

SUBJECTS

Three hundred and sixty-six women undergoing total abdominal hysterectomy (with or without other procedures) for nonmalignant disease.

INTERVENTIONS

Self-completed patient questionnaires before and ten days, six weeks and three months after surgery. Data extracted from patients' hospital case notes.

MAIN OUTCOME MEASURES

Complications plus change in symptoms, urinary and bowel function, general health status, sexual function, activities of daily living and quality of life.

RESULTS

The principal indications were bleeding, pain or both. Symptoms were severe enough to be socially debilitating and have a major impact on lifestyle. Otherwise, the women were in good health. During the first ten post-operative days the women suffered more pain, urinary discomfort, constipation and a reduction in their ability to perform activities of daily living. Urinary (25%) and wound (25%) infections were the commonest complications. At the same time, significant improvements in psychological health occurred. By six weeks, the principal symptoms had resolved for 95% of the women and early adverse effects on urinary and bowel function had settled. This was reflected in improvements in health status and quality of life including sexual activity. Despite this, these changes did not meet the pre-operative expectations of some women.

CONCLUSIONS

Most women reported substantial benefits from hysterectomy. However, women should be warned about early, transient adverse effects. These findings can serve as a benchmark for nonexperimental evaluations of the effectiveness of new treatment modalities.

Lack of influence of simple premenopausal hysterectomy on bone mass and bone metabolism

OBJECTIVE

Our purpose was to investigate the influence of premenopausal hysterectomy on bone mass.

STUDY DESIGN

A cross-sectional study was performed on 69 women who had premenopausal hysterectomy and 427 women with natural menopause 50 to 59 years old. Bone mineral density was measured in the distal forearm by single-energy x-ray absorptiometry. Body composition and bone mineral density in the anteroposterior spine, proximal femur, and total body was measured by dual-energy x-ray absorptiometry. Bone turnover was determined by plasma osteocalcin, serum alkaline phosphatase, and fasting urinary calcium corrected for creatinine excretion.

RESULTS

Women who had undergone premenopausal hysterectomy had similar bone mineral densities compared with women with an intact uterus in all compartments, apart from a 6% to 11% higher bone mineral density (p < 0.05 to 0.001) in the proximal femur. The women who had undergone premenopausal hysterectomy had 2% to 11% more fat (significant for arm fat, p < 0.05), 9% to 13% lower serum follicle-stimulating hormone levels (p < 0.01), 10% to 13% higher serum estradiol levels (not significant), and 8% to 9% lower osteocalcin levels (p < 0.05 to 0.07). This bone mineral density difference could thus be explained by extragonadal sex hormone production.

CONCLUSION

Premenopausal hysterectomy did not reduce ovarian function and increase bone turnover and bone loss.

Long-term benefits and risks of alternative methods of fertility control in the United States

A risk-benefit analysis of five alternative approaches to fertility control among US women over the age of 30 was performed: tubal ligation, vasectomy, intrauterine device, barrier method (condom), and combined oral contraceptives. Taken into account were age-specific probabilities of contraceptive failure, fecundability, spontaneous abortion, reproductive mortality (ectopic pregnancy, delivery, or induced abortion), life table mortality, and mortality from specific cancer sites (ovarian, endometrial, breast, and prostate) and cardiovascular disease. Relative to women using no contraceptive precautions, the use of any method of contraception between the ages of 30 and 50 was associated with net benefit in terms of averted deaths. However, when duration of observation was extended up to age 80, we predicted an excess of about 880 deaths from prostate cancer per 100,000 users of vasectomy. Other methods continued to be associated with net benefit, ranging from 130 to 360 deaths averted per 100,000 users. It was concluded that the non-reproductive risks and benefits of contraceptive methods continue to be relevant long after the reproductive years. The balance of risks and benefits may differ in other countries with different cause-specific and life table mortality rates.

Osteoporosis risk factors, gynaecological history and fractures in perimenopausal women--the results of the baseline postal enquiry of the Kuopio Osteoporosis Risk Factor and Prevention Study

The Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) Study examines the risk factors of osteoporosis, the relationship of risk factors to bone density and fractures, as well as the possibility to prevent bone loss by administering certain hormones. The baseline postal enquiry in 1989 was sent to all the 14,220 women aged 47-56 years residing in the Kuopio Province, Finland. The questionnaire included questions about their gynaecological history, physical exercise and smoking habits, calcium intake, body weight and height, history of bone fractures, health disorders, their current and previous use of drugs, as well as their willingness to participate in bone densitometry and in a clinical hormone trial. The response rate was 92.8%. In all, 56% reported some previous use of female hormones. Strong contraindications for oestrogen replacement therapy were found in 9.3% of the women. Almost half of the respondents reported lack of regular physical exercise, 11.9% were smokers, and 17.0% reported a calcium intake from milk products of less than 500 mg daily. The incidence of fractures increased steadily with age. The incidence of premenopausal fractures within the last 10 years was 7.65 per 1000 person/years and that of postmenopausal fractures was 17.40 per 1000 person/years (P = 0.000). The effect of menopause on fracture incidence was stronger than the effect of a 5-year age increase. Of the respondents, 84.4% were willing to participate in bone densitometry and 68.3% for long-term prevention of osteoporosis with oestrogen.

Cervical cancer incidence and mortality trends in Finland and Estonia: a screened vs. an unscreened population

Long term trends in the incidence of and mortality from invasive cervical cancer have been studied in Finland (1953-1987) and Estonia (1968-1987). The analyses are based on the data from the Finnish and Estonian Cancer Registries. An organised nationwide screening programme for cervical cancer was started in Finland in the early 1960s. In Estonia, no cytological screening programme has been introduced, and cervical malignancies are diagnosed in routine gynaecological practice. During 1968-1987, both the incidence of and mortality from cervical cancer were considerably higher in Estonia than in Finland. A decrease has taken place in the cervical cancer incidence and mortality in both countries since the mid-1960s, but whereas in Finland the decrease has been marked, in Estonia it has been less pronounced and levelled off in the 1980s. In 1987, the age-standardised (world population) incidence rate per 100,000 women was 14.0 in Estonia and 3.8 in Finland, and the age-standardised mortality rate was 6.0 and 1.6 per 100,000, respectively. The difference in the incidence of the disease in the two neighbouring countries can be partially attributed to socioeconomic factors. The main reason for the different slopes of the trend curves for cervical cancer is probably the difference in public health policies: an effective mass screening programme is being conducted in Finland but not in Estonia.

Hysterectomy among Finnish women: prevalence and women's own opinions

This article describes the prevalence of hysterectomy, women's own opinions of it, and socioeconomic characteristics of hysterectomized women compared to non-hysterectomized ones. The questionnaire was sent in spring 1989 to 2000 45 to 64-year-old Finnish women picked randomly from the Population Census. After two reminders, 1713 (86%) had responded. One fifth of the women had had a hysterectomy and 5% had also had both ovaries removed. Among the highest educated there were less hysterectomized women than among the less educated. The largest differences in the prevalence of hysterectomy were between counties, not between socioeconomic groups. Fourty-one percent of the hysterectomized women had themselves wished hysterectomy, 25% did not have any specific opinion about the operation. Results raise further questions about clinical decision making and regional variation of hysterectomy.

Ovarian cancer screening: potential effect on mortality

Serum tumor markers and ultrasonography are being investigated as possible ovarian cancer screening tests. Data from the United States on ovarian cancer incidence and survival were used to estimate the potential benefit on ovarian cancer mortality from screening tests of various sensitivities. A test with 80% sensitivity could reduce ovarian cancer mortality by 50% if all screening-detected cases were to experience current stage I survival rates; the benefit would be greatest among women aged 45 or older. For each cancer detected there would be at least 50 false-positive screening tests unless test specificity is greater than 98%. If our most optimistic assumptions about screening could be met, then universal periodic screening of women aged 45 to 74 would result in about 5000 additional 5-year survivors of ovarian cancer annually. Uptake of existing screening tests is far less than universal; thus we would expect the impact of any ovarian cancer screening program to fall short of these projections.

Prevalence and characteristics of women who have had a hysterectomy in a community survey

A community survey of 8,896 households was undertaken in the Hunter region of New South Wales to assess women's health status. Consent was gained from 5,781 of the 6,361 eligible women between 18 and 69 years of age. The prevalence of hysterectomy in this sample was 16.9%, with 34.2% of women in their fifties having had a hysterectomy. Most hysterectomies (75%) were performed on women between the ages of 30 and 49 years. The demographic variables of parent's country of birth, educational level and employment status predicted recent hysterectomies after controlling for the effect of age.

A risk-benefit analysis of elective bilateral oophorectomy: effect of changes in compliance with estrogen therapy on outcome

A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporotic fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed.

Cervix and breast cancer incidence in immigrant Caribbean women

Cervix and breast cancer incidence in 1978-82 was computed for immigrant and United States-born Black women in Brooklyn, New York. Compared to the national SEER (Surveillance, Epidemiology and End Results) rates, US-born and Haitian women had high rates of invasive cervical cancer, while English-speaking Caribbean immigrants had an average rate. However, while US-born women had an average rate of carcinoma in situ of the cervix, both immigrant groups had low rates. Both immigrant groups had low rates of breast cancer, whereas US-born Black women had an average rate.

Ten-year changes in birthweight distributions of black and white infants, South Carolina

The birthweight distributions of Black and White infants in South Carolina were compared for the paired-year periods 1975-76 and 1985-86. No discernible changes in birthweight distributions between the two time periods were observed especially among Black infants. The distributions among White infants reflected an overall improvement in birthweight most noticeably above 2500g.

Characteristics of women with hysterectomy

Socio-demographic and health information, including history of hysterectomy/oophorectomy, was obtained in a telephone survey of 2137 women aged 40-52. Subjects were randomly selected from a list of all women with a driver's license in Pittsburgh, Pennsylvania. Results showed that 27.3% of women surveyed reported having had a hysterectomy. Women who had undergone hysterectomy were more often black, less educated, older and heavier; and reported less frequent alcohol consumption, younger age at birth of first child and earlier menarche than women who did not report hysterectomy. Forty-seven percent of blacks reported hysterectomy compared with 24% of whites (P less than 0.01) and blacks were significantly younger at surgery than whites (mean age 38.5 vs. 39.6 yr, P less than 0.05). Results of multivariate analyses showed age, black race, less than a college education, menarche before age 12 and having no children to be associated with an increased risk of hysterectomy (P less than 0.01). Additional multivariate analyses conducted separately for blacks and whites showed that, for whites but not blacks, the higher a woman's educational attainment the less likely she was to report having had a hysterectomy (P less than 0.01). Black women with no children more often reported hysterectomy than those with children (P less than 0.01), but this relationship was not found among whites. These findings show the distribution of hysterectomy in the population to vary by race, education and parity.

Prevention of ovarian cancer: a survey of the practice of prophylactic oophorectomy by fellows and members of the Royal College of Obstetricians and Gynaecologists

A questionnaire designed to investigate attitudes to prophylactic oophorectomy was sent to 2817 fellows and members of the Royal college of Obstetricians and Gynaecologists. A total of 1142 replies was received from those who performed regular sessions of gynaecological surgery. The number of respondents who said they would usually remove apparently normal ovaries at the time of abdominal hysterectomy from premenopausal women in age groups 35-39, 40-44, 45-49 and over 49 years was 4 (0.4%), 27 (2%), 234 (20%) and 585 (51%) respectively, and from postmenopausal women 974 (85%). The majority of respondents said that (i) they would prescribe hormone replacement therapy in oophorectomized premenopausal women (82%); (ii) they did not consider unilateral oophorectomy to have a role in prevention of ovarian cancer (84%); and (iii) they routinely discussed the question of prophylactic oophorectomy with their patients before operation (65%). Only 128 (11%) of the respondents believed that greater than or equal to 10% of ovarian cancers in the UK could be prevented by prophylactic oophorectomy at the time of operation for benign disease, and 505 (44%) would perform prophylactic oophorectomy as a primary surgical procedure in women who had a strong family history of ovarian cancer.

Delayed diagnosis of gynecologic tumors in elderly women: relation to national medical practice patterns

PURPOSE

To evaluate the hypothesis that less aggressive cancer screening practices might result in later diagnosis of cancer in the elderly, we analyzed the stage of diagnosis of tumors by age in the Connecticut Tumor Registry.

PATIENTS AND METHODS

Using Registry data from 1960 to 1975 and 1976 to 1983, we compared the proportion of tumors that were diagnosed at a localized stage among white women of various age groups. Thirteen specific tumor sites were analyzed, accounting for 55,688 tumors between 1960 and 1975 and 38,715 tumors between 1976 and 1983.

RESULTS

Only gynecologic cancers demonstrated a significant inverse relationship between the relative proportion of tumors that were diagnosed at a localized stage and advancing patient age during both time periods. Specifically, when the youngest women (aged 25 to 34) were compared with the oldest women (aged 85 and over), between 1960 and 1975, the relative proportion of localized cervical, uterine, and ovarian cancer dropped from 98 percent to 59 percent, 92 percent to 77 percent, and 59 percent to 27 percent, respectively. Similar declines were also seen between the intermediate-age groups, and data from 1976 to 1983 demonstrated identical age-related trends.

CONCLUSION

Our study reveals that the probability of diagnosing cancer of the cervix, uterus and ovaries at a localized and potentially curable stage decreases with advancing age. Published national health practice patterns demonstrated a similar age-related decline in gynecologic examinations and Pap smears even after adjustment for the exclusion of women who would have undergone previous hysterectomy. This decreasing use of gynecologic examinations may in part explain the age-related decline in localized gynecologic cancers.

Contraception in women over forty

Contraception in women over the age of 40 has received little attention, and accurate data are not readily available. This paper compares data from surveys from the United States and five major countries in Western Europe. Consideration is given to the possible effect on these women of the threat of reduced availability of suitable contraceptive methods as a result of current developments within society at large. This is of particular importance as it appears that, especially in Western Europe, contraception is underutilized in this age group. The benefits and risks of various methods of contraception are discussed. Use of the pill by older women remains controversial. Misconceptions about pill use and the IUD seem to be widespread among women of all ages.

Effects of moderate consumption of alcoholic beverages on endocrine function in postmenopausal women. Bases for hypotheses

That alcoholic beverage consumption has not yet received attention as a variable that might influence the estrogenization of postmenopausal women is discussed within the context of the growing proportion of postmenopausal women in the population, their disease risk vis-à-vis estrogenization, and survey findings that report that the majority of postmenopausal women use alcoholic beverages to at least some degree. The available literature is reviewed concerning the effects of acute or chronic ethanol administration, alcoholic beverage consumption, or the administration of phytoestrogen-containing congeners of bourbon on the endocrine status of postmenopausal women or relevant animal models. The basic components of postmenopausal endocrine function and the factors known to affect endocrine status are presented. The importance of incorporating known endocrine-modulating factors into the design of future studies so as to maximize the detection of alcohol effects in postmenopausal women is emphasized.

Decline in the incidence of carcinoma in situ of the cervix

Temporal trends in the incidence of carcinoma in situ of the uterine cervix were evaluated in metropolitan Atlanta between 1975 and 1983. The average annual age-adjusted incidence rates per 100,000 women decreased from 61.5 in 1975-77 to 40.1 in 1981-83 for Whites and from 118.3 to 51.8 for Blacks during the same time periods. The relative declines were uniform across all age groups and exceeded the corresponding reductions in the incidence of invasive cervical carcinoma.

Absence of menopausal effect on hip fracture occurrence in white females

The rate of hip fracture among White females rises sharply between ages 40 and 44 and then continues at a constant rate of acceleration doubling every five to six years throughout life with no deviation during, or in the years immediately following, menopause. We suggest that the important role of sex hormones and other factors in osteoporosis commences prior to menopause. A premenopause prevention strategy which postpones the onset of the osteoporotic process by five or six years would be expected to reduce the risk of hip fracture by 50 per cent throughout the remainder of a woman's life.

Practice characteristics of male and female physician assistants

In a national survey of 3,294 non-military responding physician assistants, sociodemographic and practice characteristics of male and female physician assistants were compared. Differences by specialty, practice setting, size of community, and hours of work were generally similar in nature, but smaller in magnitude, than those reported for physicians, and may not be of practical significance.