Ovarian function and ovarian blood supply following premenopausal abdominal hysterectomy

Osteoporosis and Fracture Risk Following Benign Hysterectomy Among Female Patients in Korea

IMPORTANCE

Prior research about the association between hysterectomy and osteoporosis risk had limitations.

OBJECTIVE

To assess osteoporosis and fracture risk among female patients who underwent hysterectomy due to benign conditions.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, female patients aged 40 to 59 years with benign hysterectomy between 2003 and 2011 were selected from Korean National Health Insurance Data and matched by 1:1 propensity score with female patients who had health checkups and indicated that they had not had a hysterectomy. A Cox proportional hazard model was used to analyze osteoporosis and fracture risk, with participants monitored until December 31, 2020. Data analysis was performed from July 16, 2022, to January 12, 2023.

EXPOSURES

Hysterectomy with or without adnexal surgical procedure.

MAIN OUTCOMES AND MEASURES

The primary outcome was the risk of osteoporosis. Secondary outcomes included the risk of vertebral fracture, hip fracture, other fractures, and total fracture.

RESULTS

The study population included 25 910 patients; the median (IQR) age was 47 (44-50) years, and median (IQR) follow-up period was 10.9 (9.4-12.7) years. In the stratified-extended Cox proportional analysis, female patients who underwent hysterectomy without an adnexal surgical procedure were associated with a higher risk of osteoporosis within 7 years compared with female patients who did not undergo hysterectomy (hazard ratio [HR], 1.28 [95% CI, 1.19-1.37]); the analysis was divided into 7 years due to a violation of the Cox assumption, and the risk did not differ after 7 years (HR, 0.99 [95% CI, 0.93-1.06]). However, the hysterectomy group with an adnexal surgical procedure had an association with higher risk of osteoporosis compared with the nonhysterectomy group both within 7 years of study entry (HR, 1.56 [95% CI, 1.33-1.82]) and after 7 years (HR, 1.20 [95% CI, 1.04-1.40]). In the hysterectomy group without an adnexal surgical procedure, the risks of vertebral fracture, hip fracture, and total fracture were similar to those in the nonhysterectomy group. Similar trends were observed in the hysterectomy group with an adnexal surgical procedure.

CONCLUSIONS AND RELEVANCE

Hysterectomy without an adnexal surgical procedure was associated with an increased osteoporosis risk within 7 years, but not afterwards, compared with the nonhysterectomy group. Hysterectomy was not associated with vertebral and hip fractures.

Comparison of Postoperative Ovarian Reserve Function Following Laparoscopic Hysterectomy and Laparoscopic Myomectomy: A Prospective Comparative Pilot Study

This prospective study aimed to investigate the impact of laparoscopic hysterectomy (LH) and laparoscopic myomectomy (LM) on ovarian reserve by comparing serum anti-Mullerian hormone (AMH) changes following surgery. Serum AMH levels were measured preoperatively (AMH0), and 7 days (AMH1), 2 months (AMH2), and 6 months (AMH3) after LH and LM in 79 premenopausal women (LH = 59; LM = 20). AMH0, AMH1, AMH2, and AMH3 were significantly higher in the LM group than in the LH group (p = 0.012, 0.001, 0.001, and 0.015, respectively). Since there are differences in indications between myomectomy and hysterectomy, logically, women who underwent myomectomy were younger and had higher AMH baseline levels. In addition, AMH changes at 7 days postoperatively from the baseline level were significantly decreased in the LH group compared to those in the LM group (p = 0.042). However, AMH changes at 2 months and 6 months postoperatively, compared to the baseline level, were not different between the two groups (p = 0.053 and 0.752, respectively). Moreover, the significant decrease in AMH (more than 60% decrease from the baseline level) was not different at 7 days, 2 months, and 6 months postoperatively between the two groups (p = 0.415, 487, and 0.364, respectively). Our data suggest that serum AMH levels were significantly decreased directly after LH, which suggests that LH may have adverse effects on ovarian reserve. However, mid-term follow-up showed that the damaged ovarian reserve in women who underwent LH may be partially restored in 6 months.

Does Saving Uterus Save Ovaries?

Ovarian function after hysterectomy is a subject of much controversy since many years. There is increasing awareness among gynecologists that the ovaries need to be spared at hysterectomy for benign conditions. However the awareness is limited, and many practitioners believe in removal of ovaries at hysterectomy. Removal of ovaries will save lives of patients at risk of developing ovarian cancer. But it will be unnecessary for low-risk women and will in fact endanger their lives by increasing cardiac risks. Recent data suggest that ovarian epithelial cancer arises from tubal epithelium, which adds new option of performing only salpingectomy and sparing ovaries, which will serve dual purpose of preventing ovarian cancer and continuing productive function of ovaries. Reproductive function is lost with hysterectomy. But it may be worth looking at impact of hysterectomy on productive function of ovaries. This editorial will focus on this issue and look at evidence on effects of other gynecological procedures on ovarian function.

Effect of Hysterectomy on Ovarian Reserve in the Early Postoperative Period Based on the Type of Surgery

Objectives

This study aimed to evaluate the influence of simple hysterectomy on the ovarian reserve based on the type of surgery.

Methods

Eighty-six premenopausal women between 31 and 48 years who underwent hysterectomy for benign gynecologic disease without additional adnexal surgery at a university hospital participated in this study. Seventy-one patients underwent laparoscopy-assisted vaginal hysterectomy (LAVH), and 15 patients underwent abdominal hysterectomy (AH). Blood samples were obtained from all study participants on preoperative day and 3 days after the operation to determine the anti-Müllerian hormone (AMH) levels.

Results

The postoperative reduction of the mean serum AMH level in the LAVH group (0.42 ± 0.76 ng/mL) was greater than that in the AH group, although the difference was not statistically significant (0.01 ± 0.60 ng/mL) (P = 0.053). The mean baseline AMH level (2.59 ± 2.33 ng/mL) was significantly reduced to 2.24 ± 2.08 ng/mL at 3 days after hysterectomy, and the mean rate of decline of AMH levels after surgery was 13.61% ± 30.81%. In subgroup analysis based on the type of surgery, the mean serum AMH level decreased significantly after surgery in the LAVH group, but no significant changes were found in serum AMH levels before and after the surgery in the AH group.

Conclusions

These preliminary results suggest that simple hysterectomy affects the early postoperative decline of ovarian reserve, and these results might vary depending on the type of surgery.