Ovary-Sparing Hysterectomy May Accelerate Menopause Onset

Ricki Lewis, PhD

April 13, 2016

Ovary-sparing hysterectomy raises the risk for accelerated menopause, according to a study published online April 4 in Obstetrics & Gynecology.

Removing the ovaries at the time of hysterectomy in women at low risk for ovarian cancer is tied to increased risk for death, increased total cancer mortality, and cardiac and neurological disease. To counter those problems, surgeons increasingly perform ovary-sparing hysterectomies when possible.

Newer data, however, suggest that even ovary-sparing surgery may have negative consequences for women. For example, the Prospective Research on Ovarian Function cohort study showed an increased risk for menopause among women who had ovary-sparing hysterectomies compared with women who had not had hysterectomies (hazard ratio, 1.92; P = .001). The analysis, however, was hampered by the fact that the biomarker used to classify women as having ovarian failure (follicle-stimulating hormone) fluctuates in premenopausal women, which could have led to misclassification.

Therefore, in the new study, Emanuel C. Trabuco, MD, from the Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, and colleagues compared levels of anti-Müllerian hormone, a nonfluctuating marker of ovarian reserve, in women who had had ovary-sparing hysterectomy compared with women who had not had hysterectomy. The study was a preplanned secondary analysis using samples from participants in the Prospective Research on Ovarian Function study.

At baseline, median anti-Müllerian hormone levels were similar between 148 premenopausal women undergoing ovary-sparing hysterectomy for benign conditions and 172 women of similar ages (30 - 47 years).

However, a year later, the patients who had undergone hysterectomy had a significantly greater median percentage decrease of the hormone compared with women who had not had surgery (−40.7% vs −20.9%; P < .001). Similarly, a higher proportion of women in the postsurgery group had undetectable hormone compared with those in the control group (12.8% vs 4.7%; P = .02), and on average, they had 0.77 times the hormone level (P = .001). The researchers note that the differences were more pronounced for black women.

Overall, the researchers estimate that the women who had surgery became menopausal 1.9 years earlier than control patients.

The researchers also performed several subgroup analyses, classifying women according to low (anti-Müllerian hormone levels of 1.2 ng/mL or less) or high (hormone levels >1.2 ng/mL) ovarian reserve at baseline. For the high reserve group, the percentage change in hormone levels did not differ between the hysterectomy and control groups. However, the women who had had surgery had 0.81 times the anti-Müllerian hormone level at 1 year compared with the women who had not had the procedure.

Meanwhile, among the women with low ovarian reserve at baseline, change was greater for the hysterectomy group than for those who did not have surgery (median, −58.3% vs −19.1%; P = .003), and a greater percentage of them had undetectable hormone (24.6% vs 8.6%; P = .01).

The authors note their results are in line with several other studies that have examined the effect of ovary-sparing hysterectomy on ovarian reserve and menopause. Moreover, because baseline anti-Müllerian hormone levels were similar for the surgery and nonsurgery groups, but levels dropped more precipitously among women in the surgery group during follow-up, the researchers hypothesize a "yet unidentified mechanism" whereby the surgery damages the ovaries. "These findings suggest that ovarian damage was unrelated to baseline ovarian reserve," they conclude.

In an accompanying editorial, Keith A. Hansen, MD, from the Department of Obstetrics and Gynecology at the University of South Dakota School of Medicine, Sioux Falls, points out that the American College of Obstetricians and Gynecologists recommends preserving ovarian function in premenopausal women undergoing hysterectomy not at elevated cancer risk because of known risks associated with prophylactic oophorectomy. "If ovary-sparing hysterectomy accelerates the menopausal transition in premenopausal women, it could increase the overall morbidity and mortality for those women preserving their ovaries similar to, but probably later, than that caused by oophorectomy," he writes.

The study was funded by a Building Interdisciplinary Careers in Women’s Health institutional grant, and the Prospective Research on Ovarian Function cohort was funded by the National Institute of Aging. The researchers and editorialist have disclosed no relevant financial relationships.

Obstet Gynecol. Published online April 4, 2016. Article abstract

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