Hysterectomy at young age linked to elevated CV, metabolic disease risk
Women who undergo a hysterectomy with bilateral ovarian conservation appear to have an elevated risk of cardiovascular (CV) and metabolic disease, particularly those who undergo the procedure at age 35 or younger, a recent study found.
Researchers analysed data of 2,094 women (median age 40 years) from Olmsted County, Minnesota, US, who underwent a hysterectomy with bilateral ovarian conservation for benign indications and compared them with age- and county-matched women who had not undergone hysterectomy or oophorectomy (control group).
About 25 percent of women in the hysterectomy group (n=529) were aged ≤35 years at time of procedure. Women in the hysterectomy cohort had a higher incidence of hyperlipidaemia (odds ratio [OR], 1.50) and obesity (OR, 1.58) and more chronic conditions (OR, 1.90) at baseline compared with those in the control group.
After adjusting for demographic factors, education levels, and 20 pre-existing chronic comorbidities, compared with women in the control group, women who had undergone hysterectomy had elevated risks of developing hyperlipidaemia (adjusted hazard ratio [adjHR], 1.14; p=0.002), hypertension (adjHR, 1.13; p=0.01), obesity (adjHR, 1.18; p=0.01), cardiac arrhythmias (adjHR, 1.17; p=0.006), and coronary artery disease (CAD; adjHR, 1.33; p=0.001) over a median 21.9-year follow-up period. [Menopause 2017;doi:10.1097/GME.0000000000001043]
The risk was more evident among women who underwent hysterectomy at age 35 years or younger with an almost fivefold risk of congestive heart failure (CHF; adjHR, 4.59; p=0.02) and a 2.5-fold risk of CAD (adjHR, 2.49; p=0.002), as well as an elevated risk of cardiac arrhythmias (adjHR, 1.36; p=0.049).
The risk of hyperlipidaemia (adjHR, 1.14; p=0.01), hypertension (adjHR, 1.21; p=0.002), obesity (adjHR, 1.20; p=0.03), cardiac arrhythmias (adjHR, 1.21; p=0.01), and CAD (adjHR, 1.34; p=0.01) was elevated among women aged 36–50 years who underwent hysterectomy compared with the control group, though there was a reduction in the risk of CHF (adjHR, 0.63; p=0.03).
Women older than 50 years at time of hysterectomy were not at a higher risk of CV and metabolic disease than women in the control group.
CV and metabolic risk also differed according to indication where women who underwent hysterectomy for uterine leiomyomas had an elevated risk of hyperlipidaemia (adjHR, 1.22; p=0.004) and cardiac arrhythmias (adjHR, 1.28; p=0.007), while those who underwent the procedure for menstrual disorders had an elevated CAD risk (adjHR, 1.81; p=0.004). Women who underwent hysterectomy for uterine prolapse had a higher risk of obesity (adjHR, 1.59; p=0.003) but a lower risk of CHF (adjHR, 0.59; p=0.02) compared with women in the control group.
Of 792 women who underwent hysterectomy between 1998 and 2002, 22.8 percent used oestrogen therapy either alone or with progestogen compared with 12.6 percent in the control group.
Implications and research goals
“These results suggest that alternative uterine-preserving treatments may need to be considered more often in lieu of hysterectomies, especially in benign situations,” said Dr JoAnn Pinkerton, executive director of The North American Menopause Society, who was not involved in the study.
“For women having hysterectomy, hormone therapy should be considered for added protection, because ovarian function appears to be impaired by the surgery,” she said.
“There is growing evidence that hysterectomy with ovarian conservation increases the risk of future CV disease, but the mechanisms remain unclear. To the best of our knowledge, the uterus does not produce any recognized endocrine factors that could directly impact the CV system. Therefore, the effects are probably mediated by the effects on the ovaries,” said the researchers.
One potential mechanism is hysterectomy-related loss of blood flow to the ovaries leading to “decreased ovarian reserve”, while another mechanism could be a paracrine or endocrine effect of the uterus on the ovaries, they said.
The researchers acknowledged that due to the observational design of the study, confounding or bias cannot be ruled out.
“[F]urther studies are needed to clarify the direct effects of hysterectomy on ovarian function and subsequent clinical outcomes.” Another avenue for research is to look at the impact of different levels of surgery (eg, hysterectomy only, hysterectomy with unilateral oophorectomy, etc) compared with no surgery on CV and metabolic risk, they said.