Correspondence
Indications for Hysterectomy
N Engl J Med 1993; 329:275-276July 22, 1993
- Article
To the Editor:
The review of indications for hysterectomy by Carlson et al. (March 25 issue)1 provides valuable information that should reduce unnecessary hysterectomies. However, the sometimes adverse aftermath of hysterectomy was not sufficiently highlighted. Current medical opinion that hormonal changes do not occur after simple hysterectomy is most likely incorrect. A survey based on 6622 women ranging from 39 to 60 years of age showed that in all age groups women who have had a hysterectomy -- with one or both ovaries preserved -- report more severe typical climacteric symptoms (flushes or sweating and vaginal dryness) than women who have not had a hysterectomy2. Forty-year-old women who have undergone hysterectomy report severe flushes and sweating similar to those described by 50-year-old women who have not undergone hysterectomy and even more vaginal dryness than 60-year-old women who have not undergone hysterectomy. Climacteric symptoms in women who have undergone hysterectomy are often not recognized, although there is evidence that postmenopausal hormone levels are present at an earlier age in these women3.
Frequent flushing is associated with general symptoms mimicking nonpsychotic psychiatric disturbances4. Young women with flushing who have undergone hysterectomy are often rebuffed by their physicians -- “You still have your ovaries; it can't be hormonal; go see a psychiatrist” -- instead of receiving proper hormonal therapy. The literature2 shows that other adverse sequelae associated with menopausal hormonal changes, such as coronary heart disease, osteoarthritis, depression, intestinal disturbances, and sexual problems, occur more frequently in women after hysterectomy with ovarian conservation than in women of comparable ages who have not undergone hysterectomy. Until proper prospective studies have been performed, hormonal changes should be considered as possible side effects of simple hysterectomy. Physicians should also be alert for flushing and sweating in young women after hysterectomy who have a variety of psychosomatic symptoms.
4 ReferencesAnna Oldenhave, Ph.D.
Academic Hospital Utrecht, 3584 CX Utrecht, the Netherlands1
Carlson KJ ,Nichols DH ,Schiff I . Indications for hysterectomy. N Engl J Med 1993;328:856-860
Full Text | Web of Science | Medline2
Oldenhave A ,Jaszmann LJ ,Everaerd WT ,Haspels AA . Hysterectomized women with ovarian conservation report more severe climacteric complaints than do normal climacteric women of similar age. Am J Obstet Gynecol 1993;168:765-771
Web of Science | Medline3
Siddle N ,Sarrel P ,Whitehead M . The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. Fertil Steril 1987;47:94-100
Web of Science | Medline4
Oldenhave A ,Jaszmann LJB ,Haspels AA ,Everaerd WT . Impact of the climacteric on well-being: a survey based on 5213 women 39 to 60 years old. Am J Obstet Gynecol 1993;168:772-780
Web of Science | Medline
To the Editor:
I do not agree completely with the view of Carlson et al. that “cancer prevention alone does not justify hysterectomy.” The hereditary ovarian cancer syndrome involves three well-defined syndromes: breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, and hereditary nonpolyposis colorectal cancer, or Lynch syndrome II. Less well known is a fourth disorder, granulosa-theca cell tumor, and adenoma malignum of the cervix, which was reported as an integral lesion in the Peutz-Jeghers syndrome1. Lynch syndrome II occurs in families with nonpolyposis colorectal cancer, endometrial cancer, and ovarian cancer. The sisters and daughters of a woman from a family with a history of ovarian cancer syndrome may have a lifetime probability of ovarian cancer or endometrial cancer as high as 50 percent1-3. Hereditary ovarian cancer syndromes tend to occur at younger ages (45 to 52 years) than nonhereditary forms of cancer4. For a patient with Lynch syndrome II, prophylactic oophorectomy as well as hysterectomy should be performed after the completion of childbearing.
In addition, some women are from families prone to ovarian cancer. Women with one first-degree relative with ovarian cancer have an estimated 5 percent lifetime probability of ovarian cancer, and those who have two or three relatives with ovarian cancer (one first-degree and one or more second-degree relatives or two or more second-degree relatives) have a 7 percent lifetime probability of ovarian cancer2,3. If hysterectomy before the age of 45 is indicated for any reason, oophorectomy should also be performed when the patient has two or three relatives with ovarian cancer.
4 ReferencesPeter M. Gocze, M.D.
University of Oklahoma Health Sciences Center, Oklahoma City, OK 731041
Lynch HT, Lynch JF, Conway TA. Hereditary ovarian cancer. In: Rubin SC, Sutton GP, eds. Ovarian cancer. New York: McGraw-Hill, 1993:189-218.
2
Lynch HT, Lynch JF, Conway TA, Bewtra C. Genetics and gynecologic cancer. In: Hoskins WJ, Perez CA, Young RC, eds. Principles and practice of gynecologic oncology. Philadelphia: J.B. Lippincott, 1992:27-45.
3
Kerlikowske K ,Brown JS ,Grady DG . Should women with familial ovarian cancer undergo prophylactic oophorectomy? Obstet Gynecol 1992;80:700-707
Web of Science | Medline4
Amos CI ,Shaw GL ,Tucker MA ,Hartge P . Age at onset for familial epithelial ovarian cancer. JAMA 1992;268:1896-1899
CrossRef | Web of Science | Medline
To the Editor:
Unfortunately, the indications for hysterectomy discussed by Carlson et al. are not those applied throughout this country. More often, the indications are a cooperative patient with a uterus and good health insurance. It is hard to believe that 590,000 women in this country are afflicted each year with leiomyomas, dysfunctional bleeding, prolapse, endometriosis, pain, pelvic inflammatory disease, hyperplasia, and neoplasms of the severity described by the authors.
William W. Patton, M.D.
2860 Channing Way, Idaho Falls, ID 83404Author/Editor Response
The authors reply:
To the Editor: We agree that prospective data on the adverse effects of hysterectomy are lacking. Early ovarian failure is among the reported adverse effects cited in our review. There is indirect evidence of decreases in ovarian estrogen production in women who undergo hysterectomy without oophorectomy. Dr. Oldenhave's data underscore the potential for quality-of-life impairment related to premature menopause in women undergoing hysterectomy. There are few data available to address the question of whether the incidence of more serious consequences of early ovarian failure (including osteoporosis and coronary artery disease) is increased after hysterectomy. Prospective studies of the outcomes of hysterectomy are needed to determine the effects of the procedure on quality of life.
Dr. Patton's concern about the appropriateness of hysterectomy is supported by recent data showing that 16 percent of hysterectomies performed in managed-care organizations were judged inappropriate1. Changes in the financing of health care and the trend toward the use of guidelines for hysterectomy are likely to lower the rates of hysterectomy by reducing the most clear-cut instances of inappropriate surgery. We submit that an informed patient is more desirable than a “cooperative” patient. By sharing information on what is known and what is not known of the outcomes of hysterectomy, the physician can help the patient to determine whether this operation is the best alternative.
We stand by our assertion that cancer prevention alone does not justify hysterectomy in a patient without a serious precancerous pathologic condition. Dr. Gocze's comment concerns oophorectomy coincident with hysterectomy. Approximately 7 percent of the cases of ovarian cancer occur in women with familial evidence of ovarian cancer2. We agree that in the rare hereditary ovarian cancer syndromes, oophorectomy at the time of hysterectomy is indicated. In other women with a strong family history of ovarian cancer in multiple family members, oophorectomy at the time of hysterectomy should be considered after the risk of cancer and the implications of premature menopause have been discussed with the patient.
2 ReferencesKaren J. Carlson, M.D.
David H. Nichols, M.D.
Isaac Schiff, M.D.
Massachusetts General Hospital, Boston, MA 021141
Bernstein SJ ,McGlynn EA ,Siu AL , et al. The appropriateness of hysterectomy: a comparison of care in seven health plans. JAMA 1993;269:2398-2402
CrossRef | Web of Science | Medline2
Schildkraut JM ,Thompson WD . Familial ovarian cancer: a population-based case-control study. Am J Epidemiol 1988;128:456-466
Web of Science | Medline
