Summary
Hysterectomy is the most common treatment option for women with uterine fibroids, providing definitive relief of the associated burdensome symptoms. Nevertheless, as with all surgical interventions, it is associated with the risk of complications, short-term morbidities, and mortality. Although all these aspects have previously been described, information regarding the potential long-term risks of hysterectomy is only recently becoming available. Bearing this in mind, recently, Madueke-Laveaux et al. [1] conducted a systematic review of the literature to identify long-term risks related to hysterectomies performed for uterine fibroids with or without oophorectomies since the short-term risks of both morbidity and mortality have already been widely studied. They included in their review studies published between 2005 and December 2020 that assessed the long-term impact of hysterectomy for benign pathology in women, identifying 29 relevant studies. The review of the identified articles showed that hysterectomy even with ovarian preservation can increase the risk of cardiovascular events (very strongly associated with hypoestrogenism), certain cancers (i.e urinary tract), the need for further surgery, and premature ovarian failure and menopause that lead to long-term sequelae such as fragility fractures, cognitive impairment and impairment of quality of life in different domains. In addition, when hysterectomy was performed in younger women (< 44 years) a significant higher rate of depression was found after 10 years of follow-up when compared to menopausal women over 50 years with established menopause. The authors remark that it is important to recognize that the available studies examine possible associations and hypotheses rather than causality, hence the results should be taken with caution.
Commentary
It is known that uterine fibroids increase with age, reaching a cumulative incidence of 70% in Caucasian women aged 50 [2]. Of these, at least 25% require a specific treatment, with hysterectomy being the most indicated management option world-wide [3]. Despite this, there are other therapeutic alternatives such as non-surgical/minimally invasive procedures (i.e embolization of the uterine artery with magnetic resonance imaging, guided focused ultrasound and radiofrequency ablation), or medical treatment with fewer short- and long-term risks. The surgical approach route to perform a hysterectomy has been widely discussed in relation to its indications and advantages (i.e vaginal, abdominal, laparoscopic or assisted), although sharing the same long-term complications. In addition, in the vast majority of them, an oophorectomy for prophylactic purposes is performed and associated with the unfounded idea that surgery could subsequently be required for a risk of potential cancer. Performing oophorectomy exposes patients to all the deleterious effects of long-term hypoestrogenism [4]. Despite this, the studies analyzed by the authors seem to point out to the fact that even if an oophorectomy was not performed, there seems to be an association between hysterectomy and an increased risk of either premature menopause, premature ovarian failure, frailty, osteoporosis, or other vasomotor symptoms. To date it is unknown whether hysterectomy itself or the underlying condition indicating hysterectomy caused earlier ovarian failure. Nevertheless, it is important to discuss these risks with patients prior to surgery, in order to make them aware of these risks when considering options for the management of uterine fibroids. In this sense, women should be evaluated to start menopausal hormone therapy early in order to improve their quality of life and prevent chronic diseases and the aforementioned long-term risks, moreover if hypoestrogenism after a hysterectomy for benign uterine pathology such as fibroids has been observed even in patients with ovarian preservation.
Finally, we agree with the authors that it is important to recognize that the available studies examine possible associations and hypotheses rather than causality, so the results should be taken with caution and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs. Decision-making should consider the potential long-term risks and not just the classic short-term complications of this type of surgery.
Margot Acuña-San Martin, MD
President Elect
Sociedad Chilena de Climaterio
Temuco, Chile
References
- Madueke-Laveaux OS, Elsharoud A, Al-Hendy A. What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review. J Clin Med. 2021;10(22):5335.
https://pubmed.ncbi.nlm.nih.gov/34830617/ - Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100-7.
https://pubmed.ncbi.nlm.nih.gov/12548202/ - Williams ARW. Uterine fibroids – what’s new? F1000Res. 2017;6:2109.
https://pubmed.ncbi.nlm.nih.gov/29259779/ - Casiano ER, Trabuco EC, Bharucha AE, Weaver AL, Schleck CD, Melton LJ 3rd, Gebhart JB. Risk of oophorectomy after hysterectomy. Obstet Gynecol. 2013;121(5):1069-1074.
https://pubmed.ncbi.nlm.nih.gov/23635745/
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