Risk of thyroid cancer in women after hysterectomy: A nationwide cohort study

Summary

Hysterectomy is frequently performed for benign uterine pathologies, but there is some controversy of whether it is associated to an increased risk of thyroid cancer. Tai et al. [1] recently examined the associations of hysterectomy with ovarian conservation or with bilateral salpingo-oophorectomy and the incidence of thyroid cancer in Taiwan. Authors analyzed data from a nationwide health insurance claims database and identified 29,577 women aged ≥ 30 years who underwent hysterectomy with ovarian conservation or hysterectomy with bilateral salpingo-oophorectomy between 2000 and 2016. Propensity score-matching analyses were performed at ratios of 1:1 for the hysterectomy and non-hysterectomy groups, to reduce selection bias. They monitored thyroid cancer occurrence in both groups until 2017. Cox regression was used to calculate hazard ratios with 95% confidence intervals and determine thyroid cancer risk in women who underwent hysterectomy. The study comprised 29,577 patients who underwent any hysterectomy and 29,577 participants who did not. The mean follow-up period was 10 years. It was found that patients who underwent hysterectomy had higher incidence of thyroid cancer (4.72 per 10,000 person-years) than those who did not (3.06 per 10,000 person-years) and a greater risk of any thyroid cancer (adjusted hazard ratio = 1.40; 95% confidence interval = 1.08-1.82). However, there was no association between hysterectomy with bilateral salpingo-oophorectomy and thyroid cancer incidence (p > 0.05). The authors suggest as a conclusion that women who undergo hysterectomy are at a higher risk of developing thyroid cancer than those who do not.

Commentary

Hysterectomy can be carried out by laparotomy, robotics or laparoscopy and is one of the most commonly performed surgeries in women, either abdominal or vaginal, total or subtotal, with removal or preservation of the ovaries and before or after menopause [2]. This article of Tai et al. [1], is an interesting contribution for the determination of the potential relationship that a history of hysterectomy could have on the incidence of thyroid cancer could have. There is great interest in the benefits, risks or disadvantages of hysterectomy, since it is the most frequent gynecological surgery in the United States, China and Taiwan, with person-year rates of 5.8 x 100; 1.1 x 100 and 3.0 x 100, respectively [3]. Stang et al. [4] have reported that in Germany 81.4% of hysterectomies are performed to treat benign diseases: fibroids, endometriosis, hemorrhages, pain and adnexal masses, situations that affect female health and deteriorate their quality of life. However, it has been pointed out that with the passage of time, urogenital, psychological or somatic symptoms appear due to vaginal shortening, reduced synthesis of ovarian hormones, adverse events in sexual and mental health, deterioration in physical function, risk of morbidity or mortality due to different conditions and affectation in the individual imagination with personal or community repercussions [1,2,5]. We have found among hysterectomized women that sexual dysfunction and insomnia were associated with three times greater deterioration in quality of life, which can be explained by the hormonal deterioration derived from hysterectomy and subsequent organ dysfunction [5].

The relationship between thyroid cancer and a history of hysterectomy is controversial, as the authors of the present study carried out with population information comment [1]. The 40% increase in the risk of thyroid cancer in hysterectomized women (removing or preserving the ovaries) vs. non-hysterectomized women is another reason to remind medical societies that they must insist to gynecologists regarding the need to balance the positive and negative aspects of hysterectomy, both clinically and psychosocially. Of concern is the suspicion of for-profit deceptive practices by medical providers recommending hysterectomy to young women [6]. Gynecologists and their patients should be aware of the consequences of a hysterectomy and oophorectomy when they are performed at an early age. Even by preserving the ovaries, hysterectomy is associated with endocrine changes, as it eliminates paracrine signals, accelerates follicular exhaustion, and leads to early or premature menopause. Hysterectomy and oophorectomy performed during the premenopause (surgical menopause) favors abnormal concentrations of Anti-Müllerian hormone, FSH, LH and inhibin B, menopausal symptoms at an early age and risk for dementia, cognitive impairment, obesity, hyperlipidemia, arterial hypertension, cardiovascular disease, metabolic syndrome, atherosclerosis, osteoporotic fracture, Parkinson’s disease and sarcopenic obesity [7,2,8]. Additionally, we have pointed out an association between the early age of menopause and subclinical hypothyroidism [9].

In conclusion, although the design of the study does not allow exploring the mechanisms by which there is an increase in the incidence of thyroid cancer among women with a history of hysterectomy, the provided figures of the commented study provide are a wake-up call to gynecologists regarding the importance of carefully selecting patients for surgical actions, balancing benefits and risks.

Álvaro Monterrosa-Castro, MD
Grupo de Investigación Salud de la Mujer
Universidad de Cartagena, Cartagena, Colombia

References

1. 1. 1. Tai TS, Tsai CF, Yang HY. Thyroid cancer risk in women after hysterectomy: A nationwide cohort study. 2024;185:107980.
         https://pubmed.ncbi.nlm.nih.gov/38555761/
      2. Chen IJ, Shoupe D, Karim R, et al. The association of hysterectomy with or without ovarian conservation with subclinical atherosclerosis progression in healthy postmenopausal women. 2023;30(7):692-702.
         https://pubmed.ncbi.nlm.nih.gov/37192828/
      3. Monterrosa-Castro A, Castilla-Casalins A, Rincón-Teller D. Abdominal hysterectomy and impaired physical function in Colombian older women. Ginecol Obstet Mex. 2024;92(3):114-126.
         https://www.medigraphic.com/pdfs/ginobsmex/gom-2024/gom243d.pdf
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         https://pubmed.ncbi.nlm.nih.gov/21904583/
      5. Monterrosa-Castro A, Monterrosa-Blanco A, Beltrán Barrios T. Insomnia and sexual dysfunction associated with severe worsening of the quality of life in sexually active hysterectomized women. Sleep Sci. 2018;11(2):99-105.
         https://pubmed.ncbi.nlm.nih.gov/30083297/
      6. Prusty RK, Choithani C, Gupta SD. Predictors of hysterectomy among married women 15-49 years in India. Reprod Health. 2018;15(1):3.
         https://pubmed.ncbi.nlm.nih.gov/29304867/
      7. Huang Y, Wu M, Wu C, Zhu Q, Wu T, et al. Effect of hysterectomy on ovarian function: a systematic review and meta-analysis. J Ovarian Res. 2023;16(1):35.
         https://pubmed.ncbi.nlm.nih.gov/36759829/
      8. Monterrosa-Castro Á, Prada-Tobar M, Monterrosa-Blanco A, Pérez-Romero D, Salas-Becerra C, Redondo-Mendoza V. Clinical suspicion of sarcopenic obesity and probable sarcopenic obesity in Colombian women with a history of surgical menopause: a cross-sectional study. 2022;29(6):664-670.
         https://pubmed.ncbi.nlm.nih.gov/35674647/
      9. Monterrosa-Castro Á, Monterrosa-Blanco A, Sánchez-Zarza S. Possible association between subclinical hypothyroidism and age at menopause in Colombian women. Gynecol Endocrinol. 2024;40(1):2334798.
         https://pubmed.ncbi.nlm.nih.gov/38590105/

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