Effects of Hysterectomy

Long Term Effects of Hysterectomy

Summary of Forsgen C and Altman D. Long term effects of hysterectomy: focus on aging patient. Aging Health (2013)9(20) 179-187 and Medscape

Press here for link to paper  
Press here for link to Medscape

In recent years, an increasing number of studies have shown adverse effects of hysterectomy on the pelvic floor and some studies describe unwanted effects also with regard to other health aspects. These long-term effects are particularly relevant as they may occur a long time after the surgical procedure and may severely impair quality of life. For example, there is a persistent risk of stress urinary incontinence surgery 10 years after hysterectomy [‎1].

In the USA, approximately 600,000 operations are carried out annually [‎4], and almost one-third of women have had a hysterectomy by the age of 60 years. In the UK, the corresponding figure is one in five women [‎5].

Approximately 90% of hysterectomies are performed on benign indications to improve quality of life [‎13] and the most common indication for surgery is uterine fibroids [‎14,‎6,‎7,‎15].

Hysterectomy associated mortality rate is estimated to be 0.4% and the rate of severe complications approximately 3% [‎16]. The rate of perioperative complications is reported to be 20% or higher, depending on definition, but also related to mode of hysterectomy [‎17,‎18]. The most common perioperative complications of hysterectomy are infections or hematomas (wound infection, vaginal cuff infection or bleeding and urinary tract infection) [‎19].

Hysterectomy & Pelvic Floor Disorders: Pelvic organ prolapse, urinary and anal incontinence, bowel dysfunction and constipation

According to several studies, hysterectomy is a risk factor for pelvic organ prolapse [‎20-‎23] and urinary incontinence [‎1,‎23-‎27]. The procedure has also been associated with bowel dysfunction [‎28,‎29], pelvic organ fistula disease [‎30] and sexual dysfunction [‎31]. Pelvic floor dysfunction generates substantial morbidity among elderly women, resulting in substantial costs for healthcare systems worldwide [‎32-‎34] and affects most domains of individual quality of life and daily function [‎35,‎36]. 

The population-based prevalence of urinary incontinence ranges from 25 to 49% depending on definition and population [‎36,‎39,‎40]. Urinary incontinence is, according to several studies, one of the most common reasons for the elderly to be institutionalised [‎41‎,42]. Bowel dysfunction and constipation are also common problems affecting between 2 and 27% of the female population in developed countries [‎43].

In a nested case–control study by Dällenbach et al. [‎44] the incidence of prolapse for which there was a surgical correction after hysterectomy was 1.3 per 1000 women-years. In the Oxford Family Planning Association Study, the corresponding risk of pelvic organ prolapse subsequent to hysterectomy was 3.6 per 1000 women-years [‎20.]

Urinary incontinence may negatively affect quality of life with a wide range of social implications causing distress, embarrassment and loss of self-assurance [‎45]. Incontinence can also be a major hygiene problem. Symptoms of urinary incontinence are especially common among the elderly and afflict 17–46% of woman over 60 years old [‎46].

In several observational studies, hysterectomy is associated with a deterioration of bladder function [‎1,‎23,‎24,‎26,‎27,‎52,‎53]. In a nationwide study by Altman et al., there was a doubled risk for surgically managed stress incontinence subsequent to hysterectomy [‎1]. The risk was highest in the first years after hysterectomy, but was sustained at 10-year follow-up. [‎19].
Anal incontinence may result from damage to the anal sphincter complex, idiopathic (senile) degeneration of the sphincter, neurological disease or non-sphincter causes (e.g., diarrhea and dementia). A 3-year prospective study in 120 women showed that hysterectomy increased the risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for post-hysterectomy fecal incontinence [‎29].

Many women date the onset of bowel dysfunction to a hysterectomy, although there is no conclusive evidence to indicate causation. Several studies also attribute alterations of bowel function to a previous hysterectomy [‎54,‎55], usually resulting in constipation and rectal emptying difficulties [‎56]. Some of the studies showing an association between hysterectomy and bowel dysfunction have been criticized for their retrospective nature and for not stratifying bowel dysfunction according to type of hysterectomy [‎57].

In a recent prospective multicenter study from The Netherlands, 430 women were followed-up with questionnaires for 10 years [‎27]. A decade after hysterectomy, more women appeared to have bothersome defecation symptoms after vaginal hysterectomy compared with abdominal hysterectomy, explained by an increased prevalence of flatus incontinence and fecal incontinence after vaginal hysterectomy. However, after correction for differences in age, vaginal delivery, uterine descent and indication for hysterectomy, the differences were not statistically significant.

Cardiovascular Disease

There are some studies showing that hysterectomy may be associated with increased risk for cardiovascular disease [‎70,‎71]. In a nationwide Swedish cohort study, the authors found that having a hysterectomy before the age of 50 years was associated with a substantially increased risk of cardiovascular disease later in life [‎72]. The risk was consistent for both incident coronary heart disease and stroke. Early menopause is a probable risk factor for cardiovascular disease [‎71], and ovarian failure subsequent to hysterectomy may be a possible biological explanation for the association between hysterectomy and cardiovascular disease.

Sexual Function

A systematic review by Lethaby et al. [‎65], which concluded that there was no evidence to support the notion that leaving the cervix was associated with improved sexual function. Nonetheless, many of the long-term effects of hysterectomy on sexual function are still unknown [‎66].

Cancer Disease

Hysterectomy has been associated with several neoplasms including thyroid cancer, renal cancer and bladder cancer, but the associations are generally weak and inconsistent [‎19].

Altman et al. [‎67] demonstrated that hysterectomy for benign indication was associated with a significant long-term risk of renal cell carcinoma (hazard ratio: 1.5; 95% CI: 1.3–1.7) among women with hysterectomy versus women without hysterectomy. The risk of renal cell carcinoma was age dependent, and the highest risk was found within 10 years of surgery among women who underwent hysterectomy at 44 years of age or younger (hazard ratio: 2.36; 95% CI: 1.49–3.75). The mechanisms by which hysterectomy increases subsequent renal cell carcinoma risk are undecided but may include catecholamine, iron metabolism, hormonal changes and urine dynamics [‎67-‎69].

Neurodegenerative Diseases

The long-term cognitive effects of hysterectomy and oophorectomy remain controversial. Some studies indicate that hysterectomy and oophorectomy may have harmful brain effects via direct endocrinological mechanisms [‎73], and estrogen deficiency appears to play a key role in these associations [‎73]. Other studies indicate that use of hormone replacement therapy subsequent to hysterectomy may increase the risk of neurodegenerative diseases such as Parkinson's disease [‎74]. The subject is poorly investigated and there is no consensus on the possible cognitive effects of hysterectomy.
Conclusion & Future Perspective

Forsgren and Altman [‎19] state that in order for women to make an informed decision on whether or not to have a hysterectomy for benign gynecological disorders, information on immediate outcomes of surgery, as well as the risk of developing disorders later in life should be made available. Adverse long-term outcomes of hysterectomy may include pelvic organ prolapse, urinary incontinence, anal incontinence, bowel dysfunction, pelvic organ fistula and renal cell carcinoma.

1. Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk for stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007;370:1494–1499.

2. Davies A, Magos A. The hysterectomy lottery. J Obstet Gynaecol 2001;21:166–170.

3. Persson P, Hellborg T, Brynhildsen J, Fredrikson M, Kjolhede P. Attitudes to mode of hysterectomy – a survey-based study among Swedish gynecologists. Acta Obstet Gynecol Scand 2009;88:267–274.

4. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990–1997. Obstet Gynecol 2002;99:229–234.

5. Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988;27:987–994.

6. Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med. Sci. Monit 2008;14:24–31.

7. Lundholm C, Forsgren C, Johansson AL, Cnattingius S, Altman D. Hysterectomy on benign indications in Sweden 1987–2003: a nationwide trend analysis. Acta Obstet Gynecol Scand 2009;88:52–58.

8. Parker WH. Uterine myomas: management. Fertil Steril 2007;88:255–27.

9. Heliovaara-Peippo S, Halmesmaki K, Hurskainen R et al. The effect of hysterectomy or levonorgestrel-releasing intrauterine system on lower abdominal pain and back pain among women treated for menorrhagia: a five-year randomized controlled trial. Acta Obstet Gynecol Scand 2008;88:1389–1396.

10. Brett KM, Marsh JV, Madans JH. Epidemiology of hysterectomy in the United States: demographic and reproductive factors in a nationally representative sample. J Womens Health 1997;6:309–316.

11. Erekson EA, Weitzen S, Sung VW, Raker CA, Myers DL. Socioeconomic indicators and hysterectomy status in the United States, 2004. J Reprod Med 2009;54:553–558.

12. Luoto R, Keskimaki I, Reunanen A. Socioeconomic variations in hysterectomy: evidence from a linkage study of the Finnish hospital discharge register and population census. J Epidemiol Commun Health 1997;51:67–73.

13. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988–1990. Obstet Gynecol 1994;83:549–555.

14. Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med 1993;328: 856–860.

15. Brummer TH, Jalkanen J, Fraser J et al. FINHYST 2006 – national prospective 1-year survey of 5279 hysterectomies. Hum Reprod 2009;24:2515–2522.

16. McPherson K, Metcalfe MA, Herbert A et al. Severe complications of hysterectomy: the VALUE study. BJOG 2004;111:688–694.

17. Nieboer TE, Johnson N, Lethaby A et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;3:CD003677.

18. Persson P, Brynhildsen J, Kjølhede P. Short-term recovery after subtotal and total abdominal hysterectomy – a randomised clinical trial. BJOG 2010;4:469–478.

19. Forsgren C, Altman D. Long-term effects of hysterectomy. Aging Health 2013; 9:179-187.

20. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. BJOG 1997;104:579–585.

21. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027–1038.

22. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 2008;198:572.e1–572.e6.

23. Forsgren C, Lundholm CT, Johansson AL et al. Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2012;23:43–48.

24. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000;356:535–539.

25. Swift SE, Pound T, Dias JK. Case-control study of etiologic factors in the development of severe pelvic organ prolapse. Int Urogynecol J 2001;12:187–192.

26. Jackson SL, Scholes D, Boyko EJ, Abraham L, Fihn SD. Predictors of urinary incontinence in a prospective cohort of postmenopausal women. Obstet Gynecol 2006;108:855–862.

27. Lakeman MM, van der Vaart CH, Roovers JP. A long-term prospective study to compare the effects of vaginal and abdominal hysterectomy on micturition and defecation. BJOG 2011;118:1511–1517.

28. Roovers JP, van der Bom JG, van der Vaart C, Fousert DM, Heintz AP. Does mode of hysterectomy influence micturition and defecation? Acta Obstet Gynecol Scand 2001;80: 945–951.

29. Forsgren C, Zetterstrom J, Lopez A, Nordenstam J, Anzen B, Altman D. Effects of hysterectomy on bowel function: a three-year, prospective cohort study. Dis Colon Rectum 2007; 50: 1139–1145.

30. Forsgren C, Lundholm C, Johansson AL, Cnattingius S, Altman D. Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet Gynecol 2009;114:594–599.

31. Kilkku P, Grönroos M, Hirvonen T, Rauramo L. Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 1983;62:147–152.

32. Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001;98:646–651.

33. DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005;192:1488–1495.

34. Subak LL, Brubaker L, Chai TC et al. High costs of urinary incontinence among women electing surgery to treat stress incontinence. Obstet Gynecol 2008;111:899–907.

35. Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol 2005;106:615–634.

36. Milsom I. Lower urinary tract symptoms in women. Curr Opin Urol 2009;19:337–341.

37. Fialkow MF, Newton KM, Lentz GM, Weiss NS. Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. Int. Urogynecol. J Pelvic Floor Dysfunct 2008;19:437–440.

38. Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct 2008;19: 421–428.

39. Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of urinary incontinence in women in four European countries. BJU Int 2004;93:324–330.

40. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165:537–542. 

41. Nuotio M, Tammela TL, Luukkaala T, Jylhä M. Predictors of institutionalization in an older population during a 13-years period: the effect of urge incontinence. J Gerontol Biol Sci Med Sci  2003;58:756–762.

42. Matsumoto M, Inoue K. Predictors of institutionalization in elderly people living at home: the impact of incontinence and commode use in rural Japan. J Cross Cult Gerontol 2007; 22:421–432.

43. Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003;349:1360–1368.

44. Dällenbach P, Kaelin-Gambirasio I, Dubuisson JB, Boulvain M. Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol 2007;110:625–632.

45. Coyne KS, Wein AJ, Tubaro A et al. The burden of lower urinary tract symptoms: evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS. BJU Int 2009;103(Suppl.):4–11.

46. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000;356:535–539.

47. Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol 2008;111:324–331.

48. El-Toukhy TA, Hefni M, Davies A, Mahadevan S. The effect of different types of hysterectomy on urinary and sexual functions: a prospective study. J Obstet Gynaecol 2004;24:420–425.

49. Gustafsson C, Ekstrom A, Brismar S, Altman D. Urinary incontinence after hysterectomy – three-year observational study. Urology 2006;68:769–774.

50. Parys BT, Woolfenden KA, Parsons KF. Bladder dysfunction after simple hysterectomy: urodynamic and neurological evaluation. Eur Urol 1990;17:129–133.

51. Duru C, Jha S, Lashen H. Urodynamic outcomes after hysterectomy for benign conditions: a systematic review and meta-analysis. Obstet Gynecol Surv 2012;67:45–54.

52. Milsom I, Ekelund P, Molander U, Arvidsson L, Areskoug B. The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women. J Urol 1993;149:1459–1462.

53. Van der Vaart CH, van der Bom JG, de Leeuw JR, Roovers JP, Heintz AP. The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. BJOG 2002;109:149–154.

54. Heaton KW, Parker D, Cripps H. Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy – a population based study. Gut 1993;34:1108–1111.

55. Radley S, Keighly MR, Radley SC, Mann CH. Bowel dysfunction following hysterectomy. BJOG 1999;106:1120–1125.

56. van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Rectum 1997;40:1342–1347.

57. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best Pract. Res. Clin. Obstet Gynaecol 2005; 19: 403–418.

58. Weber AM, Walters MD, Schover LR, Church JM, Piedmonte MR. Functional outcomes and satisfaction after abdominal hysterectomy. Am J Obstet Gynecol 1999; 181: 530–535.

59. Leiblum SR, Koochaki PE, Rodenberg CA, Barton IP, Rosen RC. Hypoactive sexual desire disorder in postmenopausal women: US results from the Women's International Study of Health and Sexuality (WISHeS).Menopause 2006;13:46–56.

60. Rodríguez MC, Chedraui P, Schwager G, Hidalgo L, Pérez-López FR. Assessment of sexuality after hysterectomy using the female sexual function index. J Obstet Gynaecol 2012;32:180–184.

61. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine women's health study: I. Outcomes of hysterectomy. Obstet Gynecol 1994;83:556–565.

62. Roovers JP, van der Bom JG, van der Vaart CH, Heintz AP. Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ 2003;327:774–778.

63. Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol 2004;104:701–709.

64. Peterson ZD, Rothenberg JM, Bilbrey S, Heiman JR. Sexual functioning following elective hysterectomy: the role of surgical and psychosocial variables. J Sex Res 2010; 47:513–527.

65. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst. Rev. 2012;4:CD004993.

66. Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008;111: 753–767.

67. Altman D, Yin L, Johansson A, Lundholm C, Grönberg H. Risk of renal cell carcinoma after hysterectomy. Arch Intern Med 2010;170:2011–2016.

68. Zucchetto A, Talamini R, Dal Maso L. Reproductive, menstrual, and other hormone-related factors and risk of renal cell cancer. Int J Cancer 2008;123:2213–2216.

69. Goldstein MR, Mascitelli L. Increased risk of renal cell carcinoma after hysterectomy: possible causes and implications. Arch Intern Med 2001;171:1214–1215.

70. Howard BW, Kuller L, Langer R. Risk of cardiovascular disease by hysterectomy status, with and without oophorectomy: the Women's Health Initiative Observational Study. Circulation 2005;111:1462–1470.

71. Atsma F, Bartelink ML, Grobbee DE. Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis. Menopause 2006; 13:265–279.

72. Ingelsson E, Lundholm C, Johansson AL, Altman D. Hysterectomy and risk of cardiovascular disease: a population-based cohort study. Eur Heart J 2010;32:745–750.

73. Rocca WA, Grossardt BR, Shuster LT. Hysterectomy, ooporectomy, estrogen, and the risk of dementia. Neurodegener Dis. 2012;10:175–178.

74. Popat RA, van den Eeden SK, Tanner CM. Effect of reproductive factors and postmenopausal hormone use and the risk of Parkinson disease. Neurology 2005;65: 383–390.
Effects of Hysterectomy