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

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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.

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Effects of Hysterectomy