Hysterectomy Status Research Articles

Hysterectomy and Predictors for Opioid Prescription in a Chronic Pain Clinic Sample

To describe the prevalence of hysterectomy for women aged 18-45 seeking treatment at a chronic pain clinic, to describe patient characteristics (pain intensity, age, smoking status, hormone replacement status, and psychosocial factors) based on opioid and hysterectomy status, and to determine whether hysterectomy status predicted receipt of opioid prescription. Retrospective cross-sectional chart review. Total 323 new female patients aged 18-45 who completed the Brief Pain Inventory-Short Form at initial evaluation at a chronic pain clinic during a 12-month period (July 2008-June 2009). Data were collected from the Brief Pain Inventory and medical charts. Variables included opioid prescription, average pain intensity, pain type, age, hysterectomy status, smoking status, and pain-related dysfunction across domains measured by the Brief Pain Inventory. The association of opioid prescription with hysterectomy and other factors were determined by logistic regression. Prevalence of hysterectomy was 28.8%. Average pain intensity was not associated with either hysterectomy or opioid prescription status. However, hysterectomy and high levels of pain-related dysfunction were significantly and independently associated with opioid prescription after adjusting for age and pain intensity. More than 85% of women with hysterectomy and high pain-related dysfunction had opioid prescription. Hysterectomy may confer risk for pain-related dysfunction and opioid prescription in women 45 and younger. More research is needed to understand 1) how patient characteristics influence prescribing patterns and 2) the specific medical risks and consequences of chronic opioid therapy in this population.

Risk of Renal Cell Carcinoma After Hysterectomy

Hysterectomy is the most common gynecologic operation among women; study findings indicate that hysterectomy is associated with renal cell carcinoma. To assess the effects of hysterectomy on the incidence and risk of renal cell carcinoma, we performed a population-based cohort study using data from 184,945 women who had undergone hysterectomy (hereafter referred to as women with hysterectomy) and from 657,288 matched women who had not undergone hysterectomy (hereafter referred to as women without hysterectomy) by linking nationwide Swedish health care registers, including the Swedish Inpatient Register and the Swedish Cancer Register (January 1, 1973, through December 31, 2003). Risk of renal cell carcinoma owing to hysterectomy status was assessed using Cox proportional hazards regression models with hazard ratios (HRs) and 95% confidence intervals (CIs). The crude incidence rates of renal cell carcinoma were 17.4 cases per 100,000 person-years among women with hysterectomy and 13.1 cases per 100,000 person-years among women without hysterectomy. This corresponded to an adjusted overall HR of 1.50 (95% CI, 1.33-1.69) for renal cell carcinoma among women with hysterectomy vs 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 age 44 years or younger (HR, 2.36; 95% CI, 1.49-3.75). The overall risk of renal cell carcinoma after hysterectomy was consistently increased and of similar magnitude over the time strata: HR, 1.50 (95% CI, 1.26-1.78) for years 0 to 10; 1.49 (1.22-1.82) for years 11 to 20; and 1.51 (1.05-2.16) for more than 20 years after surgery. Hysterectomy for benign indications was significantly associated with renal cell carcinoma. Women undergoing the procedure at a young age were at particular risk.

Abstract 4825: Serum selenium concentration and risk of colorectal cancer in postmenopausal women: The Women's Health Initiative Observational Study

Abstract In vitro and animal experimental studies have reported beneficial effects of selenium on colorectal cancer (CRC), yet results from epidemiological studies are inconsistent. Few of these studies have examined CRC risk among women, and none have been sufficiently large to examine risk in subgroups. This study investigated whether baseline serum selenium concentration was associated with subsequent CRC risk among postmenopausal women in a case-control study nested within the Women's Health Initiative Observational Study. We included 804 CRC cases diagnosed between October 1993 and September 2005 and 804 controls matched to cases on age, enrollment date, clinical center, race/ethnicity, hysterectomy status, and prevalent condition at baseline. Baseline serum selenium concentration was measured by atomic absorption spectrometry. Multivariate logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI) associated with increasing serum selenium concentrations. The corresponding median selenium concentrations in the 1st to 5th quintiles were 110.5, 123.2, 133.5, 144.8, and 162.2 µg/l (range: 81.03 - 398.70 µg/l). The selenium concentration was weakly and positively associated with the risk of CRC (ptrend = 0.08); the adjusted ORs (95% CIs) for the risk of CRC comparing the 2nd, 3rd, 4th, and 5th quintile of serum selenium concentrations with the 1st quintile were 1.14 (0.83-1.58), 1.16 (0.84-1.60), 1.36 (0.99-1.87) and 1.27 (0.92-1.76). The trend was somewhat stronger for past and current smokers [OR (95% CI) for the 5th vs. 1st quintile = 1.38 (0.89-2.13), ptrend = 0.13] than never smokers [OR (95% CI) for the 5th vs. 1st quintile = 1.16 (0.72-1.87), ptrend = 0.48]. However, the difference was not statistically significant (pinteraction = 0.53). Findings from this large study with relatively high serum selenium concentrations suggest no beneficial effect of selenium on colorectal cancer among women, which is consistent with results of previous smaller observational studies. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4825.

Abstract 867: Oral contraceptive, menopausal hormone therapy use and risk of B-cell non-Hodgkin lymphoma in the California Teachers Study

Abstract Objective: To evaluate whether use of oral contraceptives (OC) or menopausal hormonal therapy (MHT) is associated with B-cell non-Hodgkin lymphoma (NHL). Methods: Within the prospective California Teachers Study cohort, women under age 85 with no history of hematopoietic cancer were followed from 1995 through 2007 for diagnosis of B-cell NHL. Overall, 547 women of 116,779 women eligible for analysis of OC use and 402 of 54,758 postmenopausal women eligible for analysis of MHT use developed B-cell NHL. Relative risks (RR) and 95% confidence intervals (CI) were estimated by fitting multivariable Cox proportional hazards models. Results: Women who used OCs had marginally lower risk of B-cell NHL than women who had never used OCs (RR=0.86, 95% CI=0.69-1.06). The reduced risk was most pronounced among women who started OCs before age 25, but did not decrease with increasing duration. No association with MHT was observed when MHT ever users were compared to the never users (RR=1.05, 95% CI=0.83-1.33); this result was consistent across formulations of MHT [unopposed estrogen therapy (ET), combined estrogen and progestin therapy (EPT)]. Among women who had never used MHT, women with a bilateral oophorectomy had three times greater risk than those with natural menopause (RR=3.15, 95% CI=1.62-6.13), whereas there was no association with bilateral oophorectomy among women who had used MHT. In stratified analyses according to hysterectomy and oophrectomy status, ET and EPT did not affect risk for women with natural menopause or those with hysterectomy who had at least part of an ovary remaining. Among women who had a bilateral oophorectomy, ET reduced risk of NHL (RR=0.41, 95% CI=0.21-0.82). Conclusion: These data suggest that ET use decreases the risk of B-cell NHL among women with both ovaries removed, but not among women retaining at least part of an ovary. In other subgroups MHT does not influence risk. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 867.

Meeting the cervical cancer screening needs of underserved women: The National Breast and Cervical Cancer Early Detection Program, 2004–2006

To examine the extent to which the only national organized screening program in the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), has helped to meet the cervical cancer screening needs of underserved women. Low-income, uninsured women 18-64 years of age are eligible for free cervical cancer screening services through NBCCEDP. We used data from the US Census Bureau to estimate the number of eligible women, based on insurance status and income. The estimates were adjusted for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used administrative data from NBCCEDP to obtain the number of women receiving NBCCEDP-funded Papanicolaou (Pap) tests. We then calculated the percentage of NBCCEDP-eligible women who received free cervical cancer screening through NBCCEDP. We also used the NHIS to calculate the percentage of NBCCEDP-eligible women screened nationally and the percentage unscreened. In 2004-2006, nearly 9% (775,312 of 8.9 million) of NBCCEDP-eligible women, received NBCCEDP-funded Pap test. Rates varied substantially by age groups, race, and ethnicity. NBCCEDP-eligible women 40-64 years of age had a higher screening rate (22.6%) than eligible women 18-39 years of age (2.3%). Non-Hispanic women had a higher screening rate (9.3%) than Hispanic women (7.3%). Among non-Hispanics, the screening rate was highest among American Indian and Alaska Native (AIAN) women (36.1%) and lowest among women of different race combinations (4.6%), The percentage of eligible women screened in each state ranged from 2.0 to 38.4%. Although NBCCEDP provided cervical cancer screening services to 775,312 low-income, uninsured women, this number represented a small percentage of those eligible. In 2005, more than 34% of NBCCEDP-eligible women (3.1 million women) did not receive recommended Pap tests from either NBCCEDP or other sources.

Oral Contraceptive, Menopausal Hormone Therapy Use and Risk of non-Hodgkin Lymphoma in the California Teachers Study

Abstract Objective: To evaluate whether use of oral contraceptives (OCs) or menopausal hormonal therapy (MHT) is associated with B-cell non-Hodgkin lymphoma (NHL). Methods: Within the prospective California Teachers Study cohort, women under age 85 with no history of hematopoietic cancer were followed from 1995 through 2007 for diagnosis of B-cell NHL. Overall, 547 women of 116,779 women eligible for analysis of OC use and 402 of 54,758 postmenopausal women eligible for analysis of MHT use developed B-cell NHL. Relative risks (RR) and 95% confidence intervals (CI) were estimated by fitting multivariable Cox proportional hazards models. Results: Women who used OCs had marginally lower risk of B-cell NHL than women who had never used OCs (RR = 0.86, 95% CI = 0.69-1.06). The reduced risk was most pronounced among women who started OCs before age 25, but did not decrease with increasing duration. No association with MHT was observed when MHT ever users were compared to the never users (RR = 1.05, 95% CI = 0.83-1.33); this result was consistent across formulations of MHT [unopposed estrogen therapy (ET), combined estrogen and progestin therapy (EPT)]. Among women who had never used MHT, women with a bilateral oophorectomy had three times greater risk than those with natural menopause (RR = 3.15, 95% CI = 1.62-6.13), whereas there was no association with bilateral oophorectomy among women who had used MHT. In stratified analyses according to hysterectomy and oophrectomy status, ET and EPT did not affect risk for women with natural menopause or those with hysterectomy who had at least part of an ovary remaining. Among women who had a bilateral oophorectomy, ET reduced risk of NHL (RR = 0.41, 95% CI = 0.21-0.82). Conclusion: These data suggest that ET use decreases the risk of B-cell NHL among women with both ovaries removed, but not among women retaining at least part of an ovary. In other subgroups MHT does not influence risk. Additional study of associations of MHT and OCs with B-cell NHL are warranted.

Route of Hysterectomy Influence and Teaching Hospital Status

OBJECTIVE The purpose of this study was to evaluate whether teaching hospitals are more likely to perform abdominal (laparotomy) compared with nonabdominal (vaginal, laparoscopic) hysterectomies for benign indications. METHODS We conducted a retrospective, observational study comparing abdominal and nonabdominal inpatient hysterectomies performed in Illinois between 2000 and 2005 using the COMPdata database. Obvious cancer, prolapse, or indicated-abdominal surgeries (infection and pregnancy-related cases) were excluded. The final analysis included 94,599 cases. Diagnoses and patient demographics were analyzed from the database and hospitals' teaching status, as determined by telephone interviews. The relationship between route of hysterectomy and teaching hospital status was modeled using multivariable logistic regression with a P value cutoff of less than 0.05. RESULTS Eight-two percent of hysterectomies performed at teaching hospitals were performed abdominally compared with 77% at nonteaching hospitals. After adjusting for age and diagnoses, teaching hospitals were less likely to perform hysterectomy by abdominal approach (odds ratio 0.69, 95% confidence interval 0.49-0.97, P<.035). Clinical variables associated positively with vaginal hysterectomies included primary diagnoses of menstrual disorders, other female genital disorders, and menopausal disorders. Complication rate did not differ by teaching status. Laparoscopic hysterectomy, even after adjustment for confounders, was associated with fewer complications compared with both abdominal and vaginal routes. CONCLUSION The route of hysterectomy is only minimally influenced by teaching hospital status. These findings are important for clinician-educators responsible for teaching the nation's next generation of gynecologic surgeons. Strategies to overcome presumed physician-level factors are needed to optimize patient outcomes through appropriate use of nonlaparotomy surgery. LEVEL OF EVIDENCE III.

Route of Hysterectomy Influence and Teaching Hospital Status

The purpose of this study was to evaluate whether teaching hospitals are more likely to perform abdominal (laparotomy) compared with nonabdominal (vaginal, laparoscopic) hysterectomies for benign indications. We conducted a retrospective, observational study comparing abdominal and nonabdominal inpatient hysterectomies performed in Illinois between 2000 and 2005 using the COMPdata database. Obvious cancer, prolapse, or indicated-abdominal surgeries (infection and pregnancy-related cases) were excluded. The final analysis included 94,599 cases. Diagnoses and patient demographics were analyzed from the database and hospitals' teaching status, as determined by telephone interviews. The relationship between route of hysterectomy and teaching hospital status was modeled using multivariable logistic regression with a P value cutoff of less than 0.05. Eight-two percent of hysterectomies performed at teaching hospitals were performed abdominally compared with 77% at nonteaching hospitals. After adjusting for age and diagnoses, teaching hospitals were less likely to perform hysterectomy by abdominal approach (odds ratio 0.69, 95% confidence interval 0.49-0.97, P<.035). Clinical variables associated positively with vaginal hysterectomies included primary diagnoses of menstrual disorders, other female genital disorders, and menopausal disorders. Complication rate did not differ by teaching status. Laparoscopic hysterectomy, even after adjustment for confounders, was associated with fewer complications compared with both abdominal and vaginal routes. The route of hysterectomy is only minimally influenced by teaching hospital status. These findings are important for clinician-educators responsible for teaching the nation's next generation of gynecologic surgeons. Strategies to overcome presumed physician-level factors are needed to optimize patient outcomes through appropriate use of nonlaparotomy surgery. III.

Baseline serum estradiol and fracture reduction during treatment with hormone therapy: The Women's Health Initiative randomized trial

The purpose of the study was to test the hypothesis that the reduction in fractures with hormone therapy (HT) is greater in women with lower estradiol levels. We conducted a nested case-control study within the Women's Health Initiative HT Trials. The sample included 231 hip fracture case-control pairs and a random sample of 519 all fracture case-control pairs. Cases and controls were matched for age, ethnicity, randomization date, fracture history, and hysterectomy status. Hormones were measured prior to randomization. Incident cases of fracture were identified over an average follow-up of 6.53 years. There was no evidence that the effect of HT on fracture differed by baseline estradiol (E2) or sex hormone binding globulin (SHBG). Across all quartiles of E2 and SHBG, women randomized to HT had about a 50% lower risk of fracture, including hip fracture, compared to placebo. The effect of HT on fracture reduction is independent of estradiol and SHBG levels.

Hysterectomy and weight gain

To investigate whether overweight women are more likely to have a hysterectomy and whether hysterectomy leads to increased weight gain. Survey data of middle-aged women participating in the Australian Longitudinal Study on Women's health in 1996 (ages 45-50 y; n = 13,125), 1998 (n = 10,612), 2001 (n = 10,293), and 2004 (n = 9309) included self-reported height, weight, and hysterectomy. First, we conducted a cohort analysis, comparing body mass index (BMI) of women categorized according to hysterectomy status. Second, we used a nested case-control analysis to compare weight gain between women who underwent hysterectomy and women who did not have a hysterectomy, matched for prehysterectomy weight, height, menopause status, and educational level. At survey 1, the mean BMI of women who subsequently had a hysterectomy was greater than that of women without a hysterectomy by survey 2 (difference, 1.1 kg/m; 95% CI, 0.5-1.6). Results were similar for surveys 2 to 3 (BMI difference, 0.8 kg/m; 95% CI, 0.3-1.3) and surveys 3 to 4 (BMI difference, 0.8 kg/m; 95% CI, 0.1-1.4). Having a hysterectomy between surveys 1 and 2 was not associated with percentage of weight gain over the 3 or 6 years after survey 2 (odds ratio, 0.98 [95% CI, 0.96-1.01] and 0.99 [95% CI, 0.97-1.01], respectively). Having a hysterectomy between surveys 2 and 3 was weakly associated with percentage of weight gain over 3 years (odds ratio, 1.03 [95% CI, 1.00-1.05]). Among women older than 45 to 50 years, hysterectomy did not lead to greater weight gain but was more likely to be performed in heavier women.

Changes of menopausal hormone therapy use pattern since 2000: results of the Berlin Spandau Longitudinal Health Study

Background There are virtually no prospective cohort studies in Germany regarding the changes of menopausal hormone therapy (HT) use pattern and factors associated with HT discontinuation after the release of the Women's Health Initiative (WHI) trial results.Methods We assessed HT prevalence and use pattern as well as factors associated with HT discontinuation in a cohort of 903 women 40 years of age and older, who participated in two consecutive follow-up visits in a 20-year prospective health study from July 2000 to February and from August 2002 to December 2004.Results Overall, the prevalence of HT users in the cohort declined significantly from 35.4% in 2000–2002 to 22.5% in 2002–2004. Adjusting for aging of the population, a statistically significant decrease in HT user prevalence was consistently observed across subgroups of HT users defined by type and duration of HT use. The decline was most pronounced with respect to women using combined estrogen–progestin regimens (−10.5%), higher-dose estrogens (−11.6%), oral preparations (−11.1%), as well as long-term HT users (−8.4%). The prevalence of women indicating HT use for climacteric symptoms decreased significantly (−12.4%), whereas the prevalence of women reporting use of HT for the prevention of osteoporosis increased (+1.8%) significantly. Irrespective of hysterectomy status, half of the women who continued HT changed their HT preparations and switched to lower estrogen doses (11.5%), topical estrogens (8.2%), or phytohormones (3.8%). We did not observe any significant differences between women who continued and discontinued HT regarding health-related characteristics of the study population as of 2000–2002. However, women seeing a gynecologist in the 12 months preceding the 2002–2004 visit were significantly less likely to discontinue HT use in bivariate and multivariate analyses.Conclusions Substantial declines in HT user prevalence as well as changes in HT use patterns to lower-dose estrogen preparations and non-oral routes of administration are likely to reflect effects of the publication of the WHI results. Consulting a gynecologist appeared to be relevant for a woman's decision to continue HT.

Breast cancer risk and hysterectomy status: the Multiethnic Cohort study.

The main objective was to examine the association between simple hysterectomy (without bilateral oophorectomy) and breast cancer risk. Because hysterectomy prevalence varies by ethnicity, the secondary objective was to examine whether inclusion of women with hysterectomies affects the estimates of breast cancer risk by ethnicity. The Multiethnic Cohort study was assembled between 1993 and 1996 and included 68,065 women from Hawaii and Los Angeles, aged 45-75 years, without any missing information or bilateral oophorectomy. Hysterectomy status was self-reported. After 7.7 years median follow-up, 1,862 cases of invasive breast cancer were identified. Proportional hazards models were used to estimate relative risks (RR) while controlling for known risk factors. Prevalence of simple hysterectomy varied from 12% to 29% among the ethnic groups (White, African American, Native Hawaiian, Japanese American, and Latina). Overall, hysterectomy was not associated with breast cancer risk (RR = 0.98). Although the RRs were nonsignificantly elevated by 15% in White women and nonsignificantly reduced by 15% in Latinas of non-US origin, the variation by ethnicity was not significant (p(interaction) = 0.48). The breast cancer risk associated with ethnicity was very similar when estimated with and without women with hysterectomies. This study suggests that simple hysterectomy status does not alter breast cancer risk. Therefore, inclusion of women with simple hysterectomies does not substantially change estimated risk of breast cancer by ethnicity.

Abstract A121: The association of menstrual and reproductive factors with the risk of upper gastrointestinal tract cancers in the NIH-AARP cohort

Abstract A121 Upper gastrointestinal tract cancers (UGI), including cancers of the esophagus, head and neck, and stomach have high worldwide incidence and mortality. Incidence rates are consistently higher among men than women; the male/female ratios are 2:1 for cancers of the stomach and 7:1 for cancers of the larynx. Strong environmental risk factors have been identified for these cancer sites, but do not appear to explain differences in incidence rates between men and women. Differences in sex hormones in men vs. women and among women of different ages might affect UGI risk. In nearly 10 studies of menstrual and reproductive factors with stomach cancer risk in women, significant inverse associations with older age at menopause or use of menopausal hormone therapy (MHT) were observed in some, but not all studies. Only a few studies have investigated the association of these factors with squamous cancers of the esophagus and head and neck. We prospectively investigated the association of menstrual and reproductive factors with UGI cancer risk in 201,506 women of the NIH-AARP Diet and Health cohort study. We used Cox proportional hazard models adjusted for age, alcohol intake, cigarette smoking, body mass index, physical activity, education, and total energy intake and report hazard ratios (HRs) and 95% confidence intervals. During 1,463,551 person years of follow-up from 1995/1996-2003, 162 women were diagnosed with adenocarcinomas (ACs; esophagus and stomach) and 353 women were diagnosed with squamous cell carcinomas (SCCs; oral cavity, pharynx, larynx, and esophagus). We found no significant associations between age at menopause, age at menarche, parity, or age at first birth and AC risk. Ever- versus never-use of MHT showed a borderline non-significant inverse association with adenocarcinoma (HR=0.74, 95% CI 0.54-1.02) in age adjusted models. After multivariate adjustment, the association was attenuated (HR=0.81, 95% CI, 0.59-1.12). For SCCs, we found a significant inverse association with older age at menopause but not with age at menarche, parity, or age at first birth. The HR for age at menopause of &amp;gt;55 years (vs. &amp;lt;45 years) was 0.53 (95% CI 0.28-1.01; p-value for trend=0.019). We also observed an inverse association with ever- versus never-use of MHT (HR=0.77, 95% CI 0.62-0.96). We further examined relations with the type of MHT stratified by hysterectomy status, using data from a subsequent questionnaire (1996-1997) completed by 127,385 women. In 51,515 women with a reported hysterectomy at baseline, the HRs and 95% CIs for &amp;lt;5 years of estrogen-plus-progestin MHT, relative to never MHT users, were 0.74 (0.43-1.27) for ACs (N=38) and 0.51 (0.18-1.46) for SCCs (N=80), respectively; for ≥5 years of use, the HRs and 95% CIs were 0.47 (0.19-1.16) and 0.28 (0.13-0.58), respectively. In 74,372 women with intact uteri, we found no associations between estrogen MHT and ACs (N=49) or SCCs (N=130). Our results suggest that estrogen-plus-progestin therapy is associated with reduced risk of UGI tract cancers, supporting the involvement of sex hormones in the etiology of these cancers. Future studies are needed to replicate these results. Citation Information: Cancer Prev Res 2008;1(7 Suppl):A121.

Hysterectomy and subsequent psychological health: Findings from a British birth cohort study

BackgroundThe association between hysterectomy and subsequent, long-term psychological health is still not well characterised. We aimed to test the association between hysterectomy and subsequent psychological health and examine variation in this association by characteristics of hysterectomy. MethodsUsing data on women in the MRC National Survey of Health and Development, followed up since birth in 1946 until age 53 years (N=1790) the associations between hysterectomy and General Health Questionnaire (GHQ)-28 scores were tested. ResultsThere was no clear association between hysterectomy status and GHQ-28 score at age 53 years when grouping all hysterectomies together. However, this masked significant variation in association by characteristics of hysterectomy. In unadjusted analyses women who had undergone hysterectomy for cancer had mean GHQ-28 scores at age 53 years which were 49.0% higher (95% CI: 3.4%, 94.7%) than women who had not undergone hysterectomy. In analyses adjusted for prior psychological state and vulnerability, lifetime socioeconomic position, weight at age 26 years, smoking status and hormone replacement therapy use, women who had undergone hysterectomy before age 40 years had GHQ-28 scores 29.5% higher (95% CI: 2.7%, 56.3%) than women who had not undergone hysterectomy. ConclusionsOur findings suggest that women who undergo hysterectomy at a young age are a defined group who may require more support than other women to maintain good psychological health in middle-age.

The effect of menopause and hysterectomy on systemic vascular endothelial growth factor in women undergoing surgery for breast cancer

BackgroundVascular endothelial growth factor (VEGF) is a potent angiogenic cytokine produced physiologically by the uterus. Pathological secretion by tumours promotes growth and metastasis. High circulating VEGF levels potentially have a deleterious effect on breast cancer by promoting disease progression.The aims of this study were to investigate circulating VEGF levels in breast cancer patients and assess the effect of menopause or hysterectomy on systemic VEGF.MethodsPatients undergoing primary surgery for breast cancer and controls matched for age, menopausal and hysterectomy status were prospectively recruited. Serum VEGF, FSH, LH, estrogen, progesterone and platelet levels were measured. Serum VEGF was corrected for platelet load (sVEGFp) to provide a biologically relevant measurement of circulating VEGF. SVEGFp levels were analyzed with respect to tumor characteristics, menopausal status and hysterectomy status.ResultsTwo hundred women were included in the study; 89 breast cancer patients and 111 controls. SVEGFp levels were significantly higher in breast cancer patients compared to controls (p = 0.0001), but were not associated with clinico-pathological tumor characteristics. Systemic VEGF levels reduced significantly in the breast cancer patients following tumor excision (p = 0.018). The highest systemic VEGF levels were observed in postmenopausal breast cancer patients. Postmenopausal women who had had a previous hysterectomy had significantly higher VEGF levels than those with an intact postmenopausal uterus (p = 0.001).ConclusionThis study identifies an intact postmenopausal uterus as a potential means of reducing circulating levels of VEGF which could confer a protective effect against breast cancer metastatic potential.

A multi-center, randomized, double blind placebo-controlled trial of estrogens to prevent Alzheimer's disease and loss of memory in women: design and baseline characteristics.

Observational studies and small clinical trials suggested that hormone replacement therapy (HRT) decreases risk of cognitive loss and Alzheimer's disease (AD) in postmenopausal women and may have value in primary prevention. A clinical trial was designed to determine if HRT delays AD or memory loss. This report describes the rationale and original design of the trial and details extensive modifications that were required to respond to unanticipated findings that emerged from other studies during the course of the trial. The trial was designed as a multi-center, placebo-controlled primary prevention trial for women 65 years of age or older with a family history of dementia. Recruitment from local sites was supplemented by centralized efforts to use names of Medicare beneficiaries. Inclusion criteria included good general health and intact memory functioning. Participants were randomized to HRT or placebo in a 1:1 ratio. Assignment was stratified by hysterectomy status and site. The primary outcomes were incident AD and memory decline on neuropsychological testing. Enrollment began in March 1998. In response to the Women's Health Initiative (WHI) May 2002 report of increased incidence of heart disease, stroke, pulmonary embolism, and breast cancer among women randomized to HRT, participants were re-consented with a revised consent form. Procedural modifications, including discontinuation of study medication and a modification of the planned primary outcome based on a final enrollment below the target enrollment (N = 477), were enacted in response to the subsequent WHI Memory Study report of increased risk of dementia and poorer cognitive function with HRT. The mean length of treatment exposure prior to discontinuation was 2.14 years. Participants' mean age at baseline was 72.8; mean education was 14.2 years. Minority participation was 19% and 34% had a hysterectomy. The study continues to follow these participants for a total of 5 years blind to the original medication assignment. Results reported from the WHI during the course of this study mandated extensive procedural modifications, including discontinuing recruitment before completion and halting study medication. Alternative strategies for study redesign that were considered are discussed.

Does Patient Health and Hysterectomy Status Influence Cervical Cancer Screening in Older Women?

Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy. To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status. Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35-64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS (N = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem. The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors. NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap. Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.

Is adiposity across life associated with subsequent hysterectomy risk? Findings from the 1946 British birth cohort study

To examine the associations between adiposity at time points from early life onwards and subsequent hysterectomy risk. Prospective birth cohort study. England, Scotland and Wales. Women from the Medical Research Council National Survey of Health and Development study, with complete data on hysterectomy status (n= 1790). Survival analysis methods were used to examine the associations between body mass index at time points across life and subsequent hysterectomy rates. Self-reported hysterectomy with or without oophorectomy. From 20 years onwards, those women who were classified as underweight had lower hysterectomy rates, and from 36 years onwards, those women who were overweight had higher hysterectomy rates than those who were normal weight. Women who were obese in adolescence and early adulthood had lower rates of hysterectomy than those who were normal weight, although numbers categorised as obese at these ages were small. Women who were obese in later adulthood had higher subsequent rates of hysterectomy. Greater increases in weight between ages 36 and 53 years were associated with higher rates of hysterectomy in later adulthood. These results were not explained by parity, age at menarche or socio-economic position. These results suggest that variation in hysterectomy rates may be partially explained by variation in adiposity, and so with the recent changes in levels of overweight and obesity in populations, there may be increasing demand for gynaecological treatments in the future.

Symptoms of anal incontinence and difficult defecation among women with prolapse and a matched control cohort

The purpose of this study was to quantify the risk for anal incontinence and difficult defecation among women with prolapse by comparing them with women without prolapse of similar age, body mass index, race, and hysterectomy status, and to determine whether there are characteristics or findings in women with prolapse that are associated with greater symptom severity. Women with primary pelvic organ prolapse (n = 151) were compared with women without prolapse (n = 135). All subjects underwent pelvic examination and completed symptom questionnaires regarding how frequently anal incontinence and difficult defecation were experienced. Incontinence of flatus was considered to be present if it occurred on "most" or "every" day; difficult defecation was considered to be present if it was experienced with "most" or "every" bowel movement. Symptoms that occurred "on occasion" or "never" were considered to be absent. Incontinence of flatus was reported by 23.1% of cases vs 8.3% of control subjects (P = .006). Incontinence of liquid or solid stool was present in 4.7% and 3.5%, respectively, and was not reported by control subjects (P < .001 and .009, respectively). Difficult defecation, which was characterized by pushing on the vaginal walls to complete defecation, was present in 19.7% vs 4.4% of control subjects (P = .001). Cases that reported symptoms were compared with those that did not report symptoms. Among those reporting difficult defecation, the length of the perineal body length was greater when straining (4.0 vs 3.4 cm; P = .020). Among those reporting incontinence of flatus, mean parity was higher (3.3 vs 2.5; P = .012), and a positive standing cough stress test was more likely (39.3% vs 18.5%; P = .025). Symptoms of anal incontinence and/or difficult defecation were present in 35.3% of subjects (52/147). Women with prolapse are more likely than control subjects to have symptoms of anal incontinence or difficult defecation; approximately one-third of these women will have symptoms.

Comparison of Levator Ani Muscle Defects and Function in Women with and Without Pelvic Organ Prolapse

The levator ani muscles are critical for providing upward support to the pelvic organs and minimizing the load on the connective tissue that attaches these organs to the pelvis. When the muscles fail, pelvic organ prolapse may ensue, making surgery necessary. Vaginal birth substantially increases the risk of prolapse in occurring in parous women, but it is not clear whether levator ani defects lead to prolapse later in life. The possibility that this may be the case has lent support to cesarean delivery on request. This case-control study compared the structure and function of the levator ani muscle in 151 women with prolapse and 135 control subjects matched for age, race, and hysterectomy status. Case patients had prolapse of a vaginal wall, a hysterectomy scar, or the cervix extending at least 1 cm above the hymen during a Valsalva maneuver. MR imaging served to identify major defects with more than half the levator ani missing, and minor defects with less than half the muscle missing. An instrumented vaginal speculum was used to quantify vaginal closure force at rest and during maximum pelvic muscle contraction. The incidence of major levator ani defects was 55% in cases and 16% in controls, for an adjusted odds ratio (OR) of 7.3 (95% confidence interval [CI], 3.9-13.6). Women in the two groups were, however, about equally likely to have minor defects. Incidence rates of major defects were 53% for women reporting having had a forceps delivery and 28% for the others (adjusted OR, 3.4; 95% CI, 1.95-5.78). Women with prolapse had lower estimates of vaginal closure force during pelvic muscle contraction than did control subjects (2.0 versus 3.2 Newtons). Women with levator ani defects generated less force than those lacking defects (2.0 versus 3.1 Newtons). The genital hiatus was 50% longer in case women than in controls (4.7 versus 3.1 cm). In both the case and control groups, women without levator ani defects had higher maximal contraction force estimates than those with defects. This case-control study showed that women having pelvic organ prolapse more often have defective levator ani muscles than control women, and generate less vaginal closure force during maximal muscle contraction.