Abstract and Introduction
Abstract
Objective. This study aims to estimate the effects of bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy and estrogen therapy on vaginal prolapse.
Methods. A retrospective analysis of the Women's Health Initiative estrogen-alone trial was performed. Women who retained their ovaries were compared with women who had BSO at the time of hysterectomy for the presence of cystocele or rectocele at entry into the study. Based on BSO and hormone therapy (HT) status, participants were categorized into groups. We hypothesized that BSO and prolonged hypoestrogenemia may be associated with an increased risk of prolapse. Univariate and multivariate analyses were used to determine the effects of BSO and HT status on cystocele and rectocele.
Results. Of 10,739 participants in the estrogen-alone trial, 8,879 women were included in the analysis. Older age, higher parity, higher body mass index, higher waist-to-hip ratio, and non–African-American race/ethnicity were associated with increased odds of developing cystocele or rectocele. Women who retained their ovaries had higher rates of cystocele or rectocele at screening (39%) compared with all women who had BSO (31-36%; odds ratio, 1.18; 95% CI, 1.04-1.33). After controlling for multiple variables, our analysis showed that women who retained their ovaries had higher odds of developing cystocele or rectocele compared with women who had BSO and no subsequent HT (odds ratio, 1.23; 95% CI, 1.07-1.41). All other comparisons were nonsignificant.
Conclusions. BSO at the time of hysterectomy is not associated with increased risk of cystocele or rectocele. BSO and no subsequent HT may even have a protective effect against cystocele or rectocele.
Introduction
Pelvic organ prolapse (POP) affects up to 50% of women in the United States and varies widely among different ethnic populations around the world. Almost 300,000 surgical procedures for POP are performed annually in the United States alone at a cost of more than US$1 billion. According to the US National Center for Health Statistics, POP is one of the three most common reasons for hysterectomy. Despite the impact of this condition on women's health, the pathogenesis of POP is not well understood. Several factors have been identified as potential risk factors for POP, including age, parity, mode of delivery, race/ethnicity, body mass index (BMI), estrogen status, and history of hysterectomy.
The effects of hysterectomy and/or oophorectomy on risk of POP are the subject of ongoing controversy. Hendrix et al performed a secondary analysis of the Women's Health Initiative (WHI) Hormone Replacement Therapy clinical trial database to describe the prevalence of POP and its risk factors. Forty-one percent of women with intact uterus, compared with 38% of women who had undergone hysterectomy, had some form of prolapse.
Bilateral salpingo-oophorectomy (BSO) is commonly performed at the time of hysterectomy for benign conditions to reduce the risk of subsequent ovarian cancer. According to Centers for Disease Control and Prevention data, the prevalence of concurrent BSO in women undergoing hysterectomy for benign conditions is 50% for women aged between 40 and 44 years and 78% for women aged between 45 and 64 years. Previous analyses of WHI data showed that 41% of participants had hysterectomy and approximately half of them had undergone BSO. Removal or preservation of the ovaries at the time of hysterectomy for benign conditions remains controversial. Proponents of BSO have argued for a 96% reduction in the risk of ovarian cancer and a 25% reduction in the risk of breast cancer. Opponents have emphasized observational data showing increased risks of cardiovascular disease, all-cause mortality, and lung cancer, as well as detrimental effects on bone density and possibly sexual function. Oophorectomy before menopause ("surgical menopause") leads to an abrupt reduction in estrogen and androgen levels. Menopause and the hypoestrogenic state have been suggested as risk factors for POP. Therefore, the aim of this study is to determine the association between BSO at the time of hysterectomy and hormone therapy (HT) and cystocele or rectocele in postmenopausal women participating in the WHI clinical trial. We used the estrogen-alone trial because it included only postmenopausal women who had hysterectomy, before and after menopause, with or without BSO.