9 July, 2012:

In a recent study by Gibson and colleagues, depression and anxiety symptoms were assessed in 1970 women followed up annually since premenopause for up to 10 years in a sub-study of the SWAN (Study of Women's Health Across the Nation) cohort, with the objective of examining whether mood symptoms were influenced negatively by hysterectomy, with or without bilateral oophorectomy, relative to natural menopause [1]. Women were recruited in a community-based setting, which is one of SWAN's specifications together with its multiethnic commitment [2]. They were 42–52 years of age, premenopausal, had an intact uterus and at least one ovary at baseline, as well as one or more menstrual cycles in the 3 months before. Symptoms were measured with the 'Center for Epidemiological Studies Depression Index' along with the evaluation of four anxiety items. In line with multivariate analyses, piece-wise hierarchical growth models were used to relate natural menopause, hysterectomy with ovarian conservation, and hysterectomy with bilateral oophorectomy to trajectories of mood symptoms before and after the final menstrual period or surgery.

Around 90% of the women reached natural menopause by the tenth annual visit, whereas 5.2% (n = 101) reported hysterectomy with bilateral oophorectomy and 3.9% (n = 76) hysterectomy with ovarian conservation. Depressive symptoms declined before the final menstrual period or surgery (regardless of whether the ovaries were conserved) and continued to decline afterwards. There was no significant difference in the mean rate of change in depressive symptoms relative to natural menopause. Both depressive and anxiety symptoms generally improved over the course of the menopausal transition for all women.

Hormone therapy (HT) was concurrently associated with lower levels of depressive and anxiety symptoms, while antidepressant use increased anxiety scores. HT was used at some point of the study by the majority of participants and was particularly common among women with hysterectomy and oophorectomy; but exclusion of HT users, as stated by the authors, did not affect the trajectories of changes in depressive or anxiety symptoms.

Comment

The onset of depression in the perimenopause, as well as the association between negative mood and hysterectomy (with or without oophorectomy), has been inconclusively evaluated in a diversity of epidemiological, observational and clinic-based studies [3-5]. The majority of women do not become depressed during the menopausal transition. In some women, however, depression symptoms commence in perimenopause and can successfully be treated with HT. Cross-sectional studies, suggesting that hysterectomized women, regardless of oophorectomy status, are more distressed than age-matched peers with an intact uterus, are opposed by others as the here-discussed community-based study, showing that mood symptoms improve for all women and there is no difference when comparing natural menopause with hysterectomy or hysterectomy plus oophorectomy. In fact, one major factor related to surgery and its eventual effect on mood is the physical and possibly sexual improvement after an indicated and well-performed hysterectomy; this is better seen in clinic-based studies.

Though this study has the strength of a longitudinal follow-up through the menopausal transition, there are limitations, partially pointed to by the authors and mainly referring to the difference between the selection of this study's sample and the general population. But attention should be paid to other potentially limiting factors: the absolute number of women operated on was small (see above), and the use of the beneficial HT was highest in the group of women reporting hysterectomy with bilateral oophorectomy (n = 80, 79%), and still significantly higher in the group of women reporting hysterectomy with ovarian conservation (n = 37, 49%) than in women with natural menopause (n = 430, 24%), p < 0.001. Also, the duration of HT use was significantly higher in the hysterectomy plus oophorectomy group (3.48 ± 2.97 SD years) than in the hysterectomy group (1.22 ± 1.76 SD years) and than in the natural menopause group (0.72 ± 1.58 SD years),p < 0.001. The variability of mood and anxiety symptoms requires larger numbers of patients for pertinent analyses, even though adjustment for HT use was attempted at the best.

To look at mood, menopause and hysterectomy in a population, community and clinic bases provide quite different views on the same topics. More than one-third of women in the United States have had a hysterectomy, a very common surgery, by the age of 60 years [6], but hysterectomy appears to be an infrequent event when evaluated in reportedly representative communities. This insight will most likely not change decision-making in the clinical setting: whether to accomplish a hysterectomy, with or without oophorectomy, will in the end depend on the appropriate indication for improving physical and mental health.

Ewald Boschitsch
Head of the KLIMAX Menopause Clinic, Vienna, Austria

References

1. Gibson CJ, Joffe H, Bromberger JT, et al. Mood symptoms after natural menopause and hysterectomy with and without bilateral oophorectomy among women in midlife. Obstet Gynecol 2012;119:935-41.

http://www.ncbi.nlm.nih.gov/pubmed/22525904 

2. Sowers MF, Crawford SL, Sternfeld B, et al. SWAN: a multicenter, multiethnic, community-based cohort study of women and the menopausal transition. Menopause: Biology and Pathology. New York: Academic Press, 2000:175–80

3. Harsh V, Meltzer-Brody S, Rubinow DR, Schmidt PJ. Reproductive aging, sex steroids, and mood disorders. Harv Rev Psychiatry 2009;17:87-102.

http://www.ncbi.nlm.nih.gov/pubmed/19373618 

4. Parker WH. Bilateral oophorectomy versus ovarian conservation: effects on long-term women's health. J Minim Invasive Gynecol 2010;17:161–6.

http://www.ncbi.nlm.nih.gov/pubmed/20226402 

5. Ceausu I, Shakir YA, Lidfeldt J, Samsioe G, Nerbrand C. The hysterectomized woman. Is she special? The Women's Health in the Lund Area (WHILA) study. Maturitas 2006;53:201–9.

http://www.ncbi.nlm.nih.gov/pubmed/16368473 

6. Keshavarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance. United States 1994–1999. MMWR CDC Surveill Summ 2002;51:1–8

Content updated 9 July 2012