What is Post Hysterectomy Syndrome?
Hysterectomy, after which post-hysterectomy syndrome (ASG) often develops, is a very common operation. Every 5th woman suffers a hysterectomy, there is no tendency to decrease the frequency of hysterectomy. A hysterectomy can adversely affect a woman’s quality of life and health, and the resulting ASH can reduce her ability to work. The average age of the operated patients is 40.5-42.7 years. CBC includes neuro-vegetative, psycho-emotional and metabolic-endocrine disorders as a result of hypoestrogenism due to impaired blood supply, innervation and function of the ovaries (ovary) after hysterectomy. The frequency of loss of ovarian function as a leading trigger moment of ASG varies from 20 to 80% and depends on the patient’s age, premorbid background, concomitant pathology, volume of operation, and features of blood supply to the ovaries.
Pathogenesis during Post Hysterectomy Syndrome
The starting point in the formation of ASG is a violation of the microcirculation of the ovaries and acute ischemia due to the exclusion of the branches of the uterine arteries from their blood supply. Within a month or more after the operation, the architectonics of the intraorgan vessels of the ovaries changes, intraovarial blood flow suffers. Venous congestion and lymphostasis, more pronounced in the stroma, increase in the ovaries, which leads to a change in the structure and an increase in the volume of the ovaries. As a result, steroidogenesis changes with a decrease in the level of E2. Ovarian volume is restored to normal after 1 to 3 months from the time of surgery, but the structure of the ovaries and the hormonal profile indicate the predominance of anovulatory cycles. Ovarian ischemia accelerates degenerative and atrophic processes, leads to the extinction of ovulatory and hormone-producing functions. In patients after hysterectomy with preservation of the uterine appendages, menopause with loss of cyclic function of the ovaries occurs on average 4-5 years earlier than in non-operated patients.
The frequency of ASG is influenced by the age of the patient, the volume and duration of the operation, especially the blood supply to the ovaries. Three types of regional blood supply to the ovary are known: with a predominance of the uterine artery branch (38%), the ovarian artery (11%) and with uniform blood supply to these two branches (51%). Depending on the type of blood supply, a hysterectomy can provoke catastrophic changes in the morphology and function of the ovary or not cause changes at all.
After hysterectomy, regional blood flow disorders are more significant and persistent, and the incidence of ASH is 1.7 times higher than after supravaginal amputation of the uterus. Removal of one ovary during a hysterectomy leads to an increase in the frequency of ASG by 2.3 times compared with the operated ones, which saved both ovaries. Performing an operation in the luteal phase of the cycle leads to the greatest violations of the blood supply and ovarian function, as a result of which severe neurovegetative and psychoemotional disorders develop 2 times more often. ASH is more often detected in patients with diabetes mellitus, thyrotoxic goiter compared with somatically healthy women.
When performing an operation in the age range of 41-55 years, ASH occurs most often and is more persistent, hysterectomy in reproductive age less often causes ASG, which is more often transient.
Starting and pathogenetically leading factor in ASH is hypoestrogenism. Against this background, the biosynthesis of peyrotransmitters decreases in the central nervous system, and as a result, neurovegetative functions, emotional and behavioral reactions change, cardiovascular, respiratory, and temperature reactions to external influences are distorted.
Symptoms of Post-Hysterectomy Syndrome
The clinical picture of ASG is formed by two main symptom complexes – vegetoneurotic and psychoemotional disorders.
Psychoemotional manifestations are observed in 44% of patients in the form of asthenic depression with characteristic complaints of severe fatigue, decreased performance, lethargy, severe weakness, and tearfulness. 25% of patients have anxiety with an unmotivated fear of sudden death. The cessation of menstrual and reproductive functions in reproductive age is often perceived as a loss of femininity; there is a feeling of fear, fear of family breakdown, an idea of one’s own sexual inferiority.
Vegetoneurotic manifestations occur in 30-35% of patients who complain of poor high temperature tolerance, heart attacks, chills, chills, numbness and crawling, flushing, sleep disturbance, vestibulopathy, excessive sweating, tendency to swelling, transient hypertension .
According to the time of occurrence, early and late ASG are distinguished. The early manifestations of ASG in the form of psychoemotional and vegetoneurotic manifestations begin from the 1st day of the postoperative period and significantly complicate the recovery period after surgery. ASG, which developed after 1 month – 1 year after surgery, is considered late.
According to the clinical course, transient and persistent P G C are distinguished. Transient ASG is characterized by the restoration of ovarian function within 1 month – 1 year, which occurs in 80% of patients 37-47 years old. In 20% of patients there is persistent ASG with hypoestrogenism for 1 year or more from the moment of surgery, indicating the extinction of ovarian function with the onset of premature menopause, potentiated by surgical intervention. The age of patients with persistent ASD ranges from 46 to 52 years.
Later, psychoemotional and neurovegetative manifestations with persistent ASH or accelerated onset of menopause can result in metabolic-endocrine and urogenital disorders, especially in those operated on in premenopause, which are also caused by estrogen deficiency.
Hysterectomy is a risk factor for cardiovascular disease, the frequency of which increases by 2-3 times. After the operation, atherogenic changes in the blood are observed: total cholesterol (11%), low-density lipoproteins (19%) significantly increase. In addition to hypoestrogenism, the state of the cardiovascular system is affected by a reduced level of prostacyclins secreted by the uterus, which are vasodilating, hypotensive agents, endogenous inhibitors of platelet aggregation.
After hysterectomy, urogenital disorders (dyspareunia, dysuric phenomena, colpitis, prolapse) often occur due to hypoestrogenic metabolic trophic changes in the tissues and disturbances in the architectonics of the pelvic floor.
A hysterectomy enhances osteoporosis, the average annual loss of bone mineral density is higher than in unoperated and with natural menopause. Without hormone replacement therapy after a hysterectomy, osteoporosis is diagnosed 25-30% more often than in non-operated patients.
Diagnosis of Post-Hysterectomy Syndrome
The severity of psychoemotional and vegetoneurotic manifestations in patients undergoing a hysterectomy is evaluated by the Kupperman menopausal index in the modification of E.V. Uvarova. Light, medium and heavy ASG are distinguished.
The determination of the levels of E2, FSH, and LH, which allows us to establish the functional activity of the ovaries and the degree of changes in the hypothalamic-pituitary system, is of prognostic value for CBC. Estradiol levels may decline to post-mepopausal levels. ASG is also accompanied by an increase in FSH and LH levels. High levels of FSH and LH, comparable with postmenopausal, reflect persistent dying of ovarian function.
A valuable method for diagnosing ovarian function is ultrasound with dynamic dopplerography. With the help of ultrasound it is possible to evaluate the features of intraovarial blood flow and structural reconstruction of the ovaries. Changes are most pronounced within 1 month after surgery with a “shock” ovary. Ovarian volume increases 1.5 times as a result of cystic transformation or the appearance of persistent cysts. Doppler sonography of the intraorgan ovarian vessels indicates a decrease in peak systolic blood flow velocity and an increase in venous stasis.
In patients with ASD in the late postoperative period, the ovarian volume corresponds to the age norm or tends to decrease. Ovarian stroma becomes homogeneous, with medium sound conduction, the follicular apparatus is not expressed, quantitative indicators of intra-ovarian blood circulation are approaching postmenopausal: the blood flow velocity in the parenchyma vessels decreases, the resistance index and pulsation increase to 0.6-0.9 and 0.9-1.85 respectively, indicating a decrease in ovarian perfusion.
Treatment of Post-Hysterectomy Syndrome
Treatment of ASG depends on its severity. Psychoemotional manifestations can be significantly weakened during psychological preparation for surgery. In patients with mild to moderate transient ASH in the postoperative period, it is advisable to prescribe physiotherapy to improve microcirculation of the pelvic organs; recommend galvanization of the cervical-facial region, electrophoresis of calcium and aminophylline to the collar zone, transcranial electrical stimulation by a sedative technique.
For mild and moderate ASD, sedatives (valerian, motherwort, novopassit, etc.), tranquilizers (phenazepam, relanium, lorazepam, etc.) and antidepressants (coaxil, aurorix, prozac, amitriptyline) are used, which are effective in the predominance of psychoemotional symptoms.
For the treatment of ASG, homeopathic medicines can be used: climactoplan, climadinone, etc.
In persistent and severe ASG, treatment with neurotropic drugs is advisable to combine with hormone replacement therapy (HRT), which in these cases is pathogenetically substantiated.
HRT quickly stops both psychoemotional and vegeto-vascular manifestations of ASG.
The drug of choice for HRT in the early postoperative period is gynodian-depot (4 mg of estradiol valerate + 2 mg of dihydroepiandrosterone). A single parenteral administration on the 2-4th day after the operation creates a high concentration of estradiol and stops ASG in all cases. It is important that the gynodian depot does not contain a progestogen component that would increase the risk of postoperative thrombotic complications. In addition, the combination of estrogens with androgens has an antidepressant and psychostimulating effect.
In the early postoperative period, conjugated estrogens (Premarin at a dose of 0.625), estrogen-containing patches (estraderm and climar) can be used.
In the late postoperative period, the use of any combined HRT preparations, as well as estrogen monotherapy, is possible. For the treatment of ASG, climen, climonorm, divina, femoston, cliogest, trisequens, cycloproginova, estrofem are used (1 tablet 1 time per day in accordance with the calendar package). Ginodian-Depot is administered intramuscularly in a dose of 1 ml every 4 weeks. Estraderm, menopause appoint 1 patch per week in accordance with the attached instructions.
The duration of HRT with a transient form of ASG is 3-6 months. In addition to stopping ASG, HRT aims to normalize the hypothalamic-pituitary-ovarian relationships during the rehabilitation period after surgery. After stopping ASG and canceling HRT in patients of reproductive age, ovarian steroid activity is restored. With persistent ASG, which passes into menopause, it is advisable to use HRT drugs for a longer time (1-5 years).
A prerequisite for long-term use of HRT drugs is the prevention of thrombotic complications: control of hemostasiogram with determination of blood coagulation time, plasma fibrinogen, prothrombin index and APTT; prophylactic administration of antiplatelet agents and venoprotectors (aspirin, chimes, anavenol, venoruton, eskusan, detralex, etc.). Before the appointment of HRT and during treatment, monitoring of the state of the mammary glands is necessary: a mammogram is performed once every 2 years, an ultrasound of the mammary glands and a palpation examination are performed every 6 months.