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Data from the Nurses’ Health Study show that early hysterectomy, especially with oophorectomy, significantly increases cardiovascular risk in young women.

Younger women who undergo hysterectomy with or without oophorectomy face a significantly elevated risk for cardiovascular disease (CVD), according to findings from a pooled analysis of the Nurses’ Health Study (NHS) and Nurses’ Health Study II (NHS II).

“The greatest increase in risk was observed in hysterectomy with bilateral oophorectomy cases without any use of estrogen, wherein elevated rates of CVD were noted in all age ranges except those who were older than age 60 years at time of surgery,” researchers wrote in Obstetrics & Gynecology.

“It is particularly notable that our primary and secondary outcomes were serious cardiovascular consequences of heart attack, revascularization and stroke,” Viengneesee Thao, PhD, MS, and colleagues added.

 A Common Procedure

 Hysterectomy is among the most common surgical procedures performed on women, with estimates ranging from 500,000 to 700,000 cases annually in the United States. Bilateral oophorectomy at the time of hysterectomy has been linked with increased CVD risk, but the effects of hysterectomy alone on CVD risk have been underexplored.

The research team examined data from the 239,907 participants in the NHS and NHS II longitudinal studies to investigate the long-term risk for CVD after hysterectomy with and without bilateral oophorectomy, stratified by age and hormone therapy use. They accessed hysterectomy status and age at surgery from the biennial self-reported questionnaires participants provided between 1976 and 2017, and they obtained cause-of-death data from the National Death Index.

The analysis controlled for menopausal hormone therapy, marital status, income, race, BMI, alcohol use, physical activity, diet, parity, and personal and family history of hypertension, diabetes, myocardial infarction, and stroke.

Increased CVD Risk in Younger Women

 The pooled data from NHS and NHS II participants showed that women who underwent hysterectomy before age 50 were at significantly increased risk for CVD compared with women who did not undergo surgery.

• Women who had a hysterectomy before age 46 and did not use estrogen therapy had a 21.0% increased risk for CVD compared with women who did not undergo surgery (adjusted hazard ratio [aHR], 1.21; 95% CI, 1.04-1.40).
• Among estrogen users, women who underwent hysterectomy with bilateral oophorectomy before age 46 had a 26% increased risk (aHR, 1.26; 95% CI, 1.16-1.37), and those aged 46 to 50 had an 11% increased risk (aHR, 1.11; 95% CI, 1.01-1.22), compared with women who did not undergo surgery.
• Among women who did not use estrogen in the NHS II cohort, the risk for CVD was more than doubled for those who had hysterectomy with bilateral oophorectomy before age 51 years (younger than 46 years: aHR, 2.77; 95% CI, 1.56-4.95; age 46-50 years: aHR, 2.39; 95% CI, 1.65-3.46).

Strengths and Limitations    

 Strengths of the study included access to long-term follow-up data from many geographically diverse participants, according to the researchers. This enabled them to account for important confounding factors such as menopausal hormone therapy use and baseline CVD risk factors.

They acknowledged limitations as well, such as that most participants were educated and health-literate White women, potentially limiting the generalizability of the findings. Also, hormone therapy timing and dosages were not captured in detail, and reasons for undergoing hysterectomy were unavailable. Finally, patients in the NHS II study were younger with relatively shorter follow-up, so CVD outcomes may not yet have occurred.

Important Information for Decision-Making

 The findings may help clinicians counsel patients and plan for surgery, according to the researchers.

“Armed with this information, individualized treatment plans can be created that take into account each patient’s unique characteristics and goals—whether that includes avoiding or delaying hysterectomy and oophorectomy or proceeding with these surgeries but making alterations in other modifiable cardiovascular risk factors or screenings,” Dr. Thao and colleagues wrote.