Long term effects of hysterectomy on mortality: nested cohort study
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.38483.669178.8F (Published 23 June 2005) Cite this as: BMJ 2005;330:1482All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
We thank Dr Grant for her continued interest in the Royal College of
General Practitioners’ (RCGP) Oral Contraception Study. We were unable to
adjust our results for hormone replacement therapy (HRT) because this
information was not available once women left general practitioner follow-
up (1). More deaths would have expected in our control group if combined
HRT is materially more harmful than unopposed HRT, if hysterectomy has no
effect on mortality and if an equal proportion of women in each comparison
group used HRT (albeit of different composition). We have previously
shown that women in the RCGP study who have a hysterectomy are much more
likely to use HRT than those who do not have this operation (the age
adjusted prevalence of ever use being 35.5% and 16.1% respectively by
December 1990)(2). Furthermore, in this cohort, many of those who had a
hysterectomy (41.4%) received at least one prescription for combined
therapy after their operation, and many of those who did not have the
operation (31.4%) were given unopposed oestrogen at some point in time.
Given that most women use HRT for relatively short durations (3), and
given that the breast cancer effects associated with HRT use are seen in
current or recent users (3), we believe that our results have not been
seriously affected by confounding from HRT use, although such effects can
never be discounted in an observation study. If it has occurred, it is
likely to have obscured a beneficial effect of hysterectomy on mortality,
rather than a harmful effect.
We cannot readily explain the lower risk of death observed among ever
users of oral contraceptives who were older when they had a hysterectomy.
In our previous paper ever users of oral contraceptives were more likely
to use HRT but mainly in those who did not have a hysterectomy (2). We do
not believe, therefore, that the result observed in our study was due to
confounding from HRT use. As the RCGP cohort has aged, the excess risk of
death from circulatory disease among ever users of oral contraceptives has
declined - to 1.2 (95% confidence interval, 1.0 to 1.5) in 1999 (4). This
is probably because the proportion of ever use relating to current use has
decreased substantially (the cardiovascular risks associated with oral
contraception being confined to current users, particularly those with
other risk factors such as smoking and raised blood pressure).
References
1. Iversen L, Hannaford PC, Elliott, AM, Lee AJ. Long term effects
of hysterectomy on mortality: nested cohort study. BMJ 2005; 330:1482-5.
2. Moorhead T, Hannaford P, Warskyj M. Prevalence and
characteristics associated with use of hormone replacement therapy in
Britain. Br J of Obstet Gynaecol 1997; 104, 290-7.
3. Collaborative Group on Hormonal Factors in Breast Cancer. Breast
cancer and hormone replacement therapy: collaborative reanalysis of data
from 51 epidemiological studies of 52,705 women with breast cancer and
108,411 women without breast cancer. Lancet 1997; 350, 1047-59.
4. Beral V, Hermon C, Kay CR, Hannaford P, Darby S, Reeves G.
Mortality associated with oral contraceptive use: 25 year follow up of
cohort of 46,000 women from Royal College of General Practitioners' oral
contraception study. BMJ 1999; 318, 96-100.
Competing interests:
None declared
Competing interests: No competing interests
Iversen and colleagues claim hysterectomy does not increase mortality
but they failed to record hormone replacement therapy (HRT) use during the
last 20 years when deaths were being flagged.1 Women with a mean age of
43 who have a hysterectomy are likely to take oestrogens but women with an
intact uterus usually take combined HRT. As progestogens cause more breast
cancer, vascular disease and depression than oestrogens, more HRT deaths
would be expected in controls if hysterectomy had no effect on mortality.
Breast cancer has been the commonest fatal cancer in the in the Royal
College of General Practitioners’ (RCGP) oral contraception study and
cancer has been the commonest cause of death. In The Million Women Study
53% of women had used HRT.2 Current use gave a 22% increased risk of fatal
breast cancer. 14% of women currently used oestrogens and 17% used
combined HRT. The relative risks of incident invasive breast cancer were
1.30 and 2.0, respectively. Combined HRT and combined oral
contraceptives are both predominantly progestogenic in effect. Longer use
either progestogens or oestrogens increases the risks of breast cancer.
Since 1962 increases in breast cancer incidences have matched increases in
contraceptive and menopausal hormone use.3,4
Over 60 conditions were increased among oral contraceptive users
compared with never users in the RCGP trial including breast and cervical
cancer, venous thrombosis, strokes, hypertension, cerebrovascular
accidents, heart disease and also depression and attempted suicide.5 In
1981 the mortality risk from all circulatory diseases in ever-users was
4.2. Therefore, the study’s finding of a lower risk of death among ever-
users of oral contraceptives, who had hysterectomies when they were older,
is probably due to confounding by HRT use.
Failure to record all hormone use during the last 20 years prevents
realistic conclusions about mortality being made in the RCGP study.
1 Iversen L, Hannaford PC, Elliot AE, Lee AJ. Long term effects of
hysterectomy on mortality: nested cohort study. BMJ,
doi:10.1136/bmj.38483.669178.8F
(published 1 June 2005)
2 Million Women Study Collaborators. Breast cancer and hormone-
replacement therapy in the Million Women Study. Lancet 2003; 362 429-26..
3 Grant ECG. Increases in breast cancer incidence
http://bmj.com/cgi/eletters/328/7445/921#55298, 1 Apr 2004
4 Grant ECG. Re: Rapid Responses; Authors' reply.
http://bmj.com/cgi/eletters/328/7445/921#55843, 6 Apr 2004
5 Galbraith J I. A methodological review of the Royal College of
General Practitioners’ Oral Contraception Study. J Nutr Environ Med 2005;
8: 187 -194.
Competing interests:
None declared
Competing interests: No competing interests
No mortality associated with hysterectomy
Minimally invasive types of hysterectomy evolved to become the only major abdominal surgical operations not associated with intra-operative or medium post-operative term mortality.
In fact, in certain age groups, even reduced mortality trends are evidenced. [1]
Various available hysterectomy techniques compete for operative times, length of hospitalization, hospital costs, blood transfusions, antibiotic use, antinociceptive medications, etc.[2]
Hysterectomies are better, faster, cheaper, preferred by women, definitive therapeutic interventions, compared to other available alternatives for benign conditions. [3][4][5][6][8][9][11]
Hysterectomies even increase sexual function and sexual pleasure. [7][10]
Gynaecologists lead the way in fast, minimally invasive, scarless, NOTES addominal surgical techniques.
References
[1] http://www.bmj.com/content/330/7506/1482
[2] https://www.ncbi.nlm.nih.gov/pubmed/27523922
[3] http://www.bmj.com/rapid-response/2011/11/03/hysterectomies-save-even-mo...
[4] http://www.bmj.com/rapid-response/2011/11/03/do-we-mention-women-prefer-...
[5] http://www.bmj.com/content/344/bmj.e2564/rr/584268
[6] http://www.bmj.com/rapid-response/2011/11/03/mirena-disadvantages-omitted
[7] http://www.bmj.com/content/327/7418/774
[8] http://www.bmj.com/content/330/7506/1457
[9] http://www.bmj.com/content/328/7442/730.5
[10] http://www.bmj.com/content/327/7418/0.2
[11] BMJ 2010;341:c3929
http://www.bmj.com/content/341/bmj.c3929
Competing interests: No competing interests