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R o s a n a O u ra e s S im o e s , E d m u n d C h a d a B a ra c a t, V e ra L u c ia S z je n fe ld , G e ra ld o R o d rig u e s d e L im a , W a g n e r J o s e G o n 9 a lv e s , C la u d ia d e C a rv a lh o R a m o s B o rto le tto
E f f e c ts o f s im p le h y s te r e c to m y o n b o n e lo s s
Department
of Gynecology
and Obstetrics and
Department of Medicine of Escola Paulista de Medicina,
sao Paulo - Sp, Brasil
L u m b a r sp in ~ a n d p ro xim a l fe m o ra l b o n e d e n sitie s o f C a u ca sia n w o m e n , a g e d 3 5 -4 5 , w e re m e a su re d b y d u a l p h o to n d e n sito m e try m o d e l D P X . T h e m e a su re m e n t site s w e re a sse sse d a t th e lu m b a r sp in e (ve rte b ra e L 2 to L 4 ) a n d a t th e p ro xim a l fe m u r (tro ch a n te r, fe m o ra l n e ck a n d W a rd 's tria n g le ). A fte r e xclu sio n o f w o m e n w ith clim a cte ric sym p to m s, ste rilize d p a tie n ts o r th o se w ith m e n o p a u sa l co n ce n tra tio n s o f g o n a d o tro p h in s, th e stu d y in clu d e d 2 2 su b je cts: 1 1 m e n stru a n t (co n tro l g ro u p ) a n d 1 1 h yste re cto m ize d . T h e h yste -re cto m ie s w e -re w ith o u t o o p h o -re cto m y a n d h a d b e e n p e rfo rm e d d u rin g th e p -re vio u s five ye a rs. T h e b o n e d e n sitie s o f th e h yste -re cto m ize d w o m e n w e re lo w e r th a n th o se o f th e n o rm a l o n e s, b u t sig n ifica n tly lo w e r a t th e W a rd 's tria n g le .
U N IT E R M S : P re m e n o p a u sa l h yste re cto m y. P o stm e n o p a u sa l o ste o p o ro sis. P h o to n a b so rp tio m e try.
IN T R O D U C T IO N
T
h e e f f e c t sc o n t r o v e r s i a lo f h y s t e r e c t o m ys u b j e c t a n d o n t h e o v a r i e sh a s r e c e i v e d i s s t i l l as p e c i a l a t t e n t i o n f r o m g y n e c o l o g i s t s . 'f h e r e a r e m a n ys t u d i e s a b o u t t h e e n d o c r i n e a c t i v i t y o f t h e o v a r i e s a f t e r h y s t e r e c t o m y ( 1 3 ) .
T h e r e l a t i o n s h i p b e t w e e n o v a r i a n i n s u f f i c i e n c y a n d
o s t e o p o r o s i s w a s f i r s t n o t i c e d b y A L B R I G H T e t a l . ( I).
S i n c e t h e n , t h e o c c a s i o n a l c a u s a l r e l a t i o n s h i p b e t w e e n
o v a r i a n i n s u f f i c i e n c y a n d o s t e o p o r o s i s h a s b e e n d i s c u s s e d .
I n a n a t t e m p t t o p r e v e n t o s t e o p o r o s i s , t h e r e a r e s e v e r a l s t u d i e s w h i c h t r y t o d e t e c t o t h e r r i s k f a c t o r s ,
i n c l u d i n g s i m p l e h y s t e r e c t o m y ( 1 5 ) .
A d d re s s fo r c o rre s p o n d e n c e :
R o s a n a D u ra e s S im o e s
R u a D o m J o s e A n to n io d o s R e is , 8 6 S a o P a u lo /S P - B ra s il - C E P 0 4 6 7 2 -0 3 0
T h i s p a p e r c o n t a i n s t h e a n a l y s i s o f t h e b o n e m a s s o f
w o m e n w i t h o u t c l i m a c t e r i c s y m p t o m s o r e l e v a t e d l e v e l s
o f s e r i c g o n a d o t r o p i n s , w i t h a g e s v a r y i n g f r o m 3 5 t o 4 5
y e a r s , w h o p r e v i o u s l y u n d e r w e n t h y s t e r e c t o m y , a n d d i d
n o t h a v e a n y c u r r e n t l y - k n o w n r i s k f a c t o r s f o r t h e
d e v e l o p m e n t o f o s t e o p o r o s i s .
C A S E S .A N D M E T H O D O L O G Y
A t o t a l o f 2 2 w o m e n w e r e s t u d i e d b y t h e D e p a r t m e n t o f G y n e c o l o g y a t E s c o l a P a u l i t a d e M e d i c i n a b e t w e e n
t h e y e a r s 1 9 8 5 a n d 1 9 9 0 . T h e y w e r e d i v i d e d i n t o g r o u p s I
a n d I I . T h e f i r s t g r o u p w a s c o m p o s e d o f p a t i e n t s w h o h a d
u n d e r g o n e s i m p l e h y s t e r e c t o m y , a n d i n t h e s e c o n d c o n t r o l g r o u p w e r e t h o s e w i t h i n t a c t u t e r i . I n o r d e r t o m a k e b o t h
g r o u p s a s h o m o g e n e o u s a s p o s s i b l e , w e i n c l u d e d o n l y
C a u c a s i a n w o m e n a n d e x c l u d e d t h o s e w i t h a n y o f t h e f o l l o w i n g c h a r a c t e r i s t i c s : a b o d y - w e i g h t o v e r 9 0 k g ; t h e
p r e s e n c e o f e i t h e r c l i m a c t e r i c s y m p t o m s o r h i g h l e v e l s o f
seric gonadotropins
(compatible
with the climacteric
syndrome);
uni- or bilateral oophorectomy;
undue habits
such as heavy smoking
or alcoholism;
the use of drugs
such as corticosteroids,
antacids, anticonvulsants, diuretics,
or estrogen;
the presence
of either endocrine
disease
(mellitus diabetes, hyperthyroidism,
giucoc0l1icoid excess,
hyperprolactinemia)
or rheumatic diseases.
W omen
belonging
to. group I had been submitted
previously
to
a
simple
hysterectomy
(without
oophorectomy)
uterine myoma as the main characteristic.
Those belonging
to group II did not show the previously
mentioned
risk
factors
and, furthermore,
had taken
hormonal contraceptives
or undergone tubal sterilization.
Bone
density
was
measured
by
dual
X-ray
absorptiometry,
Lunar radiation model DPX, at the lumbar
spine (L2-L4) and at the proximal femur (femoral neck,
trochanter and W ard's triangle), with a level of precision
error around 2%.
Appropriate nonparametric
analyses, which included
analyses of variables according to Friedman's
and
Mann-W hitney tests, were performed
(5,14).
R E S U L T S
Table
I shows
the measurements
of individual
densities in both groups, on the lumbar spine (L2 and L4)
and on the proximal femur (femoral neck, W ard's triangle
and trochanter).
Analysis of the bone densities revealed a statistically
significant
reduction
at
the
W ard's
triangle
in
T A B L E I
C o m p a r i s o n o f l u m b a r s p i n e a n d p r o x i m a l f e m o r a l b o n e d e n s i t i e s b e t w e e n g r o u p s o f h y s t e r e c t o m i z e d s u b j e c t s w i t h o u t u t e r u s ( G r o u p I ) a n d w i t h i n t a c t u t e r u s ( G r o u p I I ) .
L U M B A R S P IN E F E M O R A L N E C K W A R D 'S T R IA N G L E T R O C H A N T E R
G R O U P I G R O U P II G R O U P I G R O U P II G R O U P I. G R O U P II G R O U P I G R O U P II
1 ,0 8 9 1 ,2 3 9 0 ,9 7 2 1 ,0 0 6 0 ,8 7 7 0 ,9 2 2 0 ,7 5 3 0 ,8 5 4
1 ,1 9 6 1 ,1 4 5 0 ,8 1 0 0 ,9 3 9 0 ,6 7 5 0 ,8 0 0 0 ,7 2 5 0 ,7 6 4
1 ,0 8 5 1 ,0 6 3 0 ,9 1 9 0 ,9 5 5 0 ,7 9 8 0 ,8 2 2 0 ,6 5 5 0 ,8 1 8
1 ,0 2 3 1 ,3 5 2 0 ,8 8 0 0 ,9 6 5 0 ,7 1 6 0 ,8 4 2 0 ,7 6 0 0 ,9 0 0
1 ,0 2 4 1 ,2 6 4 0 ,9 6 6 0 ,8 8 5 0 ,8 8 8 0 ,8 7 9 0 ,8 9 9 0 ,7 3 1
1 ,2 7 3 1 ,2 4 5 1 ,0 2 6 0 ,9 9 6 0 ,8 7 8 0 ,9 4 6 0 ,7 9 0 0 ,7 8 0
1 ,3 4 2 1 ,0 3 9 1 ,0 4 5 0 ,9 7 2 0 ,8 7 3 0 ,9 3 7 0 ,8 6 4 0 ,7 3 7
1 ,1 5 0 0 ,9 8 0 0 ,8 8 3 1 ,1 0 6 0 ,7 4 3 1 ,0 2 2 0 ,7 4 8 0 ,7 5 7
0 ,9 9 5 1 ,2 7 5 0 ,7 8 3 0 ,9 9 5 0 ,6 4 9 1 ,0 1 5 0 ,6 3 5 0 ,9 6 8
1 ,2 0 6 1 ,2 3 1 0 ,9 5 1 1 ,1 0 7 0 ,9 5 9 1 ,0 0 8 0 ,7 3 8 0 ,8 8 1
1 ,1 7 9 1 ,3 1 8 0 ,9 4 2 0 ,9 4 0 0 ,7 6 2 0 ,9 1 9 0 ,.8 1 3 0 ,8 3 2
X 1 ,1 4 2 1 ,1 9 5 0 ,9 2 3 0 ,9 8 8 0 ,8 0 2 0 ,9 1 9 0 ,7 6 2 0 ,8 2 0
X = A V E R A G E
F r ie d m a n 's T e s t: G r o u p I : X c a lc = 2 8 ,0 9 * G r o u p II: X c a lc = 2 7 ,3 3 *
M a n n - W h itn e y 's T e s t: ( g r o u p I x g r o u p II)
T R O C H A N T E R
U c a lc = 3 1 ,0 W A R D 'S T R IA N G L E
U c a lc = 2 1 ,0 * F E M O R A L N E C K
U c a lc = 3 3 ,5 L U M B A R S P IN E
U c a lc = 4 0 ,0
( g r o u p I < g r o u p II)
1 - T h e a v e r a g e v a lu e s o f lu m b a r s p in e a n d p r o x im a l fe m u r n e c k , W a r d 's tr ia n g le a n d tr o c h a n te r b o n e d e n s itie s o f
h y s te r e c to m iz e d w o m e n ( I) a n d c o n tr o l g r o u p ( II) .
S IM O E S , R .D .; B A R A C A T , E .C .; S Z J E N F E L D , V .L .; L IM A , G .A .; G O N Q A L V E S , w .J . & B O R T O L E T IO , C .C .R . - E ffe c ts o f s im p le h y s te r e c to m y o n b o n e lo s s
average value of bone density (g/cm2)
1.4
1.2
1.0
0.8
0.6
0.4
G R O U P I
G R O U P 1\
G R O U P I
G R O U P II
L2-L4
1.14
1.19
N EC K
0 . 9 2
0.98
W AR D 'S TR IAN G .
0.8
0.91
TR O C H AN TER
0 . 7 6
0.93
FIGURE 1 - The average values of lum bar spine and proxim al fem ur neck, W ard's triangle and trochanter bone densities of
hysterectom ized w om en (I) and control group (II).
h y s t e r e c t o m i z e d w o m e n i n c o m p a r i s o n w i t h t h o s e w h o s e
u t e r i w e r e i n t a c t . T h e i n f l u e n c e t h a t h y s t e r e c t o m y h a d o n
b o n e d e n s i t y i s i l l u s t r a t e d i n F i g u r e I. T h e r e w a s a s t a t i s t i c a l l y s i g n i f i c a n t r e d u c t i o n o f b o n e m a s s a t t h e
W a r d 's t r i a n g l e i n h y s t e r e c t o m i z e w o m e n i n c o m p a r i s o n
w i t h t h o s e w h o s e u t e r i w e r e i n t a c t .
D ISC U SSIO N
O u r s t u d y s h o w e d a l o w e r b o n e d e n s i t y i n t h e l u m b a r
s p i n e a n d p r o x i m a l f e m u r i n h y s t e r e c t o m i z e d w o m e n w h e n
c o m p a r e d t o w o m e n w i t h i n t a c t u t e r i . H o w e v e r , a
s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e w a s c o r r e l a t e d o n l y a t
t h e W a r d 's t r i a n g l e . H y s t e r e c t o m y c o u l d l e a d t o
h y p o e s t r o g e n i s m , u n d e t e c t e d b y s e r i c s a m p l i n g o f t h e
g o n a d o t r o p i n s , y e t s u f f i c i e n t e n o u g h t o l e a d t o b o n e l o s s .
B o n e m i n e r a l d e n s i t y o f t h e l u m b a r ; s p i n e a n d
p r o x i m a l f e m u r w e r e n o t c o m p a r e d , b e c a u s e t h e
m e a s u r e m e n t s o f t h e d e n s i t y o f a b o n e r l l a y n o t a l w a y s
p r e d i c t t h e b e h a v i o r o f o t h e r b o n e s i n t h e s a m e p a t i e n t s
a n d t h e s e a r e t h e s i t e s m o s t o f t e n a s s o c i a t e d w i t h
o s t e o p o r o s i s .
I d e n t i f i c a t i o n o f t h e p r e c i s e t i m e o f o v a r i a n f a i l u r e
c a n b e d i f f i c u l t i f h y s t e r e c t o m y h a s b e e n p e r f o r m e d .
O v a r i a n f a i l u r e i s a g r a d u a l p r o c e s s a s s o c i a t e d w i t h
f l u c t u a t i o n s i n s t e r o i d o g e n e s i s a n d , t h e r e f o r e ,
g o n a d o t r o p i n l e v e l s ( 1 3 ) .
Sao Paulo M edical Journal/R PM 113(6): 1012-1016, 1995 SIM O ES, R .D .; BAR AC AT, E.C .; SZJEN FELD , V.L.; LIM A, G .R .; G O N c;ALVES, w 'J. &
B i lateral oophorectom y is related to the acceleration
of bone loss, and already dem onstrated in radiological and
densitom etric studies (9).
T he possibility of hysterectom y as a risk factor for
the developm ent of osteoporosis w as taken into
consideration.
S ID D L E et al. (13), stated that one-third of
hysterectom ized w om en loose their ovarian function one
to tw o years after operation. R IE D D L E et al. (12),
estim ated rates of betw een 30 and 50% .
T otal or partial rem oval of the uterus in anim als
induces structural and functional alterations of the ovaries.
In 25 hysterectom ized w om en Z E C C H I D E S O U Z A et
al. (16) found, after ovarian biopsy, a strom al hyperplasia
of 87% , w ith no changes detected in serum estradiol and
estrone levels, thus confirm ing previous results from
C O R S O N et al. (4).
B lood circulation to the ovary m ay be supplied
entirely by the ovarian artery or (in extrem e cases) by the
uterine artery.
In
m ost cases, both arteries contribute tothe blood supply to the ovary, w ith their respective shares
varying considerably (12).
H ysterectom y could affect the blood supply to the
ovaries, or even of the uterus itself, through interaction
w ith ovarian function (7,8,12,13). U terine tissue
hom ogenates can produce prostaglandins: and uterine
venous drainage contains high prostaglandin m etabolite
levels. T he uterus is thus considered an endocrine organ.
In a series of 60 w om en w ho had undergone sim ple
hysterectom y w ithout oophorectom y, 28 w om en (47% of
the total) had norm al gonadotropins and estradiol
concentrations although they com plained of hot tlushes
(10). T hese flushes, how ever, did have a significantly
dim inished bone m ineral index (single photon
absorptiom etry of the radius). T hese data show that
although the m enopausal concentrations of gonadotropins
and estradiol w ere sim ilar to those in w om en of com parable
age w ith natural m enopause, a subtle reduction in
estrogenization is frequent.
H R E S H C H Y S H Y N et al. (6) using dual photon
absorptiom etry for density m easurem ents of the lum bar
spine and fem oral neck, observed that the bone densities
of 37 hysterectom ized w om en w ithout bilateral
oophorectom y w ere significantly low er than those of 60
m enstruant w om en.
In addition, som e epidem iological evidence suggests
that hysterectom y m ay also increase the risk of coronary
heart disease (3).
T he uterus m ay be a horm onal organ im portant in
the production of a prostaglandin identified as prostacyclin,
w hich is a potent vasodilator that also prevents platelet
aggregation (2,3).
P rostaglandins w ere the first substances to be
identified as possible local regulators of physiological and
pathological responses in the bone. P rostaglandin E 2 is
the principal product of arachidonic acid m etabolism in
the bone, and w as initially show n to be a potent stim ulator
of bone reabsorption. P rostaglandin I2 and prostaglandin
F 2 alpha have also been identified in bone-cell and organ
cultures and can affect bone reabsorption (2,8, I I ) .
In conclusion, one subgroup of hysterectom ized
w om en show ed low er bone densities only at the W ard's
triangle w hen com pared to w om en w ith intact uterus in
the absence of alterations of gonadotropins.
H ow ever the m easurem ents of bone densities at other
sites did not show significant reduction of bone m ass.
A C K N O W L E D G E M E N T S
T he authors thank N eil F erreira N ovo and Y ara
Juliano for the statistical analysis.
Introdw;:ao: Os autores propuseram-se a avaliar a densidade ossea de mulheres submetidas a histerectomia. Esta cirurgia e, na atualidade, procedimento corriqueiro na pratica ginecologica. A histerectomia poderia, eventualmente, alterar a fun9ao ovariana e, por consequElncia, determinar queda da massa ossea. Material e Metodos: Para tanto, estudaram-se 22 mUlheres, entre 35 e 45 anos, que faram divididas em dois grupos: grupo I,constitufdo por mulheres submetidas a l1isterectomia' total previa e, grupo II,formado par aquelas com utero intacto. Avaliou-se a densidade ossea por meio de densitometro de dupla emissao, com fontes de raio X (DPX), em col una lombar (L2-L4), colo do femur, triangulo de Ward e trocanter. Para a analise dos resultados utilizou-se. 0 teste de Mann-Whitney e 0teste de Friedman (p<O,05). Resultados: Verificou-se que houve diminuic;:ao significativa da massa ossea no triangulo de Ward nas mulheres histerectomizadas, quando compamdas as com utero intacto. Ademais, a densidade ossea foi menor na coluna lombar e colo do femur das mulheres histerectomizadas.
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