<![CDATA[Removing the uterus and both ovaries, due to many
reasons, are still performed at perimenopausal age and
due to many reasons, uterus and ovaries removal are
still performed at reproductive age. Hysterectomy
with or without salphingooophorectomy is still the
most common procedure performed not only in developing
countries but also in developed countries.
Among of all reasons the most frequent one is to improve
the quality of life and prevent future malignancies
if the uterus and both ovaries are not removed.
Malignancies might probably occur although the incidence
rate is very low. When both of the ovaries
are removed, estrogen will decrease significantly, this
will cause short and long term medical problems and
decrease the quality of life. The incidence of coronary
heart disease and fractures increases as estrogen decreases.
A study performed by Parker et al with some
of 10.000 women who underwent total hysterectomy and
bilateral salphingooophorectomy at the age of 50 - 54
years old and did not receive HRT, shows that 838 died
due to heart disease.1 Other studies reported cognitive
disturbances among women who underwent bilateral
salphingooophorectomy.2 Further more, the incidence
of depression, anxiety and sexual disturbances is
higher in women whose ovaries were removed compared
to those who underwent natural menopausal
state.
If both ovaries were removed and then medical
problems occured, the next question would be whether
the clinician is willing to give HRT or whether
the patient is willing to have HRT? In Indonesia, clinicians
are afraid of giving HRT and patients are not
willing to have HRT. Then what will happen to the
patient? Symptomatic medication is then given. One
of the reasons of removing both ovaries is to prevent
the occurence malignancies of ovary and breast. HRT
will increase the incidence of breast cancer. If it is
so, then the patient is at the point of no return. If the
uterus is removed, will medical problems happen?
Yes, there are papillary thyroid cancer found in women
whose uterus were removed.3 It shows that uterus
also plays important role in controlling thyroid
glands. Levi et al. reported an increased risk of epithelial
thyroid cancer in women with artificial menopause
(OR 6.3%, 95% CI: 1.7 - 23.2).4 Several studies
in Europe and USA concluded that hysterectomy will
increase the risk of thyroid cancer.5,6 Estrogen indirectly
takes part in controlling the release of HRT, if
there is no estrogen then HRT release will increase
and trigger the growth of thyroid tumor.3
Myometrium and endometrium also have the ability
to produce thyroid hormone. The level of iodothyronine
deodinase enzyme is high in myometrium and
endometrium, especially during pregnancy.7,8 There
are 2 types of deodinase enzyme, type 2 and type 3.
D2 enzyme transforms T4 to active T3, while D3
transforms T4 to inactive T3.7,8 If uterus is removed,
the T3 will decrease and HRT release will be uncontrolled.
Estrogen only (+ progesterone) will increase
D2 enzyme activity while estrogen + progesterone
will increase D3 activity.9 It shows that estrogen plays
more important role in increasing D2 enzyme activity.
If there is no uterus, then there is no D2 enzyme available.
Uterus also has the ability to syntezise prostacycline.
Prostacycline has vasodilatation effect, increasing
the blood flow to the heart. Women without uterus
will have an increased risk of heart disease. Removing
the uterus has to be considered carefully. The incidence
of malignancies as a consequence of conserving
the uterus is lower compared to the adverse effect due
to hysterectomy and bilateral salphingooophorectomy.
Further study is needed in Indonesia to evaluate the
consequences of hysterectomy and bilateral salphingooophorectomy
towards thyroid cancer and quality
of life in the future.]]>
