Hysterectomy, after which posthysterectomy syndrome (ASG) often develops, is a very common operation. Hysterectomy may adversely affect the quality of life and health of a woman, and the resulting CBC – reduce the ability to work. The average age of the operated – 40.5—42.7 years. ASG includes neuro-vegetative, psychoemotional, and metabolic-endocrine disorders as a result of hypoestrogenism, since after removal of the uterus, blood supply, innervation, and ovarian function (ovary) occur. The frequency of loss of ovarian function as the leading starting factor ranges from 20 to 80% and depends on the patient’s age, premorbid background, comorbidity, volume of surgery, and features of the blood supply to the ovaries. The course of PGS aggravates the removal of at least one ovary, surgical intervention in the luteal phase, diabetes mellitus, and thyrotoxic goiter.
Pathogenesis. The starting point of the formation of PGS are impaired microcirculation of the ovaries and acute ischemia as a result of exclusion from the blood supply of the branches of the uterine arteries. During the first month or more after surgery, the architectonics of the intraorgan ovarian vessels changes, and the intra-ovarian blood flow suffers. In the ovaries, venous congestion and lymphostasis increase, more pronounced in the stroma, which leads to a change in structure and an increase in ovarian volume. As a result, steroidogenesis changes with a decrease in estradiol levels. The volume of the ovaries is restored to normal after 1-3 months after 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 uterine appendages, menopause with a loss of cyclic ovarian function occurs on average 4-5 years earlier than in non-operated ones.
When performing an operation at the age of 41–55 years, an ASG occurs most often and is more persistent; a hysterectomy at reproductive age less frequently causes ASG, which is more often transient.
The starting and pathogenetic leading factor is hypoestrosis. Against this background, the biosynthesis of neurotransmitters decreases in the central nervous system and, as a result, the neurovegetative functions and emotional behavioral reactions change, cardiovascular, respiratory, and temperature reactions to external influences are disturbed.
The clinical picture of ASG is formed by two main symptom complexes – vegeto-neurotic and psycho-emotional disorders. Emotional manifestations are observed in 44% of patients in the form of asthenic depression with characteristic complaints of severe fatigue. decreased performance, lethargy, marked weakness, tearfulness. Anxiety with unmotivated fear of sudden death is noted in 25% of patients. Termination of menstrual and childbearing functions in reproductive age is often perceived as a loss of femininity, a feeling of fear, a fear of family breakdown, an idea of their own sexual inferiority appear.
Vegeoneurotic manifestations occur in 30-35% of patients who complain of poor tolerance to high temperatures, heart palpitations at rest, chilliness, chills, numbness and crawling, chills, sleep disturbances, vestibulopathy, increased sweating, tendency to edema, transient hypertension.
Early and late G1GS are distinguished by the time of occurrence. Early manifestations of ASG in the form of psycho-emotional and vegeto-neurotic manifestations begin from the 1st day of the postoperative period and make the recovery period heavier. PGS that developed 1 month later – 1 year after surgery is considered late. According to the clinical course distinguish transient and persistent PGS. Transistor PGS is characterized by the restoration of ovarian function within 1 month – 1 year, which occurs in 80% of patients at 37–47 years old. In 20% of patients aged 46–52 years, a persistent PGS with hypoestrogens has been observed for 1 year or more from the time of surgery, indicating that ovarian function has subsided with the onset of premature menopause caused by surgery.
Hysterectomy is a risk factor for the development of cardiovascular disease, the frequency of which increases 2-3 times. After the operation, atherogenic changes in the blood are observed: the content of total cholesterol (by 11%), low-density lipoprotein (by 19%) increases significantly. In addition to hypoestrogism, the state of the cardiovascular system is affected by a reduced level of prostacyclin secreted by the uterus, which are vasodilating, antihypertensive agents, endogenous inhibitors of platelet aggregation.
After hysterectomy, urogenital disorders often occur: dyspareunia, dysuric phenomena, colpitis, prolapse.
Hysterectomy enhances osteoporosis; the average annual loss of bone mineral density is higher than that of unoperated women and during natural menopause. Without hormone replacement therapy (HRT) after hysterectomy, osteoporosis is diagnosed 25-30% more often than in non-operated ones.
Diagnostics. Allocate light, moderate and heavy PGS. The determination of the level of estradiol, FSH, and LH has a prognostic value; This allows to establish the functional activity of the ovaries and the degree of changes in the hypothalamic-pituitary system. Estradiol levels may decrease to postmenopausal values. PGS is also accompanied by an increase in FSH and LH levels. High FSH and LH levels, comparable to postmenopausal ones, reflect persistent ovarian failure.
A valuable method for diagnosing ovarian function is ultrasound with dopperography in dynamics. Using ultrasound, it is possible to assess the features of the intra-arterial blood flow and the structural rearrangement of the ovaries. Changes are most pronounced within 1 month after surgery for a “shock” ovary. The volume of the ovaries increases 1.5 times as a result of cystic transformation or the appearance of persistent cysts. Doppler indices of intraorgan ovarian vessels indicate a decrease in peak systolic blood flow velocity and an increase in venous stasis.
In patients with PGS in the late postoperative period, the state of the ovaries approaches that in postmenopausal women: the blood flow rate in the parenchyma vessels decreases, resistance and pulsation indices increase, respectively, to 0.6–0.9 and 0.9–1.85, which indicates about reducing ovarian perfusion.