Hysterectomy with removal of the uterine appendages is one of the most frequently performed operations in gynecology and is associated with the development of the syndrome after total oophorectomy (SPTO). Among abdominal operations, hysterectomy in Russia is 38%, in the UK – 25%, in the USA – 36%, in Sweden – 35%. About 20% of women experience hysterectomy during their lifetime. The average age of patients at the time of surgery is 43-45 years. Along with therapeutic efficacy in relation to the underlying disease, hysterectomy may adversely affect the health and quality of life of a woman.
The SCTD develops after bilateral removal of the ovaries and includes vegetovascular, neuropsychiatric and metabolic-endocrine disorders caused by hypoestrogen. The CTWT is also called the surgical (induced) menopause syndrome (based on the common pathogenetic mechanisms). The incidence rate of VETS varies from 55 to 100% depending on the age of the patient at the time of the operation, premorbid background, and the functional activity of the adrenal glands. In general, the frequency of the LWSP is 70-80%.
PGS and SPTO are more often detected in those operated on in perimenopause, as well as in patients with diabetes mellitus, thyrotoxic goiter (than in somatically healthy women).
Pathogenesis. In CTOT, the triggering and pathogenetic leading factor is hypoestrogenism with its characteristic multiplicity of manifestations. Disorders in the hypothalamic-pituitary region are accompanied by maladaptation of subcortical structures that regulate the cardiac, vascular and temperature reactions of the body, since the deficiency of estrogen reduces the synthesis of neurotransmitters responsible for the functioning of subcortical structures.
The consequence of reducing the level of sex hormones with the termination of the action of inhibin is a significant increase in the activity of LH and FSH to postmenopausal. Disorganization of adaptation processes can lead to increased levels of TSH and ACTH. Prolonged estrogen deficiency affects the state of estrogen-receptive tissues, including the urogenital system – muscular and connective tissue atrophy increases with a decrease in the number of collagen fibers, reduced vascular organ involvement, and the epithelium becomes thinner. The lack of sex hormones leads to the gradual progression of ossoporosis.
The clinical picture of the STO includes psycho-emotional, neuro-vegetative, and metabolic and endocrine disorders. Emotional disorders can occur from the first days of the postoperative period. Asthenic (37.5%) and depressive (40%) manifestations are most pronounced, phobic, paranoiac and hysterical are less common. In the formation of psycho-emotional disorders play a role as hormonal changes, and psycho-traumatic situation in connection with the perception of hysterectomy as a crippling operation.
Vegeto-neurotic disorders are formed from 3-4 days after ovariectomy and are characterized by mixed sympathic-tonic and vagogomic manifestations with the predominance of the first. Thermoregulation is disturbed in 88% of patients and is manifested by hot flushes, chills, and goosebumps, and bad weather can be tolerated. In 45% of patients sleep is disturbed, the fear of confined spaces is less often observed. Cardiovascular manifestations in the form of tachycardia, subjective complaints of palpitations, constricting pain in the heart area and an increase in systolic blood pressure are detected in 40% of patients.
The clinical picture of the SCTT is similar to that in CBC, but, as a rule, it is more pronounced and long lasting. The reverse development of clinical manifestations without correction during the year occurs in 25% of patients, in patients of reproductive age more often (in 70% of cases), which is explained by the inversion of the main source of sex hormones, which become adrenal glands.
Removal of the ovaries during hysterectomy causes metabolic endocrine and urogenital disorders that occur after psycho-emotional and neuro-vegetative manifestations – 1 year or more after surgery and are most common in premenopausal patients. The frequency of obesity, diabetes mellitus, ischemic heart disease, thrombophilia gradually increases, the atherogenic index increases.
Hysterectomy is a risk factor for IHD, and the earlier the operation is performed, the higher the risk (1.5–2 times) of the occurrence of IHD at a young age. Already in the first months after the operation, atherogenic changes in blood are observed: the content of total cholesterol (by 20%), low-density lipoproteins (by 35%) significantly increases. After removal of the ovaries, the risk of myocardial infarction increases by 2–3 times, the mortality from cardiovascular diseases increases.
Removal of the uterus is associated with a higher risk of AH as a result of a decrease in the level of prostacyclin secreted by the uterus as vasodilating, antihypertensive agents, endogenous platelet aggregation inhibitors.
Hysterectomy contributes to the emergence of urogenital disorders (dyspareunia, dysuric phenomena, colpitis, prolapse), both as a result of hypoestrogenic and trophic changes in the tissues, and because of a violation of the architectonics of the pelvic floor. 3-5 years after the removal of the uterus, urogenital disorders of one or another degree are observed in 20-50% of patients.
Hysterectomy with removal of the uterine appendages helps to accelerate and strengthen the process of osteoporosis; after her average annual loss of bone mineral density is higher than in natural menopause. The incidence of osteoporosis in patients with CTE is higher than that of non-operated peers.
Diagnostics. The severity of psycho-emotional and vegeto-neurotic manifestations in patients undergoing hysterectomy is assessed by the modified Kupperman menopausal index (MMI) in the EV modification. Uvarova. Allocate a light, moderate and severe pathological SPTO. If necessary, use additional methods for the diagnosis of psycho-emotional, urogenital disorders and osteoporosis.