Postcastration syndrome is a symptom complex that includes vegetative–vascular, neuroendocrine and neuropsychic disorders that develop as a result of total ovariectomy (surgical castration) in women of reproductive age. The clinic of postcastration syndrome is characterized by vegetative symptoms (hot flashes, tachycardia, sweating, arrhythmia, hypertensive crises), changes in metabolic processes (obesity, hyperglycemia, hyperlipidemia), psychoemotional disorders (tearfulness, irritability, aggressive-depressive states, deterioration of sleep and attention), urogenital symptoms. Diagnosis of postcastration syndrome is based on anamnestic data, a comprehensive gynecological examination, and a study of hormone levels. HRT, physiotherapy, and balneotherapy are used in the treatment of postcastration syndrome.
General information
Postcastration syndrome is characterized by the cessation of menstrual function as a result of bilateral removal of the ovaries or uterus with ovaries (pangisterectomy). Synonyms of postcastration syndrome in gynecology are “postovariectomy syndrome” and “surgical (induced) menopause”. The incidence of postcastration syndrome is about 70-80%; in 5% of cases, postovariectomy syndrome occurs with severe manifestations leading to disability. The severity of postcastration syndrome is affected by the patient’s age at the time of surgery, premorbid background, functional activity of the adrenal glands and other factors.
Causes
The development of postcastration syndrome is preceded by total or subtotal ovariectomy with or without removal of the uterus. Total ovariectomy with the abandonment of the uterus is often performed for tuboovarial (pyovar, piosalpinx) and benign ovarian neoplasms in women who have not realized reproductive function. In the future, the onset of pregnancy in this category of women is possible with the help of IVF.
The most common cause of the development of postcastration syndrome in the reproductive period is a pangisterectomy performed in connection with endometriosis or uterine fibroid. Total ovariectomy with hysterectomy in premenopausal women is usually performed for reasons of oncological sensitivity. The probable non-surgical cause of postcastration syndrome may be the death of the ovarian follicular apparatus due to gamma or X-ray irradiation. It was noted that postcastration syndrome develops more often in patients with a burdened background – thyrotoxic goiter, diabetes mellitus.
Pathogenesis
The leading pathogenetic and triggering factor in postcastration syndrome is sharply occurring hypoestrogenism, causing a wide range of pathological manifestations. In subcortical structures, the secretion of neurotransmitters regulating cardiovascular, respiratory and temperature reactions is disrupted. This is accompanied by the appearance of pathological symptoms similar to those in the development of menopausal syndrome.
Hypoestrogenism causes changes on the part of estrogen-receptive tissues: in the genitourinary system, the phenomena of atrophy of connective and muscle fibers increase, vascularization of organs worsens, thinning of the epithelium develops. After surgical shutdown of ovarian activity by the feedback mechanism, the level of gonadotropins increases, which leads to disruption of the functioning of peripheral glands.
In the cortical layer of the adrenal glands, the synthesis of glucocorticoids increases and the formation of androgens decreases, which further aggravates the maladaptation of the body. With post-castration syndrome, the formation of thyroxine (T4) and triiodothyronine (T3) in the thyroid gland is disrupted; the secretion of parathyroid hormone and calcitonin decreases, which leads to a violation of calcium metabolism and contributes to the development of osteoporosis. T. A. if, during natural menopause, the function of the ovaries fades gradually over several years, then with post-castration syndrome there is a sudden momentary shutdown of the hormonal function of the ovaries, which is accompanied by a breakdown of adaptive mechanisms and disorganization of the biological adaptation of the body to a new state.
Symptoms of postcastration syndrome
The onset of manifestations of postcastration syndrome is noted 1-3 weeks after ovariectomy and reaches its full development in 2-3 months. In the clinic of postcastration syndrome, disorders of vegetative–vascular regulation are the leading ones – they occur in 73% of cases. Vegetative-vascular reactions are characterized by attacks of hot flashes, sweating, redness of the face, palpitations (tachycardia, arrhythmia), pain in the heart, headaches, hypertensive crises. As with menopause, the severity of postcastration syndrome is determined by the frequency and intensity of hot flashes.
15% of patients with postcastration syndrome have endocrine and metabolic disorders, including hyperglycemia, hypercholesterolemia, atherosclerosis. Against this background, diabetes mellitus, obesity, coronary heart disease, hypertension, thromboembolism develops over time. Metabolic disorders also include dystrophic processes in the genitourinary organs. The phenomena of atrophic colpitis, leukoplakia and vulvar kraurosis, mucosal cracks, cystitis, cystalgia, replacement of the glandular tissue of the mammary glands with fatty and connective tissue are noted.
With postcastration syndrome, osteoporosis develops and progresses, which is manifested by local pain in the thoracic and (or) lumbar spine, in the shoulder, wrist, knee joints, muscles, and an increase in the frequency of bone fractures. The weakening of the reparative mechanisms of gum regeneration often causes the development of periodontal disease.
In 12% of women, well-being suffers due to psychoemotional disorders – tearfulness, irritability, sleep disorders, impaired attention, depressive states. In the first 2 years of post-castration syndrome, the predominance of neurovegetative symptoms is noted; in the future, the severity of endocrine-metabolic disorders increases; psychoemotional disorders usually persist for a long time.
The clinic of postcastration syndrome is similar to the manifestations of posthysterectomy syndrome, but is more pronounced. The severity of post-castration syndrome correlates with the presence of a history of infectious and gynecological diseases, pathology of the hepatobiliary system.
Diagnostics
The diagnosis of post-castration syndrome is established taking into account the gynecological history (ovariectomy) and typical manifestations. During gynecological examination, atrophic changes in the mucous membrane of the vulva and vagina are determined. Gynecological ultrasound allows you to dynamically monitor the processes in the pelvis after total ovariectomy.
Of great diagnostic importance in post-castration syndrome is the study of the level of gonadotropins (FSH, LH), pituitary hormones (ACTH), thyroid gland (T4, T3, TSH), bone metabolism (parathyroid hormone, osteocalcin, etc.), blood glucose. To assess the severity of osteoporosis, densitometry is performed. With changes in the cardiovascular system, ECG and EchoCG are indicated.
Before the appointment of HRT, mammography, colposcopy, smear examination for oncocytology, liver samples, coagulogram, cholesterol and lipoprotein levels are required to identify contraindications. Gynecologists-endocrinologists, neurologists, mammologists, cardiologists, urologists, endocrinologists are involved in the examination of patients with postcastration syndrome.
Treatment
In the treatment of postcastration syndrome, clinical gynecology uses non-drug and drug methods aimed at normalizing the regulation of adaptation processes, compensation and hormonal balance.
Therapy of postcastration syndrome begins with restorative measures by prescribing exercise therapy, UFOs, cervical-facial and endonasal galvanization, microwave therapy for the adrenal glands, general and neurosedative massage, general therapeutic baths (coniferous, marine, sodium chloride, radon), climatotherapy. It is also advisable to prescribe vitamin therapy (B, PP C, A, E), hepatoprotectors, disaggregants and anticoagulants (acetylsalicylic acid, pentoxifylline, dipyridamole) taking into account the results of the coagulogram. Patients with psychoemotional manifestations of post-castration syndrome are shown to take sedatives (valerian, motherwort, etc.), tranquilizers (phenazepam, diazepam, etc.), antidepressants (sodium tianeptine, moclobemide, etc.).
The main method in the treatment of manifestations of postcastration syndrome is the appointment of sex hormones. The choice of the regimen and the drug for HRT depends on the duration of the planned treatment, the presence of contraindications. HRT can be performed in various ways: by oral administration of tablets or pills or parenteral (transdermal, intravaginal, intramuscular) administration.
In the treatment of post-castration syndrome, various HRT prescribing modes can be used. Monotherapy with estrogens (estradiol, estriol, patches, gels) is indicated for hysterectomy. In women with a preserved uterus, two- and three-phase drugs (estradiol + levonorgestrel, estradiol + didrogesterone, estradiol + ciproterone, estradiol + norethisterone, etc.) are used in a cyclic mode of contraception. Absolute contraindications for the appointment of HRT are the detection of uterine or breast cancer, coagulopathy, liver disease, thrombophlebitis.
Prognosis and prevention
The timeliness of prescribing therapy after ovariectomy makes it possible to prevent and significantly reduce the manifestations of post-castration syndrome. The severity of the course of postcastration syndrome is determined by age, premorbid background, the volume of surgery, the timeliness of the initiation of corrective therapy and prevention of disorders. Thanks to modern reproductive technologies, pregnancy in women who have undergone ovariectomy is possible with the help of artificial insemination using a donor egg or transplanting donor embryos into the uterus. The patient’s desire to have children after hysterectomy can be realized through surrogacy.
Women after total ovariectomy are under the dispensary supervision of a gynecologist, endocrinologist, mammologist, neurologist, cardiologist. Patients with postcastration syndrome, especially those on HRT, require systematic monitoring of the condition of the mammary glands (ultrasound, mammography), examination of the hemostasis system, liver tests, cholesterol, densitometry.