Posthysterectomy syndrome is a set of neuropsychiatric and metabolic disorders that occur after removal of the uterus (hysterectomy) while preserving one or both ovaries. Clinically, post-hysterectomy syndrome is manifested by neurovegetative and psycho-emotional disorders: tachycardia, sweating, hot flashes, hypertension, depression, weakness, lability, anxiety, etc. When diagnosing posthysterectomy syndrome, they rely on gynecological history, ultrasound data and hormone studies. HRT, physiotherapy, sedatives, antidepressants are used in the treatment of post-hysterectomy syndrome.
The problem of post-hysterectomy syndrome is relevant due to the widespread use of total and subtotal hysterectomy in gynecology for various diseases of the uterus. In the absence of adequate treatment after total removal of the uterus or supravaginal amputation of the uterus, a persistent form of post-hysterectomy syndrome may develop with the onset of physiological menopause 4-5 years earlier than expected.
The development of posthysterectomy syndrome is associated with a sharp decrease in the cyclic function of the preserved ovaries, the development of hypoestrogenism and its negative effect on the central nervous system. The frequency of posthysterectomy syndrome among operated patients depends on the age, volume of hysterectomy, the nature of ovarian blood supply and concomitant pathology. The development of post-hysterectomy syndrome in women of socially active age negatively affects the state of health, ability to work and quality of life.
According to the terms of development, posthysterectomy syndrome can be early, developing in the first days of the postoperative period, and late, occurring within a year after hysterectomy. Posthysterectomy syndrome may have mild, moderate or severe severity of clinical manifestations.
According to the duration, persistent and transient forms of posthysterectomy syndrome are distinguished. In the transient form, which occurs in the reproductive age, in the period from 1 month to 1 year after hysterectomy, ovarian function is restored. Symptoms of persistent form may appear a year or more after surgery, indicating the extinction of ovarian function and the risk of early menopause.
The pathogenetic factor leading to the formation of posthysterectomy syndrome is hypoestrogenism. Violation of ovarian innervation, removal of uterine artery branches from their blood flow after hysterectomy causes a weakening of the blood supply to the uterine appendages, the development of acute ischemia, venous and lymphatic stagnation, structural and functional changes in them. The ovulatory and hormone-producing function of the ovaries decreases with the predominance of anovulatory cycles and a decrease in the level of estradiol; after removal of the myometrium and endometrium, reverse receptor connections are disrupted.
Posthysterectomy syndrome is more common after extirpation, compared with supravaginal amputation of the uterus, as well as with the removal of one ovary than with the preservation of both. Severe posthysterectomy syndrome is more likely when performing surgery in the luteal phase of the cycle, in patients with thyrotoxicosis and diabetes mellitus.
Symptoms of posthysterectomy syndrome
Neurovegetative and psychoemotional disorders form the basis of the clinic of posthysterectomy syndrome. Psychoemotional disorders can occur in the form of asthenic syndrome and depression, in which patients experience weakness, lethargy, fatigue, deterioration of attention and memory, a tendency to tears and a sense of anxiety, a sense of inferiority and fear of loneliness.
Neurovegetative changes in posthysterectomy syndrome include rapid heartbeat (tachycardia) at rest, hypersensitivity to low and high temperatures, vestibulopathy, numbness of the skin and a feeling of goosebumps, hot flashes and excessive sweating, swelling, hypertension, insomnia. The frequency of cardiovascular pathology, obesity, and osteoporosis increases. In the case of persistent post-hysterectomy syndrome, urogenital disorders may appear – stress urinary incontinence, colpitis, vaginal dryness, pain during sexual intercourse, etc.
Diagnosis of post-hysterectomy syndrome includes assessment of psychoemotional and neurovegetative disorders, structural and functional changes in the ovaries and their blood flow, disorders of the hypothalamic-pituitary system in the period of rehabilitation after hysterectomy.
To determine the severity of clinical manifestations of posthysterectomy syndrome, the Kupperman menopausal index is used. To assess the functional activity of the ovaries, hypothalamic-pituitary regulation and prognosis of posthysterectomy syndrome, estradiol, FSH and LH levels are studied in dynamics.
Ultrasound of the uterine appendages with vascular dopplerography reveals structural changes in the ovaries and intraovarial blood flow after hysterectomy. There is a cystic transformation of the preserved ovaries (persistent cysts), in the intraovarial blood supply – a slowdown in the speed of blood flow, increased venous congestion. Persistent posthysterectomy syndrome is accompanied by a decrease in the volume of the ovaries, depletion of their follicular apparatus, an increase in the echogenicity of the stroma, a decrease in perfusion and vascular rearrangement of intraovarial blood flow approaching postmenopausal indicators. With transient posthysterectomy syndrome, a gradual restoration of the volume and structure of the ovaries is observed over time.
Examination and management of patients with posthysterectomy syndrome requires coordination of actions of gynecologist-endocrinologist, mammologist, cardiologist and neurologist.
The nature of therapy for posthysterectomy syndrome depends on its severity and duration of course. In the rehabilitation period of mild and moderate-severe post-hysterectomy syndrome with pronounced psycho-emotional symptoms, sedatives, tranquilizers and antidepressants, homeopathic remedies, reflexotherapy are prescribed. To normalize microcirculation in the pelvic organs and the collar area, physiotherapy is used: electrophoresis, galvanization of the cervical-facial region, transcranial electrical stimulation by sedative technique.
In severe or persistent post-hysterectomy syndrome, hormone replacement therapy (HRT) is added to treatment, which quickly relieves psychoemotional and vegetative-vascular disorders, normalizes hypothalamic-pituitary regulation of the ovaries, prevents the development of metabolic disorders. With early posthysterectomy syndrome, parenteral administration of combined estrogen–androgenic drugs is indicated, the use of estrogen-containing patches is possible. In the late postoperative period, treatment with various combined drugs or monotherapy with estrogens is carried out.
With prolonged HRT, it is necessary to control the blood coagulation system by examining the coagulogram, as well as the prevention of thrombosis with the appointment of disaggregants and venoprotectors. Assessment of the condition of the mammary glands before and during HRT is performed using palpatory examination, ultrasound of the mammary glands and mammography.
The duration of HRT in transient posthysterectomy syndrome is from 3 to 6 months; after its cancellation, the functional activity of the ovaries is restored in patients of reproductive age. With persistent posthysterectomy syndrome, it is advisable to continue HRT until the expected onset of natural menopause (1-5 years).
Assisted reproductive technologies have made motherhood possible for women who have undergone uterine removal. If the ovaries are preserved, it is possible to obtain eggs by puncture of follicles, fertilization of eggs in vitro (if necessary using donor sperm), subsequent cultivation of embryos and gestation of the fetus by the method of surrogate motherhood.
Prevention of the development of post-hysterectomy syndrome, first of all, contributes to the rational determination of indications for total extirpation of the uterus. If possible, it is desirable to limit the volume of intervention to supravaginal amputation of the uterus. It is advisable to perform the operation during the follicular phase of the cycle.
After removal of the uterus, early initiation of rehabilitation therapy is necessary to prevent the development of severe forms of post-hysterectomy syndrome.