Correspondence (letter to the editor): Antihormonal Therapy

Approximately 10% of all hysterectomies are indicated for cancer. The remaining 90% or so are for benign diseases, 80% of which involve symptomatic uterine fibroids. Women relatively frequently undergo surgery in the premenopausal time period.

Since eliminating ovarian function significantly reduces uterine fibroid volume, symptoms are also reduced. This hormone dependency leads to anti-hormonal therapy: progesterone receptors are blocked using ulipristal acetate (UPA). This oral medication stops uterine fibroid-related vaginal bleeding within one week, causes volume shrinkage in the fibroids of up to 50% within only a few months, and is effective for up to six months. Repeat treatment is approved in the European Union (1).

Thus, it is possible to bridge a number of years until the onset of menopause, i.e., „spontaneous resolution“ via physiological hormone withdrawal.

Too little attention is paid to this new treatment aspect in the clinical guidelines (2). Instead, vaginal hysterectomies, including organ-preserving methods, are favored at the risk of impaired ovarian function several years prior to menopause. This is tantamount to a shortening of the fertile phase and damages the vascular system (myocardial infarction in non-smoking, healthy females not until after menopause).

Iatrogenically reducing the duration of ovarian function damages brain vessels. A large Mayo Clinic study showed that women with a history of hysterectomy (unilateral/bilateral oophorectomy) are at significantly greater risk for cognitive impairment and dementia: 190 out of 1489 versus 113 out of 1472 (hazard ratio [HR]1.46; p<0.0001) (3).

Another vascular problem is showing a similar increase as a result of hysterectomy, or its invasive alternatives: ischemic insult (4), which affects a total of 250 000 individuals annually. Hysterectomy and its invasive alternatives should not exacerbate this problem and clinical guidelines should point this out.