Issues surrounding surgical menopause. Indications and procedures

More than 25% of women in the United States undergo hysterectomy by age 60. In assessing the appropriateness of this procedure, physicians should consider the surgical techniques available, the impact of ovary removal and the subsequent induction of menopause, and the requirement of long-term estrogen replacement. The option of ovarian preservation should also be explored. When ovaries are healthy and viable, without malignancy, preservation may be possible to ensure that the maximum natural hormonal benefits can be gained by the patient, thus avoiding the immediate and sharp decline in hormone production created by surgical menopause. The long-term effects of loss of ovarian function--including impact on cardiovascular and bone health and the immediate vasomotor symptoms and urogenital impact--are also problematic. The loss of androgens and estrogen, the physical and psychologic implications, and the requirement of compliance with a hormone replacement regimen over a longer period of time should be balanced carefully. In the gynecologic profession, no consensus exists concerning the optimum method by which to perform a hysterectomy in different situations. The method selected depends more on the experience and biases of the surgeon than on a critical evaluation of operative and outcome data. This paper reviews indications for hysterectomy, the advantages and disadvantages of various procedures, and the circumstances in which ovarian preservation is warranted. Options and various procedures are discussed for treating such conditions as pelvic inflammatory disease and tuboovarian abscess, chronic pelvic pain, cancer and residual ovary syndrome. Also discussed is the impact of various procedures on patient well-being, cost, complications and the need for additional surgery.