Hysterectomy, oophorectomy, and bone health: a systematic review and meta-analysis

To review the association between hysterectomy, with and without oophorectomy, and fracture, osteoporosis, and bone mineral density (BMD) change.

We undertook a systematic review and meta-analysis, searching PubMed, Embase, Cochrane Central, and CINAHL from inception to November 2024. Eligible studies included women aged ≥18 years and assessed the relationship between having a hysterectomy and/or oophorectomy and fracture, osteoporosis, or BMD.

Of 15 305 articles screened, 29 met the inclusion criteria, with 19 included in the meta-analyses. Bilateral oophorectomy compared to no oophorectomy was associated with a higher risk of fracture (pooled relative risk [RR] 1.17, 95% CI 1.03-1.33, 10 studies) and osteoporosis, although the latter was not statistically significant (RR 1.46, 95% CI 0.94-2.27, 4 studies). Hysterectomy with bilateral oophorectomy was not associated with a higher fracture risk compared to hysterectomy without oophorectomy (RR 0.99; 95% CI 0.83-1.18, 4 studies). However, hysterectomy without oophorectomy compared to no surgery was associated with a higher osteoporosis risk (RR 1.45; 95% CI 1.37-1.53, 2 studies). Findings showed moderate to high heterogeneity, and most studies did not account for variables such as age at surgery, menopausal hormone therapy use, and indications for surgery.

Our review supports evidence showing that bilateral oophorectomy is negatively associated with bone health and suggests that hysterectomy alone may also increase osteoporosis risk, although more data are required. To support personalised clinical decision-making, further large-scale longitudinal studies with longer follow-up and detailed assessment of surgery extent, timing, and medication use are essential.