Excess mortality and morbidity tied to estrogen therapy underuse in premenopausal women following surgical menopause: Study

The study, published in the American Journal of Obstetrics and Gynecology, revealed an association between the underuse of estrogen therapy in premenopausal women who undergo oophorectomy and substantial excess morbidity and mortality.

"Based on current practice patterns of women who have oophorectomy for benign indications and experience surgical menopause, ET underuse results in a substantial rise in the number of excess cases and deaths from coronary heart disease, lung cancer, and stroke," the researchers reported.

Surgical menopause, often induced by the removal of ovaries due to medical conditions such as endometriosis or ovarian cancer, plunges women into an abrupt cessation of ovarian hormone production. This abrupt hormonal shift not only leads to troublesome symptoms like hot flashes, mood swings, and vaginal dryness but also puts women at increased risk of developing serious health complications, including cardiovascular diseases and osteoporosis.

Contrary to clinical guidelines, there has been a decrease in overtime use of estrogen therapy in premenopausal women undergoing bilateral oophorectomy for benign indications. Considering this, Jason D. Wright, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, and colleagues aimed to estimate the excess mortality and morbidity associated with current patterns of estrogen therapy use in women who undergo bilateral oophorectomy with hysterectomy for benign indications.

For this purpose, the researchers developed 2 Bayesian sampling Markov state-transition models to estimate the excess disease incidence (incidence model) and mortality (mortality model). For both models, the starting cohort was women who had undergone bilateral oophorectomy with hysterectomy for benign indications at 45 to 49 years of age. The models tracked outcomes in intervals of 5 for 25 years.

The incidence model estimated the excess incidence of lung cancer, breast cancer, coronary heart disease, colorectal cancer, and stroke; the mortality model estimated excess mortality due to coronary heart disease, lung cancer, breast cancer, and all other-cause mortality.

The models compared current rates of using estrogen therapy with optimal (100%) use and calculated the mean difference in each simulated outcome to determine excess disease incidence and death.

The following were the study’s key findings:

• By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 94 fewer colorectal cancer cases, 658 more coronary heart disease cases, and 881 more stroke cases.
• By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 189 more breast cancer deaths, 380 more coronary heart disease deaths, and 759 more all-other-cause deaths.
• In sensitivity analyses where estrogen therapy was defined as use as a duration of >2 years of use, these differences increased >2-fold.

In conclusion, the study highlights the urgent need to address the underuse of estrogen replacement therapy in premenopausal women following surgical menopause. Failure to provide adequate hormonal support post-surgery not only compromises women's quality of life but also exposes them to heightened risks of serious health complications. Moving forward, concerted efforts are needed to ensure that women receive appropriate education and access to hormone replacement therapy to safeguard their long-term health and well-being.

Reference:

Ferris, J. S., Suzuki, Y., Prest, M. T., Chen, L., Elkin, E. B., Hur, C., Hershman, D. L., & Wright, J. D. (2024). Excess morbidity and mortality associated with underuse of estrogen replacement therapy in premenopausal women who undergo surgical menopause. American Journal of Obstetrics and Gynecology, 230(6), 653.e1-653.e17. https://doi.org/10.1016/j.ajog.2024.02.007