Effects Of Hysterectomy On Cognitive Function In Women Of Reproductive Age

Objective:(1)Meta analysis was performed to systematically evaluate the effect of hysterectomy on ovarian function in women of reproductive age.(2)Through retrospective investigation and prospective study of female patients undergoing hysterectomy at reproductive age,the changes of cognitive function and ovarian function in women undergoing hysterectomy at reproductive age were observed,and the effects of hysterectomy on cognitive function and possible reasons were discussed.Method:(1)Meta analysis: Chinese and English journals published before December 31,2018 in Pub Med,Conchrane Library,Web of Science,Ovid,CNKI,Wanfang,Wipro and China biomedical literature database were searched by computer.English retrieval words included "hysterectomy" and "ovarian function",Anti Miillerian Hormone(AMH)was used as the index to evaluate ovarian function,and the literatures were selected through multiple processes.The quality of the included literatures was evaluated by using the "Newcastle-Ottawa standard" and "AHRQ cross-sectional study evaluation standard".The Rev Man5.3 software provided by Cochrane collaboration was used for Meta analysis.(2)Retrospective investigation: a retrospective study was conducted to collect 402 unmenopausal women aged ?50 who underwent hysterectomy without ovarian surgery for non-malignant diseases in the department of gynaecology of the Zhongda Hospital affiliated to Nanjing Southeast University From January 2007 to December 2016.A total of 528 patients who underwent simple hysterectomy for non-malignant in the same period were collected as the control group.Factors such as age,body mass index(BMI)and education level were matched between the two groups.All patients underwent a questionnaire survey of the Mini-Mental Mental State Scale(MMSE),the Montreal Cognitive Assessment Scale(Mo CA),and the modified Kupperman Menopausal Index(KMI)to assess cognitive function and menopausal symptoms in women undergoing hysterectomy.(3)Prospective study: from March 2017 to January 2018,58 non-menopausal women aged ?50 who underwent hysterectomy without ovarian surgery for non-malignant diseases were prospectively collected in the department of gynaecology of the Zhongda Hospital Affiliated to Southeast University.Meanwhile,60 non-menopausal women aged ?50 who underwent simple hysterectomy for non-malignant diseases were selected as operation control group.Patients with a prior history of ovarian surgery were excluded.The ovarian function was assessed by measuring the serum levels of follicle-stimulating hormone(FSH),luteinizing hormone(LH),estradiol(E2)and AMH before surgery,1 month after surgery and 1 year after surgery.MMSE,Mo CA and KMI were used to assess the cognitive function and menopausal symptoms of women undergoing hysterectomy.Results:(1)Meta analysis: a total of 881 cases were included in 15 references.Meta-analysis results showed that at 1 month,3 months,6 months and 12 months after hysterectomy,the serum AMH level decreased compared with that before surgery,and the difference was statistically significant(P < 0.05).(2)Retrospective investigation: Using the MMSE scale,3 patients in the hysterectomy group had cognitive dysfunction,and 1 patient in the control group had cognitive dysfunction.The difference between the two groups was not statistically significant(P=0.199).Using the Mo CA scale,10 patients in the hysterectomy group had cognitive dysfunction,and 3 patients in the control group had cognitive dysfunction.The difference between the two groups was statistically significant(P=0.014).According to the modified KMI scale scoring criteria,compared with the simple hysterectomy group,the incidence of menopausal symptoms in the hysterectomy group was higher,and the difference was statistically significant(P < 0.001).(3)Prospective study:(i)Cognitive function evaluation: the MMSE scores of the hysterectomy group and the control group were within the normal range before surgery,1 month after surgery and 1 year after surgery,and no cognitive impairment was found.Using the Mo CA scale,it was found that only 1 patient in the hysterectomy group had mild cognitive impairment 1 year after surgery,and the rest were within the normal range,while there was no statistically significant difference in cognitive impairment 1 year after surgery between the two groups(P=0.492).(ii)Comparison of serum levels of AMH between groups: there was no difference in preoperative AMH level between the hysterectomy group and the simple hysterectomy group(P=0.587),and the AMH level in the hysterectomy group was significantly lower than that in the control group(P=0.001 1 month after surgery,P<0.001 1 year after surgery,all P<0.05).For intra-group comparison,the pairwise comparison differences of the hysterectomy group before surgery,1 month after surgery and 1 year after surgery were statistically significant(all P<0.001),and the AMH level 1 month after surgery and 1 year after surgery was significantly lower than that before surgery.There was no statistically significant difference between the control group at different time points(P=0.078).(iii)Comparison of serum levels of FSH,LH and E2: if FSH>40IU/L,LH did not increase at the same time,and E2<100pmol/L,it was considered as ovarian hypofunction.In the hysterectomy group,1 patient,2 patients and 8 patients had ovarian dysfunction before surgery,1 month after surgery and 1 year after surgery,respectively.In the control group,only one person had ovarian dysfunction before surgery,1 month after surgery,and 1 year after surgery.The incidence of ovarian dysfunction was significantly higher in the hysterectomy group than in the control group.The difference was statistically significant(P=0.016).(iv)KMI scores: There was no significant difference in the incidence of menopausal symptoms between the hysterectomy group and the control group before surgery and 1 month after surgery(P= 0.707 before surgery,P=0.524 1 month after surgery,P>0.05),At 1 year after surgery,the incidence of menopause symptoms in the hysterectomy group was higher than that in the control group,difference was statistically significant(P = 0.006);For intra-group comparison,in the hysterectomy group,there was no statistically significant difference between the preoperative and 1 month after surgery(P=0.569),and the incidence of menopausal symptoms at 1 year after surgery was significantly higher than before surgery(P=0.018),while there was no statistically significant difference between the simple hysterectomy group at different time points(P>0.05).Conclusion:(1)Women of reproductive age who underwent hysterectomy showed maydecreased ovarian function within 1 year after surgery,presenting as mild menopausal symptoms.(2)The effect of hysterectomy on short-term(within one year)cognitive function in women of reproductive age is not obvious,but hysterectomy may be one of the risk factors for longterm cognitive decline.(3)In the retrospective investigation,all the patients with cognitive dysfunction had obvious menopausal symptoms,considering that the decline of ovarian function may be one of the causes of cognitive dysfunction.(4)The MMSE scale is simple and easy to be used for clinical assessment of cognitive function after hysterectomy,but the Mo CA scale is more comprehensive and efficient.