Validity of self-reported hysterectomy and oophorectomy in a population-based cohort: The HUNT study.

OBJECTIVE: To validate self-reported hysterectomy and bilateral oophorectomy. DESIGN: Validation study. SETTING: Large population-based cohort study in Norway: The Trøndelag Health Study (HUNT). POPULATION: The Trøndelag Health Study 2 and 3 (HUNT2 and HUNT3) included questions on gynaecological history. Women who answered questions regarding hysterectomy and/or oophorectomy were included. In total, 30 263 women were included from HUNT2 (1995-1997) and 23 138 from HUNT3 (2006-2008), of which 16 261 attended both HUNT2 and HUNT3. METHODS: We compared self-reported hysterectomy and bilateral oophorectomy with electronic hospital procedure codes. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value and negative predictive value of self-reported hysterectomy and bilateral oophorectomy, by comparing with hospital procedure codes. RESULTS: Self-reported hysterectomy and bilateral oophorectomy in HUNT2 and/or HUNT3 both had specificity and negative predictive value above 99%. Self-reported hysterectomy had a sensitivity of 95.9%, and for bilateral oophorectomy sensitivity was 91.2%. Positive predictive value of self-reported hysterectomy was 85.8%, but for self-reported bilateral oophorectomy it was 65.4%. CONCLUSIONS: Self-reported hysterectomy corresponded quite well with hospital data and can be used in epidemiological studies. Self-reported bilateral oophorectomy, on the other hand, had low positive predictive value, and results based on such data should be interpreted with caution. Women who report no previous hysterectomy or bilateral oophorectomy can safely be classified as unexposed to these surgeries.

All-cause and cardiovascular mortality after hysterectomy and oophorectomy in a large cohort (HUNT2).

INTRODUCTION: Hysterectomy and bilateral oophorectomy are common major surgical procedures that have been associated with increased mortality risk. We aimed to assess the association of hysterectomy and/or bilateral oophorectomy with all-cause and cardiovascular mortality in a Norwegian population. MATERIAL AND METHODS: Cohort study with data from The Trøndelag Health Study (HUNT2) linked to the Norwegian Cause of Death Registry, with follow-up from 1996 until 2014 or death. The unexposed group (n = 18 673) included women with both their ovaries and uterus intact, while the two exposed groups included women with hysterectomy alone (n = 1199), or bilateral oophorectomy with or without hysterectomy (n = 907). We compared mortality in exposed vs unexposed groups and adjusted for relevant covariates by Cox regression. Further, we performed analyses stratified by age at surgery (≤39, 40-52, ≥53 years) and subgroup analyses among women ≤52 years of age at inclusion. RESULTS: Among the 47 312 women in HUNT2 (1995-1997), 20 779 provided complete information regarding gynecological surgery and previous health. The hysterectomy group had increased all-cause mortality (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.06-1.58) and cardiovascular mortality (HR 1.47, 95% CI 1.09-1.97). We found no significant association between bilateral oophorectomy and all-cause or cardiovascular mortality in the total population. However, among women ≤52 years at inclusion, cardiovascular mortality was increased in the hysterectomy group (HR 2.71, 95% CI 1.19-6.17) with a similar, but less precise estimate in the bilateral oophorectomy group (HR 2.42, 95% CI 0.84-6.93). CONCLUSIONS: Hysterectomy was associated with increased all-cause and cardiovascular mortality, whereas bilateral salpingo-oophorectomy was not. Among women ≤52 years at inclusion, both hysterectomy and bilateral oophorectomy were associated with a twofold increased risk of cardiovascular mortality, but the results were imprecise. Women after hysterectomy and/or bilateral salpingo-oophorectomy constitute a group with increased cardiovascular mortality that may need closer attention to cardiovascular disease risk from the healthcare system to ensure timely and effective preventive interventions.

Symptom Experience and Self-rated Physical Functioning in Patients With Ovarian Cancer Receiving Chemotherapy: A Longitudinal Study.

OBJECTIVES: In this longitudinal study, we investigated occurrence of multiple symptoms during chemotherapy in patients with ovarian cancer. We also evaluated whether self-rated physical functioning, selected demographic, and clinical variables were associated with symptom burden over time. METHODS AND MATERIALS: In total, 82 patients provided longitudinal data (4 time points) by completing questionnaires including the Memorial Symptom Assessment Scale, the Karnofsky Performance Status Scale, and the Self-Administered Comorbidity Questionnaire. Demographic and clinical data were collected from medical records. Karnofsky Performance Status Scale score of less than 80 was defined as low and Karnofsky Performance Status Scale score 80 or higher as high physical functioning. Possible associations between the most frequent symptoms and selected variables were modeled using binary logistic regression for repeated measures. RESULTS: Palliative treatment was the main reason for treatment for 85% of the patients. Sixty percent of the patients reported high prevalence of symptoms, particularly lack of energy, difficulty sleeping, and worrying. The total number of symptoms increased during the treatment and returned to enrollment values at 6 months. This trend was dominated with physical symptoms. When we compared women with low (n = 33) versus high physical functioning (n = 49) at enrollment, low physical functioning was significantly associated with more symptoms and distress for the study period. Patients with low physical functioning were more likely to experience lack of energy (odds ratio [OR] = 8.33), feeling drowsy (OR = 4.17), feeling bloated (OR = 2.44), feeling sad (OR = 3.33), having pain (OR = 4.72), and worrying (OR = 2.50), and this remained stable throughout the observation period of 6 months. CONCLUSIONS: A high symptom burden was reported in this cohort of patients with ovarian cancer mainly treated with palliative intent. Low self-rated physical functioning was strongly associated with high symptom burden for the 6-month period. When chemotherapy is discussed with patients with ovarian cancer with low physical functioning, possible palliation benefits must be weighed against the added risk of long-term distressful symptoms that chemotherapy implies.

Hormone Levels and Sexual Functioning After Risk-Reducing Salpingo-Oophorectomy.

INTRODUCTION: Women after risk-reducing salpingo-oophorectomy (RRSO) can have impaired sexual functioning, but whether there is an association between hormone levels and sexual functioning is unclear. AIM: To determine whether hormone levels are associated with sexual functioning in women after RRSO. METHODS: This is a retrospective cohort study of 198 sexually active and 91 inactive women after RRSO. Participants completed the Sexual Activity Questionnaire, questionnaires concerning hormone replacement therapy (HRT), quality of life, care from partner, body image, and comorbidity and provided blood samples. Associations between sexual functioning scores and covariates were examined by linear regression. Variables associated with sexual activity were examined by logistic regression. MAIN OUTCOME MEASURES: Associations with sexual pleasure and sexual discomfort scores were expressed by multivariable regression coefficients and associations with sexual activity were expressed by odds ratios. RESULTS: None of the hormone levels were associated with sexual pleasure in contrast to age (P = .032), current use of systemic HRT (P = .002), and more care form partner (P < .001). Increased free androgen index (P = .016), more care from partner (P = .017), systemic HRT (P = .002), and no history of cardiovascular disease (P = .001) were associated with less sexual discomfort. The odds ratio of being sexually active increased with younger age, no breast cancer, better quality of life, and more care from partner. CONCLUSIONS: Our results indicate that other factors than hormone levels are important for sexual functioning, although systemic HRT can have a positive impact on sexual functioning in women who have undergone RRSO. Testosterone therapy could improve women's sexual functioning after RRSO; however, the inverse association between free androgen levels and sexual discomfort should be addressed in future studies. Johansen N, Liavaag AH, Mørkird L, Michelsen TM. Hormone Levels and Sexual Functioning After Risk-Reducing Salpingo-Oophorectomy. Sex Med 2018;6:143-153.

Use of hormone replacement therapy after risk-reducing salpingo-oophorectomy.

INTRODUCTION: After premenopausal risk-reducing salpingo-oophorectomy (RRSO) to prevent ovarian cancer, the non-cancer-related morbidity and mortality may be increased if sex hormones are not replaced. Several guidelines recommend systemic hormone replacement therapy (HRT) to these women until the expected age of menopause. We aimed to study the use of HRT after RRSO. MATERIAL AND METHODS: Participants were 324 women after RRSO and 11 160 postmenopausal controls. A subsample of 950 controls had undergone bilateral salpingo-oophorectomy (BSO). All participants completed the same questionnaire regarding HRT use. We compared HRT use in the RRSO group with the BSO controls using logistic regression. RESULTS: Among the women aged ≤52 years without a history of breast cancer, 51.7% of the RRSO group and 48.7% of the BSO controls reported current use of systemic HRT (odds ratio 1.13, 95% confidence interval 0.72-1.76). Among the HRT users, systemic estrogen was used by 35.1% and 58.7% in the RRSO and BSO control groups, respectively (p = 0.001). Among the women aged >52 years, 16.8% of the RRSO group and 38.4% of the BSO controls (p < 0.001) used systemic HRT. CONCLUSIONS: Among the RRSO women and BSO controls ≤52 years old without a history of breast cancer, relatively few were current users. If there are no contraindications, these women would benefit from systemic HRT. Additionally, almost 40% of the BSO controls >52 years used systemic HRT. Doctors should be aware of this practice and prescribe systemic HRT when indicated.

Sexual activity and functioning after risk-reducing salpingo-oophorectomy: Impact of hormone replacement therapy.

OBJECTIVE: To examine sexual activity and functioning in women after risk-reducing salpingo-oophorectomy (RRSO) compared with the general population (NORM). METHODS: Retrospective cohort study. 294 women who underwent RRSO and 1228 women from the NORM group provided written information based on mailed questionnaires. Sexual pleasure and discomfort scores and frequency of sexual activity were evaluated using the Sexual Activity Questionnaire. RESULTS: The RRSO group reported less sexual pleasure (10.5 vs. 11.9, P=0.009), more discomfort (1.9 vs. 0.83, P<0.001), and less frequent sex than did the controls. Significant associations were observed between a lower pleasure score and being in the RRSO group, older age, history of cancer, low body image, high level of role functioning, and low level of global quality of life (QoL). Further, significant associations were detected between more discomfort and being in the RRSO group, older age, history of cancer, poor body image, and low level of global QoL. Hormone replacement therapy (HRT) use had no impact on pleasure or discomfort score in regression analyses among all the sexually active women. However, in subanalyses of the RRSO group, users of systemic HRT reported less discomfort (1.2 vs. 2.4, P=0.001) than did the nonusers. CONCLUSIONS: After RRSO, women reported significantly less sexual pleasure, more discomfort, and less frequent sex compared with the controls. In the RRSO group, systemic HRT users reported less discomfort than did the nonusers. Health care providers should be attentive to these issues when counseling before and after prophylactic surgery.

Association between hysterectomy with ovarian preservation and cardiovascular disease in a Norwegian population-based sample.

BACKGROUND/AIMS: Some previous studies have reported that hysterectomy predicts increased prevalence of cardiovascular diseases, but the findings are disputed. We aimed to examine associations between hysterectomy and cardiovascular disease in a Norwegian cross-sectional health study. METHODS: The data were obtained from the population-based cross-sectional Nord-Trøndelag Health Study (The HUNT-2 Study). Of 46,709 invited females, 35,280 (76%) participated; 939 (3%) reported hysterectomy without oophorectomy (exposed women). Each exposed woman was age-matched with four randomly chosen women (n = 3,756) without hysterectomy or oophorectomy. Oophorectomy and hysterectomy status was self-reported by the women. Hazard ratio for cardiovascular diseases was calculated by Cox regression analyses with hysterectomy as a time-dependent covariate. RESULTS: Median time since hysterectomy was 14 years (range 0-56 years). We calculated a significantly larger cumulative probability of cardiovascular diseases after hysterectomy with a hazard ratio of 1.92, 95% CI (1.51-2.38) after adjustments for cardiovascular risk factors (diabetes, age, use of hormonal replacement therapy and positive family history of myocardial infarction). CONCLUSION: Women had a significantly increased risk of cardiovascular diseases after hysterectomy compared to age-matched controls. Studies with longitudinal design and confirmed medical outcome data are needed.

"The impact of cancer scale" version 1: psychometric testing of the Norwegian translation in a heterogeneous sample of cancer survivors.

PURPOSE: The impact of cancer scale version 1 (IOC-1) from 2006 has only been tested psychometrically in a heterogeneous sample of 193 American long-term cancer survivors (LTSs). The Norwegian version of IOC-1 compares the psychometric findings of that study with those observed in a heterogeneous sample of 809 Norwegian LTSs. METHODS: We performed exploratory (EFA) and confirmatory (CFA) factor analyses, tests of internal consistency, correlational studies with various other tests and a change over time examination in order to test reliability and validity of the IOC-1. RESULTS: The American factor structure of the IOC-1 with 10 dimensions showed adequate fit with CFA in the Norwegian sample, but internal consistency was insufficient in 2 dimensions. EFA of the Norwegian sample found a 9 factor solution that also showed adequate fit on CFA, and with sufficient internal consistencies for all dimensions. The SF-36 dimensions, anxiety, depression, neuroticism, fatigue and body image all showed low correlations with the positive dimensions of the IOC-1, but higher correlations with the IOC-1 negative dimensions. The IOC-1 dimensions showed considerable stability over time. CONCLUSIONS: In our big heterogeneous sample of LTSs, the Norwegian version of the IOC-1 showed discriminant and concurrent validity, and reliability was supported.

Follow-up routines in gynecological cancer - time for a change?

OBJECTIVE: To determine current practice of follow-up of Norwegian gynecological cancer patients, and to review available randomized controlled trials (RCTs) in gynecologic, breast and colorectal cancer patients in order to discuss whether such studies are feasible in gynecological cancer patients. DESIGN: A combined questionnaire study and a systematic review of RCTs in follow-up of gynecological, breast, and colorectal cancers. POPULATION: Gynecological, breast, and colorectal cancer patients. METHODS: A questionnaire regarding follow-up routines was mailed to 31 gynecological departments in Norway. A systematic search on MEDLINE, EMBASE, and the Cochrane Library databases was conducted to identify RCTs in follow-up of breast, colorectal, and gynecological cancers. RESULTS: The questionnaire study showed that the number of controls varied from eight to 16 during the first five years' post-treatment. Routine investigations such as chest X-ray and cytology were frequently used in endometrial and cervical cancer. All departments used CA-125 in follow-up of ovarian cancer patients. Reviewing the literature, 19 RCTs of varying methodological quality were identified for colorectal and breast cancers, and none for gynecologic cancer. Different follow-up models were compared, and most studies concluded that there were no significant differences in the detection of recurrence, overall survival, and quality of life between the studied groups. CONCLUSIONS: Follow-up routines after gynecological cancer vary in Norway. The optimal approach is unknown and RCTs comparing follow-up protocols are missing. Studies of breast and colorectal cancer patients show that studies on follow-up strategies are feasible but sufficient sample size and observation time are important.

Bilateral oophorectomy before 50 years of age is significantly associated with the metabolic syndrome and Framingham risk score: a controlled, population-based study (HUNT-2).

OBJECTIVE: Bilateral oophorectomy (BOE) is often recommended in order to prevent cancer at hysterectomy for non-malignant diseases and when familial risk of ovarian and breast cancer has been identified. Surgical menopause increases the risk of cardiovascular mortality, however, the intervening mechanisms are not clear. We compared the prevalence of the metabolic syndrome (MetS) and Framingham cardiovascular risk scores in women with BOE before 50 years of age to age-matched controls in a population-based study. METHODS: 20,765 women aged 40-69 years were invited to a health study (HUNT-2 Norway 1995-97) and 17,650 (85%) attended. We compared 263 women with BOE before 50 years of age [63 with intact uterus (BO1 group), and 200 with hysterectomy also (BO2 group)] with 3 age-matched controls per case (n=789). Data on demographic, somatic, mental, and lifestyle variables, physical measurements and blood tests were obtained. RESULTS: The BO1 and BO2 groups did not differ significantly regarding risk variables, and 4% had natural menopause. The combined BOE group had increased prevalence of MetS compared to controls according to the International Diabetes Federation's definition (47% versus 36%; p=.001) and the revised NCEP ATP III definition (35% versus 25%; p=.002), which remained after adjustments (for reproductive, global health, and lifestyle variables). The prevalence of Framingham risk score > or =10% was higher in cases (22%) versus controls (15%) p=.005. CONCLUSION: The higher prevalence of MetS and increased Framingham risk scores in women with bilateral oophorectomy before 50 years of age suggests that these women may be at higher risk of type 2 diabetes and cardiovascular disease compared to their counterparts in the general population.

A controlled study of sexual activity and functioning in epithelial ovarian cancer survivors. A therapeutic approach.

OBJECTIVES: To explore sexual activity and functioning in epithelial ovarian cancer survivors (EOCSs) compared to age-adjusted controls from the general population (NORM) with focus on findings that should be given therapeutic considerations. METHODS: A cross-sectional study of 189/287 (66%) EOCSs treated at The Norwegian Radiumhospital 1979-2003 using a mailed questionnaire including demographic and somatic issues, and schedules concerning sexuality, fatigue, mental distress and quality of life. Blood tests for sex hormone determination were taken at their GPs. RESULTS: Among EOCSs 47% (95% CI 40-54%) were sexually active compared to 53% (95% CI 48-58%) in NORM. The sexually active EOCSs reported lower levels sexual pleasure (p<0.001) and higher levels of sexual discomfort than NORM (p<0.001). In sexually active EOCSs an association between higher level of sexual discomfort and both lower serum levels of estradiol (p=0.02) and higher levels of SHBG (p=0.04) was observed. Sexually active EOCSs were significantly more often in a paired relation and showed lower levels of fatigue and better quality of life compared to inactive EOCSs. Lack of interest (36%) and physical problems (23%) were significantly more common in sexually inactive EOCSs compared to NORM. In multivariable analyses of sexually active EOCSs premenopausal oophorectomy, having had chemotherapy, age at survey, mental health and body image were significantly associated with sexual functioning. CONCLUSIONS: Our findings on sexual inactivity and poorer sexual functioning among EOCSs point to issues in need of consideration. We present therapeutic strategies for evaluation and treatment for sexual problems in EOCSs.

Controlled study of fatigue, quality of life, and somatic and mental morbidity in epithelial ovarian cancer survivors: how lucky are the lucky ones?

PURPOSE: There are few studies of somatic and mental morbidity in epithelial ovarian cancer survivors (EOCSs). The aim of this controlled, cross-sectional study was to explore fatigue, quality of life (QOL), and somatic and mental morbidity in EOCSs. PATIENTS AND METHODS: Among 287 EOCSs treated according to protocols at The Norwegian Radium Hospital between 1977 and 2003, 189 patients (66%) participated. Information was collected by a questionnaire containing demographic and morbidity items and self-rating scales. Internal comparisons of various subgroups of EOCSs were performed, and EOCSs were compared with age-adjusted controls from the general population. RESULTS: Minimal differences were observed relating to somatic and mental morbidity, fatigue, and QOL between EOCSs with and without relapse, long or short follow-up time, and prognostic index status. Chronic fatigue was found in 22% (95% CI, 16% to 28%), and only body image was significantly associated with chronic fatigue in multivariable analyses. EOCSs showed significantly more somatic and mental morbidity, somatic complaints, use of medications, and use of health care services than controls. The levels of anxiety and fatigue were also significantly higher in EOCSs than in controls, whereas the levels of depression and of several QOL dimensions were lower. The prevalence of chronic fatigue was 12% among controls. CONCLUSION: EOCSs had more somatic and mental morbidity, more fatigue, poorer QOL, and used more medication and health services than controls. Minimal differences were observed between various EOCS subgroups. Health care professionals should try to improve and be attentive to the health of EOCSs.