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Hysterectomy and risk of cardiovascular disease: a population-based cohort study
Abstract
AIMS: Hysterectomy for benign indications is one of the commonest surgical procedures in women, but the association between the procedure and cardiovascular disease (CVD) is not fully understood. In this population-based cohort study, we studied the effects of hysterectomy, with or without oopherectomy, on the risk of later life CVD. METHODS AND RESULTS: Using nationwide healthcare registers, we identified all Swedish women having a hysterectomy on benign indications between 1973 and 2003 (n = 184,441), and non-hysterectomized controls (n = 640,043). Main outcome measure was the first hospitalization or death of incident CVD (coronary heart disease, stroke, or heart failure). Occurrence of CVD was determined by individual linkage to the Inpatient Register. In women below age 50 at study entry, hysterectomy was associated with a significantly increased risk of CVD during follow-up [hazard ratio (HR), 1.18, 95% confidence interval (CI), 1.13-1.23; HR, 2.22, 95% CI, 1.01-4.83; and HR, 1.25, 95% CI, 1.06-1.48; in women without oopherectomy, with oopherectomy before or at study entry, respectively, using women without hysterectomy or oopherectomy as reference]. In women aged 50 or above at study entry, there were no significant associations between hysterectomy and incident CVD. CONCLUSIONS: Hysterectomy in women aged 50 years or younger substantially increases the risk for CVD later in life and oopherectomy further adds to the risk of both coronary heart disease and stroke.
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“In addition, the treatments of endometriosis, such as hysterectomy or oophorectomy (20-24) and analgesics (25) may confer increased risk of CHD to women with endometriosis.”
From Endometriosis and Risk of Coronary Heart Disease (2016) · cites this paper as [23]
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“The surgically-induced menopause prior to a natural menopause may increase risk of CHD among women, and this elevated risk may be most evident at a younger age (i.e., before all women reach natural menopause). (20-24)”
From Endometriosis and Risk of Coronary Heart Disease (2016) · cites this paper as [23]
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“A nationwide study from Sweden showed that hysterectomy without oophorectomy was associated with an increased risk of cardiovascular diseases in women age<50 but not in women age ≥50.(23, 24)”
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“Loss of ovarian function and subsequent deficiency of endogenous estrogens may be the biologic mechanism for association between bilateral oophorectomy and cardiovascular diseases, while simple hysterectomy can interfere with ovarian blood flow and may result in premature ovarian failure.(23)”
From Endometriosis and Risk of Coronary Heart Disease (2016) · cites this paper as [23]
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ResultFemale- and Male-Specific Risk Factors for Stroke
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Laughlin-Tommaso, S. K., Khan, Z., Weaver, A. L., Smith, C. Y., Rocca, W. A., & Stewart, E. A. (2017) · Menopause The Journal of The North American Menopause Society · doi:10.1097/gme.0000000000001043 · Cited by 149
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“Evidence on the long-term effects of hysterectomy, although inconsistent, also suggests hysterectomy is associated with higher risk of cardiovascular disease, with higher risk among younger women and women who have undergone oophorectomy (Fletcher et al. 2010; Ingelsson et al. 2011; Rocca et al. 2012; Yeh et al. 2013).”
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Endometriosis and cardiovascular disease
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“Second, hysterectomy in women aged 50 years or younger has been associated with a significantly increased risk of ischaemic heart disease, with oophorectomy linked to an increased risk of both CAD and stroke.(96,97) Similar risk was evidenced in the NHSII cohort,(92) as 42% of the association between CAD and endometri…”
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“By opting for conservative treatment, women avoid potential surgical complications like bleeding, infection, and damage to the bladder and bowels,(6) and long-term risks, such as physical and mental impairment,(7,10) post-surgical pain,(8,9) and cardiovascular disease.(10,11) On the other hand, an increasing number of…”
BackgroundClinical 24 month experience of the first MRgFUS Unit for treatment of uterine fibroids in Australia
Dobrotwir, A., & Pun, E. (2012) · Journal of Medical Imaging and Radiation Oncology · doi:10.1111/j.1754-9485.2012.02376.x · Cited by 52
Ovarian conservation vs removal at the time of benign hysterectomy
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“There have been several other large studies that associated CHD with hysterectomy and oophorectomy, including the Mayo Clinic Cohort Study of Oophorectomy and Aging,(30) and a cohort using Swedish Health Care registers.(31) Not all studies supported the association between surgical menopause and CHD.”
ResultSurgically Induced Menopause—A Practical Review of Literature
Secoşan, C. A., Balint, O., Pirtea, L., Grigoraş, D., Bălulescu, L., & Ilina, R. Ş. (2019) · Medicina · doi:10.3390/medicina55080482 · Cited by 52
“demonstrated that hysterectomy with bilateral oophorectomy in women <50 years increases the risk for cardiovascular diseases by 40% [39].”
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Appiah, D., Schreiner, P. J., Bower, J. K., Sternfeld, B., Lewis, C. E., & Wellons, M. (2015) · American Journal of Epidemiology · doi:10.1093/aje/kwv162 · Cited by 47
Moving Toward Individualized Medicine for Uterine Leiomyomas
Laughlin-Tommaso, S. K., & Stewart, E. A. (2018) · Obstetrics and Gynecology · doi:10.1097/aog.0000000000002785 · Cited by 41
Cardiometabolic Risk Factors and Benign Gynecologic Disorders
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Hysterectomy in young women associates with higher risk of stroke: A nationwide cohort study
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“Our findings were in line with those of a previous cohort study [7], which demonstrated that hysterectomy in young women substantially increased the risk of cardiovascular disease later in life.”
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Risk of hypertension after hysterectomy: a population‐based study
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InfluentialSelf-citationIschemic stroke across sexes: What is the status quo?
Liberale, L., Carbone, F., Montecucco, F., Gebhard, C., Lüscher, T. F., Wegener, S., & Camici, G. G. (2018) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2018.05.001 · Cited by 37
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Gao, M., Allebeck, P., Mishra, G. D., & Koupil, I. (2019) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2018-211811 · Cited by 34
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“023 A recent study found that hysterectomy in women below 50 years old substantially increases the risk for cardiovascular diseases later in life [3].”
BackgroundAl-Hendy, A. A., Venturella, R., Ferreira, J. C. A., Li, Y., Soulban, G., Wagman, R. B., & Lukes, A. S. (2023) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2023.08.030 · Cited by 26
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“However, emerging evidence from cohort studies indicates that hysterectomy with ovarian preservation is associated with higher risk of cardiovascular disease and metabolic disorders [6, 7] and all-cause mortality for women who underwent hysterectomy before age 50 and without hormonal therapy.”
BackgroundCancer Treatment-Related Cardiovascular Toxicity in Gynecologic Malignancies
Parashar, S., Akhter, N., Paplomata, E., Elgendy, I. Y., Upadhyaya, D., Scherrer‐Crosbie, M., Okwuosa, T. M., Sanghani, R. M., Chalas, E., Lindley, K. J., et al. (2023) · JACC CardioOncology · doi:10.1016/j.jaccao.2023.02.002 · Cited by 26
“Patients requiring a hysterectomy, with or without oophorectomy, are at greater risk of coronary artery disease and stroke, especially in younger women (age <50 years).(68) Surgically induced menopause (ie, bilateral oophorectomy) before age 40 years increases the risk of CVD.”
BackgroundDavey, D. A. (2012) · Women s Health · doi:10.2217/whe.12.61 · Cited by 24
Gartner, D. R., Delamater, P. L., Hummer, R. A., Lund, J. L., Pence, B. W., & Robinson, W. R. (2020) · Epidemiology · doi:10.1097/ede.0000000000001171 · Cited by 25
Michelsen, T. M., Dørum, A., Cvancarova, M., Liavaag, A. H., & Dahl, A. A. (2012) · Gynecologic and Obstetric Investigation · doi:10.1159/000345072 · Cited by 23
Risk of Diabetes After Hysterectomy With or Without Oophorectomy in Postmenopausal Women
Luo, J., Manson, J. E., Urrutia, R. P., HENDRYX, M. S., LeBlanc, E. S., & Margolis, K. L. (2017) · American Journal of Epidemiology · doi:10.1093/aje/kwx023 · Cited by 23
“Increased knowledge about the long-term effects of hysterectomy and BSO on women’s health will improve medical decisionmaking for women and their providers (10).”
BackgroundAssociation of Early Hysterectomy With Risk of Cardiovascular Disease in Korean Women
Yuk, J., Kim, B. G., Lee, B. K., Seo, J.-K., Kim, G. S., Min, K., Lee, H. Y., Byun, Y. S., Kim, B. O., Yang, S., et al. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.17145 · Cited by 22
Malignant and borderline epithelial ovarian tumors in the pediatric and adolescent population
Nasioudis, D., Alevizakos, M., Holcomb, K., & Witkin, S. S. (2016) · Maturitas · doi:10.1016/j.maturitas.2016.11.011 · Cited by 21
Quality of Life after Laparoscopic and Open Abdominal Myomectomy
Rodriguez-Triana, V. M., Kwan, L. C., Kelly, M. A., Olson, T. H., & Parker, W. H. (2020) · Journal of Minimally Invasive Gynecology · doi:10.1016/j.jmig.2020.07.023 · Cited by 20
Diabetes mellitus risk after hysterectomy
Chiang, C., Chen, W., Tsai, I., Hsu, C. Y., Wang, J., Lin, S., & Ding, D. (2021) · Medicine · doi:10.1097/md.0000000000024468 · Cited by 23
Endometriosis and menopause—management strategies based on clinical scenarios
Jakson, I., Hirschberg, A. L., & Gidlöf, S. B. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14583 · Cited by 19
Li, Y., Zhao, D. H., Wang, M., Sun, J., Liu, J., Qi, Y., Hao, Y., Deng, Q., Liu, J., Liu, J., et al. (2021) · BMC Cardiovascular Disorders · doi:10.1186/s12872-021-01919-5 · Cited by 25
“A nationwide Swedish cohort study found a 47% increased risk of stroke among women who underwent hysterectomy plus bilateral oophorectomy before age 50 years compared with women who did not have either of these surgeries [22].”
BackgroundSemiparametric causal inference in matched cohort studies
Kennedy, E. H., Sjölander, A., & Small, D. S. (2015) · Biometrika · doi:10.1093/biomet/asv025 · Cited by 20
“For example, Ingelsson et al. (2011) used a matched cohort design to estimate the effect of hysterectomy on the risk of cardiovascular disease.”
Assessment of cardiovascular risk in natural and surgical menopause
Pandey, A., Abbas, S. Z., Sangawan, V., & Das, A. (2018) · Indian Journal of Endocrinology and Metabolism · doi:10.4103/ijem.ijem_620_17 · Cited by 19
“[10] These findings are consistent with the idea that estrogen deficiency associated with hysterectomy is related to the development of CVD.”
BackgroundResultInfluentialHysterectomy is associated with large artery stiffening in estrogen-deficient postmenopausal women
Gavin, K. M., Jankowski, C. M., Kohrt, W. M., Stauffer, B. L., Seals, D. R., & Moreau, K. L. (2012) · Menopause The Journal of The North American Menopause Society · doi:10.1097/gme.0b013e31825040f9 · Cited by 19
“Large artery stiffening, a biomarker of vascular aging, increases the risk for CVD.”
BackgroundResultInfluentialBrennand, E. A., Scime, N. V., Huang, B., Edwards, A. D., Kim-Fine, S., Hall, J., Birch, C., Robert, M., & Carter Ramirez, A. (2025) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2024.10.021 · Cited by 18
Update: Estrogen and Estrogen plus Progestin Therapy in the Care of Women at and after the Menopause
Davey, D. A. (2012) · Women s Health · doi:10.2217/whe.12.1 · Cited by 18
“83) [72].”
Updates in uterine artery embolization for leiomyomas
Kim, A., Arabkhazaeli, M., Ulrich, A., Lerner, V. T., & Shin, J. H. (2020) · Current Opinion in Obstetrics & Gynecology · doi:10.1097/gco.0000000000000635 · Cited by 18
Madika, A., MacDonald, C. J., Gelot, A., Hitier, S., Mounier‐Véhier, C., Béraud, G., Kvaskoff, M., Boutron‐Ruault, M., & Bonnet, F. (2021) · Maturitas · doi:10.1016/j.maturitas.2021.06.001 · Cited by 17
Nitschke, A. S., do Valle, H. A., Dawson, L. M., Kwon, J. S., & Hanley, G. E. (2023) · Cancers · doi:10.3390/cancers15030711 · Cited by 17
“The Mayo Clinic Cohort Study of Oophorectomy and Aging [34], a cohort from the Swedish Health Care Registers [35], and the Nurses’”
BackgroundHysterectomy is associated with higher risk of coronary artery disease
Ding, D., Tsai, I., Hsu, C. Y., Wang, J., & Lin, S. (2018) · Medicine · doi:10.1097/md.0000000000010421 · Cited by 17
Long-Term Effects of Hysterectomy: A Focus on the Aging Patient
Forsgren, C., & Altman, D. (2013) · Aging Health · doi:10.2217/ahe.13.7 · Cited by 19
Self-citationChen, Y., Li, F., Liang, L., Hua, H., Liu, S., Yu, Z., Chen, Q., Huang, S., & Qin, P. (2024) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.17843 · Cited by 17
“31 Recently, Hassan et al. performed a meta-analysis for the association between hysterectomy with bilateral salpingo-oophorectomy and long-term outcomes, and they found an increased risk of CVD (HR 1.18, 95% CI 1.11–1.25; I 2 = 67%), which added further evidence for the adverse effect of…”
InfluentialImpact of hysterectomy on cardiovascular disease and different subtypes: a meta-analysis
Wang, Z., Li, X., & Zhang, D. (2021) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-021-06240-2 · Cited by 15
Association of Severe Maternal Morbidity With Subsequent Birth
Tsamantioti, E., Sandström, A., Wollmann, C. L., Snowden, J. M., & Razaz, N. (2024) · JAMA · doi:10.1001/jama.2024.20957 · Cited by 15
Kun, C., & Liu, X. (2022) · Annals of Translational Medicine · doi:10.21037/atm-22-4681 · Cited by 14
“For example, in a Swedish national study (14), hysterectomy was associated with an increased risk of stroke [hazard ratio (HR) 2.22 (95% CI: 1.01–4.83)], especially in females aged 50 years.”
InfluentialOlejek, A., Olszak-Wąsik, K., & Bednarska‐Czerwińska, A. (2016) · Menopause Review/Przegląd Menopauzalny · doi:10.5114/pm.2016.58774 · Cited by 15
“The hazard for coronary disease events and stroke is then raised [12, 13].”
BackgroundUterine cells are recruited to the infarcted heart and improve cardiac outcomes in female rats
Xaymardan, M., Sun, Z., Hatta, K., Tsukashita, M., Konecny, F. A., Weisel, R. D., & Li, R. (2012) · Journal of Molecular and Cellular Cardiology · doi:10.1016/j.yjmcc.2012.03.002 · Cited by 15
“Hysterectomy, with or without bilateral oophorectomy, in premenopausal women has been associated with an increased risk of adverse cardiovascular outcomes [15–17,31].”
BackgroundInfluentialWang, Z., Wu, J., & Zhang, D. (2021) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2021.04.009 · Cited by 14
Hassan, H., Allen, I., Rahman, T., Allen, S., Knott, C. S., Huntley, C., Loong, L., Garrett, A., Walburga, Y., Morris, E. J. A., et al. (2025) · The Lancet Oncology · doi:10.1016/s1470-2045(25)00156-1 · Cited by 13
Michelsen, T. M., Rosland, T. E., Åsvold, B. O., Pripp, A. H., Liavaag, A. H., & Johansen, N. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14531 · Cited by 11
Cardiovascular Disease After Hysterectomy in the Nurses' Health Study and Nurses' Health Study II
Thao, V., Borah, B. J., Stewart, E. A., Farland, L. V., Laughlin-Tommaso, S. K., Khan, Z., Coutinho, T., & Rassier, S. L. C. (2025) · Obstetrics and Gynecology · doi:10.1097/aog.0000000000005902 · Cited by 13
Maeda, E., Koshiba, A., Mori, T., Ito, F., Kataoka, H., Okimura, H., Sugahara, T., Tarumi, Y., Kusuki, I., Khan, K. N., et al. (2020) · European Journal of Obstetrics & Gynecology and Reproductive Biology X · doi:10.1016/j.eurox.2020.100108 · Cited by 12
“Cardiovascular events in patients with endometriosis are attributed to chronic inflammation, oxidative stress induced by endometriosis [4–6], and surgical treatment such as hysterectomy or oophorectomy or both [2,7].”
BackgroundScime, N. V., Brown, H. K., Metcalfe, A., & Brennand, E. A. (2021) · Women s Health Reports · doi:10.1089/whr.2021.0069 · Cited by 13
“events and mortality, particularly when performed during reproductive years.(7) Although the overall volume of hysterectomy is decreasing, there are persistent sociodemographic disparities in who undergoes this surgery.”
BackgroundDemakakos, P., Steptoe, A., & Mishra, G. D. (2022) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.17088 · Cited by 12
Bazzigaluppi, P., Adams, C., Koletar, M. M., Dorr, A. E., Pikula, A., Carlen, P. L., & Stefanovic, B. (2018) · Frontiers in Molecular Neuroscience · doi:10.3389/fnmol.2018.00338 · Cited by 12
Saad, M., Ansari, I., Ibrahim, Z., Batool, R. M., Ahsan, S. I., Arshad, M. S., Collins, P. M., & Ahmed, R. (2025) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2025.114081 · Cited by 15
Colombo, G. E., Mahamat‐Saleh, Y., Armour, M., Madan, K., Sabag, A., Kvaskoff, M., Missmer, S. A., Condous, G. S., Pathan, F. K., & Leonardi, M. (2025) · Heart · doi:10.1136/heartjnl-2024-324675 · Cited by 11
“Furthermore, health-care professionals would be aware to monitor their patients with NMGD for early signs and symptoms of C/CVD, and potentially diagnose atypical presentations of C/CVD with the knowledge of the underlying risk for this group of patients.”
InfluentialCardiovascular risk factors in women and the role of sex hormones
Yureneva, S. V., Мычка, В. Б., Ильина, Л. М., & Tolstov, S. N. (2011) · CARDIOVASCULAR THERAPY AND PREVENTION · doi:10.15829/1728-8800-2011-4-128-135 · Cited by 10
Gonzales, T. K., Yonker, J. A., Chang, V., Roan, C., Herd, P., & Atwood, C. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-011529 · Cited by 11
Metadata
- Authors
- Ingelsson, E., Lundholm, C., Johansson, A. L. V., & Altman, D.
- Affiliations
- Karolinska Institutet (SE)
- Danderyds sjukhus (SE)
- Corresponding author
- Altman, D.
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2010-12-24
- Volume
- 32
- Issue
- 6
- Pages
- 745-750
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W2118949079
- Semantic Scholar
- 5f1a80939f17c3c1044625194d9e31260af878bd
- Cited by
- 200
- References
- 24
- Citations by year
- 2026: 12 · 2025: 13 · 2024: 22 · 2023: 21 · 2022: 11 · 2021: 12 · 2020: 13 · 2019: 11 · 2018: 18 · 2017: 9 · 2016: 10 · 2015: 9 · 2014: 7 · 2013: 11 · 2012: 14
- FWCI
- 14.01
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Heart Journal (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Uterine Myomas and Treatments
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Menopause: Health Impacts and Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
- Keywords
- hysterectomy, oophorectomy, cardiovascular disease, coronary artery disease, stroke, heart failure, benign hysterectomy, young women, postmenopausal women, surgical risk
- MeSH terms
- Adolescent, Adult, Cardiovascular Diseases, Coronary Disease, Female, Humans, Hysterectomy, Middle Aged, Ovariectomy, Risk Factors, Sweden, Cohort Studies, Incidence, Stroke, Young Adult
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