Increased risk of osteoporosis with hysterectomy: A longitudinal follow-up study using a national sample cohort

Published:February 12, 2019DOI:


      Premenopausal hysterectomy is associated with a decreased ovarian reserve, follicular atresia, and subsequently reduced long-term estrogen secretion. Therefore, women who undergo hysterectomy will experience greater gradual bone mineral loss than women with an intact uterus and have an increased risk of osteoporosis.


      This study aimed to evaluate the association between hysterectomy without/with bilateral oophorectomy and the occurrence of osteoporosis using a national sample cohort from South Korea.

      Study Design

      Using the national cohort study from the Korean National Health Insurance Service, we extracted data for patients who had undergone hysterectomy (n=9082) and for a 1:4 matched control group (n=36,328) and then analyzed the occurrence of osteoporosis. The patients were matched according to age, sex, income, region of residence, and medical history. A Cox proportional hazards model was used to analyze the hazard ratios and 95% confidence intervals. Subgroup analyses were performed based on age and bilateral oophorectomy status. The age of the participants was defined as the age at the time of hysterectomy.


      The adjusted hazard ratio for osteoporosis was 1.45 (95% confidence interval, 1.37–1.53, P<.001) in the hysterectomy group. The adjusted hazard ratios for osteoporosis in the different age subgroups of this group were 1.84 (95% confidence interval, 1.61–2.10) for ages 40–44 years, 1.52 (95% confidence interval, 1.39–1.66) for ages 45–49 years, 1.44 (95% confidence interval, 1.28–1.62) for ages 50–54 years, 1.61 (95% confidence interval, 1.33–1.96, all P<.001) for ages 55–59 years, and 1.08 (95% confidence interval, 0.95–1.23, P=.223) for ages ≥60 years. The adjusted hazard ratios for osteoporosis according to hysterectomy/oophorectomy status were 1.43 (95% confidence interval, 1.34–1.51) in the hysterectomy without bilateral oophorectomy group and 1.57 (95% confidence interval, 1.37–1.79) in the hysterectomy with bilateral oophorectomy group.


      The occurrence of osteoporosis was increased in patients who had undergone hysterectomy compared with that in matched control subjects regardless of bilateral oophorectomy status.

      Key words

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      Linked Article

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        American Journal of Obstetrics & GynecologyVol. 222Issue 1
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          We thank Dr Morse for his interest and comments on our recent paper regarding hysterectomy and the risk of osteoporosis. Accordingly, we again reviewed our manuscript.
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      • Hysterectomy and the risk of osteoporosis
        American Journal of Obstetrics & GynecologyVol. 222Issue 1
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          I read with interest the study by Choi et al1 regarding the association of subsequent development of osteoporosis with previous hysterectomy. The completeness and universality of South Korea’s National Healthcare database is enviable. However, their singular focus on the possible loss of ovarian reserve as the explanation for this association does seems somewhat narrow. Although this is indeed a possible explanation, one should be somewhat circumspect about a finding of a modest increase in adjusted hazard ratios based on what is essentially an administrative claims database.
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      • Additional procedures for measuring the effect of hysterectomy on osteoporosis
        American Journal of Obstetrics & GynecologyVol. 221Issue 2
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          Choi et al1 analyzed the risk of osteoporosis in women who underwent hysterectomy using Korean insurance cohort data. The authors suggested that hysterectomy increases the risk of osteoporosis.1 The authors performed 1:4 matching according to age, income, and region of residence to reduce the bias in their study. Despite these efforts, however, there are some problems with the study.
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        American Journal of Obstetrics & GynecologyVol. 221Issue 2
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          We thank Dr Kim and his colleagues for their interest and comments on our recent paper regarding an additional procedure for measuring the effect of hysterectomy on osteoporosis. Accordingly, we again reviewed our manuscript. We know that several gynecological cancers can negatively affect bone directly or through cancer treatment, including chemotherapy and sex-hormone deprivation therapy.1
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