移除卵巢不能降低糖尿病女性的CVD风险


  【24drs.com】一篇新研究认为,停经后的第二型糖尿病女性患者中,有双侧输卵管卵巢切除术病史者,死于心血管疾病(CVD)的机率并未降低,不过,在45岁以下妇女,卵巢切除术和CVD有关联。
  
  这些研究结果由明尼亚波利斯明尼苏达大学的Duke Appiah博士等人,在线发表于10月12日糖尿病照护期刊。
  
  作者们表示,这些资料来自参与骨质疏松性骨折之大型研究的其中7,977名女性,认为相较于没有糖尿病的妇女或不论有无糖尿病的同龄男性,高雄性素血症(hyperandrogenemia)不是第二型糖尿病妇女更可能发生心衰竭与死于心血管事件的主要解释因素。
  
  Appiah博士表示,至于年轻女性在卵巢切除术和心血管疾病之间的关联,并不会削弱前述解释。
  
  我们以前的研究和其它人的研究都显示,双侧输卵管卵巢切除术与心血管疾病之间的整体关联,似乎是因为在比较年轻时进行卵巢切除术而引起。
  
  因此,Appiah博士指出,卵巢切除术并不一定意谓著比较容易发生心血管疾病,我们的分析认为,卵巢切除和心血管疾病之间的正相关,反而反映出在较年轻时即进行卵巢切除术妇女的不良心血管健康。
  
  他表示,研究结果有几个临床意义。
  
  第一,他们并未支持双侧输卵管卵巢切除术对于心血管健康有直接负面影响的看法。第二,双侧输卵管卵巢切除术对于糖尿病妇女缺乏好处,意谓著治疗他们的高雄性素血症不太能改善他们的心血管健康。
  
  他指出,他们的研究结果并未挑战目前的观念,年轻时进行双侧输卵管卵巢切除术之妇女的荷尔蒙治疗,可能可以提供缓解热潮红等效益,而这与心血管疾病风险可能有关。
  
  在这篇研究中,检视了平均年龄71.5岁的7,977名妇女— 6% (502人)有糖尿病、18% (1,441人)有双侧输卵管卵巢切除术史。患有糖尿病的502人中,20% (101人)曾经进行卵巢切除术,进行过卵巢切除术的妇女比较可能使用荷尔蒙治疗,而那些糖尿病患者比较不可能服用荷尔蒙。
  
  在平均追踪15年间,共有4,797名妇女死亡,其中1,638人死于心血管疾病。
  
  CVD死亡率与没有糖尿病者(不论有没有进行卵巢切除术)相似(没有糖尿病也没有进行卵巢切除术者为12.9/1000;没有糖尿病但有进行卵巢切除术者为12.7/1000 )。整体而言,对所有的女性糖尿病患者,不论有无进行卵巢切除术,其CVD死亡率上升(P < .001)。
  
  对于有糖尿病且未切除卵巢者,心血管原因死亡的校正风险比(HR)为1.95 (相较于没有糖尿病或没有进行卵巢切除术的妇女) ,对于有糖尿病且有进行双侧输卵管卵巢切除术,HR是2.56,不过,这两组之间的差异并未达统计上的显著意义(P = .12)。
  
  整体而言,双侧输卵管卵巢切除术与CVD死亡率无关(HR, 1.05),糖尿病-卵巢切除术情况与荷尔蒙治疗之间也无显著的相互影响(P = 0.34)。针对45岁以上与45岁以下妇女进行的分析中,不论其停经年龄,糖尿病者的CVD死亡率增加。
  
  不过,在第二型糖尿病者中,在45岁之前进行过双侧输卵管卵巢切除术者的CV死亡率比未切除卵巢者增加(HR, 2.75;P = 0.012),而在45岁之后才进行此手术者,则与未切除卵巢者没有差异(HR, 0.94,P = .86)。
  
  Appiah博士表示,尽管其它研究人员已经提出,进行过双侧输卵管卵巢切除术之妇女的CVD风险上升,或许可用雌激素不足来解释,但有新证据显示,妇女在年轻时进行卵巢切除术等手术倾向会有心血管疾病家族史,且在进行手术前就有长期之不良的心血管风险因素。
  
  他表示,进行子宫切除术治疗功能障碍性子宫出血的妇女,倾向比较年轻且有良性卵巢囊肿,会影响进行双侧输卵管卵巢切除术的决定。这些妇女可能有多囊性卵巢症候群,是胰岛素阻抗、糖尿病与CVD的高风险组,可能因此而使这些妇女风险上升。
  
  另外,Appiah博士指出,过去廿年来,选择进行双侧输卵管卵巢切除术者大幅度下降,因为美国妇产科医学会认为,对于卵巢癌遗传风险并未增加的停经前妇女,强烈考虑保留正常的卵巢。
  
  我们的结果与这个建议一致,第二型糖尿病妇女与年轻时进行过双侧输卵管卵巢切除术者的CVD风险增加,还需要后续研究。
  
  资料来源:http://www.24drs.com/
  
  Native link:Ovary Removal Doesn't Cut CVD Risk in Women With Diabetes

Ovary Removal Doesn't Cut CVD Risk in Women With Diabetes

By Miriam E Tucker
Medscape Medical News

A history of bilateral salpingo-oophorectomy does not reduce the odds of death from cardiovascular disease among postmenopausal women with type 2 diabetes, although there may be an association between oophorectomy and CVD in women 45 and younger, a new study suggests.

The findings were published online October 12 in Diabetes Care by Duke Appiah, PhD, of the University of Minnesota, Minneapolis, and colleagues.

The data, from a subset of 7977 women who participated in a larger investigation of osteoporotic fractures, suggest that hyperandrogenemia is not a primary explanation for why women with type 2 diabetes are more likely to develop heart failure and to die of a cardiovascular event than are either women without diabetes or men of the same age, with or without diabetes, the authors say.

The finding of an association between oophorectomy and cardiovascular disease in younger women doesn't undercut that interpretation, Dr Appiah told Medscape Medical News.

"Our previous work and studies by others have shown that the overall association of bilateral salpingo-oophorectomy with cardiovascular disease seems to be driven by oophorectomy performed at an earlier age."

Thus, oophorectomy "may not independently predispose to incident cardiovascular disease, and our analysis suggests that the positive associations of ovarian removal with cardiovascular disease may instead be a reflection of adverse cardiovascular health among those women who undergo oophorectomy at a young age," Dr Appiah noted.

The study findings have several clinical implications, he said.

"First, they do not provide support for the opinion that bilateral salpingo-oophorectomy negatively affects cardiovascular health directly. Second, the lack of benefit of bilateral salpingo-oophorectomy for women with diabetes suggests that treatment of their hyperandrogenism is unlikely to improve their cardiovascular health."

He added, "Our results do not challenge the current idea that hormone therapy for women undergoing bilateral salpingo-oophorectomy at an earlier age may provide benefits such as relief from hot flashes, which have been linked to cardiovascular disease risk."

Diabetes Elevates CVD Risk, Regardless of Oophorectomy

In the study 7977 women with a mean age of 71.5 years at baseline were examined — 6% (502) had diabetes and 18% (1441) had a history of bilateral salpingo-oophorectomy. Among the 502 with diabetes, 20% (101) had had an oophorectomy. The women with oophorectomy were more likely to use hormone therapy, while those with diabetes were less likely to take hormones.

A total of 4797 women died over a mean follow-up of 15 years, including 1638 attributed to cardiovascular disease.

The rate of CVD mortality was similar among those without diabetes regardless of whether or not they had oophorectomy (12.9 per 1000 for women with neither compared with 12.7 per 1000 for those with no diabetes but who underwent oophorectomy).

Overall, CVD mortality was elevated for all the women with diabetes, regardless of oophorectomy status (P<.001).

For those with diabetes and intact ovaries, the adjusted hazard ratio (HR) for CV death was 1.95 (compared with women without diabetes or oophorectomy) and for those diabetics who also underwent bilateral salpingo oophorectomy, it was 2.56, but the difference between these two groups wasn't statistically significant (P=.12).

Overall, bilateral salpingo-oophorectomy was not associated with CVD mortality (HR, 1.05), and there was no significant interaction between diabetes-oophorectomy status and hormone therapy (P = 0.34).

Link Between Oophorectomy and CVD Death Seen in Younger Women

In the analysis examining women older than 45 years vs those aged 45 or younger, CVD mortality was increased among those with diabetes regardless of age at menopause.

However, among just those with type 2 diabetes, CV death was increased in those who had bilateral salpingo-oophorectomy before or at age 45 compared with those with intact ovaries (HR, 2.75; P = 0.012), whereas there was no difference among those who had the surgery after age 45 compared with those with diabetes who had intact ovaries (HR, 0.94, P = .86).

Dr Appiah told Medscape Medical News that although other investigators have proposed that the elevated CVD risk among women who have bilateral salpingo-oophorectomy may be explained by estrogen deficiency, there is emerging evidence that women who undergo such oophorectomy at an earlier age tend to have a family history of CVD and adverse CV risk factors long before undergoing the procedure, which may be performed for a variety of reasons.

Women who have hysterectomy for dysfunctional uterine bleeding tend to be younger and have benign ovarian cysts that might influence the decision for bilateral salpingo-oophorectomy. These women may have polycystic ovary syndrome, a high-risk group for insulin resistance, diabetes, and CVD, which may be driving the elevated risk among this group of women, he said.

And, Dr Appiah pointed out, elective bilateral salpingo-oophorectomy has declined dramatically in the past 2 decades since the American College of Obstetricians and Gynecologists recommended that strong consideration be made for retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer.

"Our results are in keeping with this recommendation. The elevated risk for CVD among women with type 2 diabetes and those who have bilateral salpingo-oophorectomy at an early age requires further study."

The study from which these data were obtained was supported by the National Institutes of Health. Dr Appiah and his coauthors have no relevant financial relationships.

Diabetes Care. Published online October 12, 2015.

    
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