Psychiatry and Clinical Neurosciences 2010; 64: 95–98

doi:10.1111/j.1440-1819.2009.02044.x

Short Communication

Higher incidence of hysterectomy and oophorectomy inwomen suffering from clinical depression: Retrospectivechart review
pcn_2044

95..98

Akio Mantani, MD, PhD,1,2* Hidehisa Yamashita, MD, PhD,2 Tokumi Fujikawa, MD, PhD3 andShigeto Yamawaki, MD, PhD21Yoshida General Hospital, 2Department of Psychiatry and Neurosciences, Division Frontier Medical Science, Graduate
School of Biomedical Sciences, Hiroshima University, and 3Fujikawa Clinic, Hiroshima, JapanThe aim of the present study was to retrospectivelyevaluate women who were admitted to Hiroshima
University Hospital, Department of Psychiatry andNeurosciences, from 1979 to 2008. The women wereclassified as ‘depressed women’ (n = 159; meanage, 52.3 ⫾ 5.7 years) or ‘non-depressed women’(n = 182; mean age, 51.5 ⫾ 4.5 years). A total of
14.5% of the depressed women and 3.3% of thenon-depressed women had a hysterectomy and/orHE LIFETIME INCIDENCE of mood disorders inwomen is approximately twice that of men.1
There are two peaks for the first onset of depression inwomen, during the childbearing years and after age
45.1 An endocrine mechanism, especially estrogen
withdrawal, related to the menopausal transitionand perimenopause is considered one factor in thepathophysiology of perimenopausal depression.2
Gynecologic operations, such as hysterectomy andoophorectomy, also lead to estrogen withdrawal. A
higher than expected incidence of depressive symptoms or minor depression has been observed insurgically menopausal women.3 Factors other thanan endocrine mechanism were also assumed to beamong the causes of depression after hysterectomy
and oophorectomy.4,5 Recent prospective studies
have emphasized that hysterectomy and oophorectomy resulted in positive outcomes, improvement ofT*Correspondence: Akio Mantani, MD, PhD, Division of Psychiatry,
Yoshida General Hospital, 3666 Yoshida, Akitakata-shi, Hiroshima
731-0595, Japan. Email: mantani@bigfoot.com
Received 26 July 2007; revised 14 September 2009; accepted
26 September 2009.

oophorectomy; this difference was statistically significant (P = 0.0003). This is consistent with previous
reported information as well as clinical experiencethat depressed women had a higher incidence ofhysterectomy and/or oophorectomy.
Key words: affective disorder, depression, hysterectomy, menopausal woman, oophorectomy.

pelvic pain, pressure symptoms, urinary incontinence, sexual function, depression and anxiety.6 The
relationship between the experience of hysterectomy
or oophorectomy and depression is still controversial
and the mechanism of depression associated withhysterectomy and oophorectomy remains unknown.
We investigated women who were admitted to a
Japanese hospital psychiatric unit for depression
compared to other psychiatric diagnoses as towhether they had a hysterectomy or oophorectomy,
to determine the relationship between the experienceof hysterectomy or oophorectomy and depression.

METHODSubjects
All the women in the present study were admitted toHiroshima University Hospital, Department of Psychiatry and Neurosciences, between 1979 and 2008.
Their charts were retrospectively reviewed and classified as ‘depressed women’ or ‘non-depressed women’.
‘Depressed women’ were defined as women who met
the criteria for affective disorder described in the© 2010 The Authors
Journal compilation © 2010 Japanese Society of Psychiatry and Neurology

95

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A. Mantani et al.

ICD-10 classification of mental and behavioral disorders as determined by a clinical interview when they
were admitted. The diagnosis of affective disorder
included major depression, bipolar disorder withcurrent depressive episode, persistent affective disorder and other affective disorder. Women wereexcluded if they had been suffering from both affective
disorder and another psychiatric disorder. Women
who had shown depressive symptoms before theexperience of hysterectomy or oophorectomy wereexcluded. If the women had been admitted more than
twice to Hiroshima University Hospital, only the firstadmission was examined. If the women had suffered
recurrent depressive disorder, only the first episode ofdepression was examined. Non-depressed women
were defined as women who had suffered a psychiatricdisorder other than affective disorder. The psychiatricdiagnoses of the ‘non-depressed women’ were as
follows: organic mental disorders; mental and behavioral disorders due to psychoactive substance use;
schizophrenia, schizotypal and delusional disorders;anxiety, neurotic, stress-related and somatoform disorders; eating and sleep disorders; adult personality
and behavior disorders; and mental retardation. The
diagnoses of gynecologic disorders are shown inTable 1. This study was carried out according to theguideline of the Ethics Committee of Hiroshima University Hospital.

Procedure
These two groups were compared in three respects: (i)average age at admission; (ii) number of women who
experienced hysterectomy and/or oophorectomy;and (iii) number of women who had a family historyof psychiatric disorder. We also extracted the age ofonset of psychiatric disorder, the age at hysterectomy
or oophorectomy, psychiatric diagnosis, and gynecologic diagnosis from the medical charts. The hysterectomy or oophorectomy was performed within
10 years before the onset of psychiatric disorder.

Statistical analysis
Parametric data are reported as mean ⫾ SD. Student’s
t-test was used to compare mean differences in parametric data between groups. Fisher’s exact test wasused to compare non-parametric numerical data. The
significance level was set at P < 0.05 (two-tailed test).
Statistical analysis of data was carried out with Statcel

Psychiatry and Clinical Neurosciences 2010; 64: 95–98(2nd edn) in Excel for Windows and StatView 5.0 forMacintosh.

RESULTS
The mean age at admission of these two groups ofwomen did not significantly differ (Table 1). The
depressed women suffering from affective disorderwere fourfold more likely to have had a hysterectomy
and/or oophorectomy than the non-depressed
women who suffered from other psychiatric disorders(14.5% vs 3.3%; P = 0.0003).

DISCUSSION
Review of the literature did not find any reports
showing that the incidence of hysterectomy oroophorectomy in psychiatric patients with diagnoses
other than affective disorder was different from thatof the general population. Therefore we consideredthat the non-depressed women were appropriate forthe control group of this study.
Several studies have reported the effects of hysterectomy and oophorectomy on psychiatric symptoms
and quality of life.6–8 These studies, as well as ourclinical experience, suggested that women who had ahysterectomy and/or oophorectomy had a higher
incidence of depression, although paradoxically thissurgery resulted in a significant improvement ofdepressive symptoms that had been observed before
the operation. The precise mechanism accounting forthe high incidence of hysterectomy and oophorectomy in patients with depression is not known, but
one possible explanation is that the low estrogenstate after hysterectomy and oophorectomy may playa role. Kugaya et al. showed, using positron emission
tomography, that estrogen increases serotonin 2A
receptor binding in human prefrontal regions, andsuggested that estrogen played some role in depression partly involving the serotonin system.9 Bilateraloophorectomy leads to a marked decrease in estrogenlevels and might be one of the contributors to developing depression. In the present study, however, theincidence of bilateral oophorectomy did not statistically differ between the groups, although this may
be attributed to the small number of participants
who had this procedure (Table 1). Alternatively,
factors other than an endocrine mechanism, such as
loss of fertility, poorer body image, or worsened
sexual function, might also be involved in developing depression after hysterectomy and/oroophorectomy.4,5,10–13© 2010 The Authors
Journal compilation © 2010 Japanese Society of Psychiatry and Neurology

Psychiatry and Clinical Neurosciences 2010; 64: 95–98

Gynecologic operations and depression

97

Table 1. Characterization and incidence of hysterectomy and/or oophorectomy vs presence of depression
Depressed(n = 159)

Non-depressed(n = 182)P

52.3 ⫾ 5.7

51.5 ⫾ 4.5

0.0736

Age at admission (years)(mean ⫾ SD)
Psychiatric diagnosis†, nF0: organic mental disorder
F1: psychoactive substance use
F2: schizophrenia
F3: affective disorder
F4: anxiety disorder
F5: eating disorder and sleep disturbanceF6: personality disorder
F7: mental retardation

47468
15950
48
1

Gynecologic diagnosis, nUterus myomatosus
Ovarian cyst
Uterus cancer
Ovarian cancer
Extrauterine pregnancy
Dysfunctional bleeding
Endometriosis
Uterine prolapse

30
7
42
1
1
11

122
3000
10

History of hysterectomyn (%)
Age at operation (years), mean ⫾ SD
Age at onset of psychiatric disorder (years),mean ⫾ SD

18 (11.3)
45.7 ⫾ 5.1
48.2 ⫾ 5.8

6 (3.3)46.2 ⫾ 7.9
48.1 ⫾ 8.70.0050
0.89610.9333

History of oophorectomyn (%)
Age at operation (years), mean ⫾ SD
Age at onset of psychiatric disorder (years),mean ⫾ SD

10 (6.3)
44.2 ⫾ 6.4
46.2 ⫾ 4.9

3 (1.6)44.0 ⫾ 10.5
44.3 ⫾ 10.5

0.0434
0.97100.7027

Incidence of hysterectomy and/oroophorectomy, n (%)

Hysterectomy and/or oophorectomy
hysterectomy(+), oophorectomy(+)
hysterectomy(+), oophorectomy(-)
hysterectomy(-), oophorectomy(+)
hysterectomy(-), oophorectomy(-)
bilateral oophorectomy(+)

23 (14.5)5 (3.1)14 (8.8)
5 (3.1)135 (84.9)
3 (1.9)6 (3.3)3 (1.6)3 (1.6)0 (0)176 (96.7)
1 (0.5)0.00030.48050.0026
0.21300.0002
0.342457 (35.8)

52 (28.6)

0.1635

Family history of psychiatricdisorder, n (%)

Student’s t-test was used to compare mean age, and Fisher’s exact test was used to compare the incidence of each operation andfamily history of psychiatric disorder.
†ICD-10 classification of mental and behavioral disorders criteria.
Depressed women were diagnosed as having affective disorder; non-depressed women were diagnosed as having psychiatricdisorders other than affective disorder.

ACKNOWLEDGMENT

REFERENCES

The authors would like to thank Dr Shoichiro Ohta,
Department of Laboratory Medicine, Saga Medical
School, for his assistance in statistical analysis.

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© 2010 The Authors
Journal compilation © 2010 Japanese Society of Psychiatry and Neurology