Post-total oophorectomy syndrome (PTOS)
Following a hysterectomy with removal of the uterine appendages, patients naturally develop post-gonadectomy syndrome (PGS), or PTOS. This condition is characterized by pronounced vasovagal and psychoemotional manifestations due to the abrupt cessation of ovarian function. For the treatment of severe and persistent PGS, the pathogenetic combination of neurotropic drugs and hormone replacement therapy (HRT) is justified, allowing for the rapid relief of pathological symptoms.
HRT in the early postoperative period
In the first days after surgery, it is extremely important to properly select a hormonal drug to avoid vascular catastrophes.
- Drug of choice: Gynodian Depot (a combination of 4 mg estradiol valerate and 2 mg prasterone [dehydroepiandrosterone]).
- Timing and route of administration: prescribed once parenterally on the 2nd–4th day after surgical intervention.
- Advantages: the drug contains no progestogen component, which completely eliminates the risk of postoperative thrombosis. The resulting high concentration of estradiol effectively relieves PGS in all cases, and the addition of androgens provides a pronounced psychostimulatory and antidepressant effect.
- Alternative options: conjugated estrogens (Premarin 0.625 mg), estradiol gel (Divigel), or an estrogen-containing patch (Climara).
Management of the late postoperative period
At later stages of rehabilitation, the use of any combined HRT agents or estrogen monotherapy is permitted.
- Oral forms: Climen, Klimonorm, Divina, Femoston, Kliogest, Trisequens, estradiol (taken as 1 tablet once daily according to the calendar pack).
- Parenteral and transdermal forms: Gynodian Depot (intramuscularly 1 ml every 4 weeks) or Climara patch (once a week).
The duration of the course directly depends on the severity of the condition:
- Transient form of PGS: therapy lasts 3–6 months. The main goal is the normalization of hypothalamic-pituitary-ovarian relationships. In women of reproductive age, steroid activity of the ovaries may recover after HRT is discontinued.
- Persistent PGS (progressing to climacteric period): long-term use of medications for a period of 1 to 5 years is indicated.
Prevention of complications during long-term HRT
Long-term hormone intake after hysterectomy requires strict medical supervision to avoid serious side effects.
1. Prevention of thrombotic complications:
- Laboratory monitoring: regular hemostasiogram testing (assessment of blood clotting time, plasma fibrinogen level, prothrombin index, and aPTT).
- Medical support: prescription of antiplatelet agents and venoprotectors (acetylsalicylic acid, dipyridamole, Anavenol, Venoruton, Aescin, Detralex).
2. Breast monitoring:
- Breast ultrasound and palpation exam — every 6 months.
- Mammography — once every 2 years (before and during treatment).
Hysterectomy as an outcome of obstetric pathologies
In a number of cases, removal of the uterus itself is an unavoidable complication or the final stage of treatment in severe obstetric situations.
- Placental anomalies: occur due to a defect in the decidua basalis. There are three degrees: adherence (placenta accreta, 84%), invasion (placenta increta, 13%), and perforation beyond the serosa (placenta percreta, 3%). This condition is the leading cause of peripartum hysterectomy, in which maternal mortality reaches 7%. The main risk factors are a uterine scar and placenta previa. Planned cesarean section for placental invasion is performed at 34–36 weeks in a level III hospital, with the patient signing a consent form for hysterectomy in advance.
- Postpartum hemorrhage (PPH): hysterectomy is used as a "last resort" method when conservative measures (uterotonics), intrauterine balloon tamponade, B-Lynch compression sutures, and uterine artery embolization have proven ineffective. The frequency of peripartum hysterectomies serves as the primary criterion for auditing the quality of PPH treatment in obstetric hospitals.
Class and exam questions
What is the main consequence that occurs after hysterectomy with oophorectomy?
Post-total oophorectomy syndrome (PTOS) develops, accompanied by severe vasovagal and psychoemotional disorders due to a sharp drop in sex hormone levels.
Why should HRT not contain progestogens in the early postoperative period?
The absence of a progestogen component in medications (e.g., in Gynodian Depot) is critically important to rule out the risk of postoperative thrombosis.
How long should hormones be taken in the transient form of post-castration syndrome?
The course lasts from 3 to 6 months. This time is usually sufficient to normalize the function of the hypothalamic-pituitary-ovarian system during the rehabilitation period.
In what cases is hysterectomy inevitable in obstetric practice?
Surgery often becomes the only solution in cases of deep invasion of the placenta into the myometrium or massive postpartum hemorrhage when all organ-sparing methods (including vascular embolization) have failed.
What else to study on this topic
- Uterine artery embolization (UAE) as an alternative to hysterectomy
- Pathogenesis and classification of placental anomalies (accreta, increta, percreta)
- Management algorithm for massive postpartum hemorrhage
- Preoperative preparation for myomectomy with GnRH agonists
- Hormonal therapy for uterine fibroids: progestogens and the Mirena IUD
Master the entire topic in the "Obstetrics and Gynecology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Complications of Hysterectomy" and 973 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 21 video lessons on the subject
Other topics in the "Additional Topics" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.