FERTILITY AND STERILITY威
VOL. 82, NO. 2, AUGUST 2004
Received April 15, 2003;
revised and accepted
November 18, 2003.
Supported by National
Institutes of Health grant
AG18400 and a grant from
the Women’s Health
Research Group at the
University of Maryland.
Reprint requests: Jodi A.
Flaws, Ph.D., Department
of Epidemiology and
Preventive Medicine,
University of Maryland, 660
W. Redwood Street,
Baltimore, Maryland 21201
(FAX: 410-706-1503; E-
mail: jflaws@epi.umaryland.
edu).
0015-0282/04/$30.00
doi:10.1016/j.fertnstert.2003.
11.060
502
Copyright ©2004 American Society for Reproductive Medicine
Published by Elsevier Inc.
Printed on acid-free paper in U.S.A.
Tubal sterilization and hot flashes
A cross-sectional study was conducted among women ages 40 – 60 years to assess the association between
tubal sterilization and the occurrence of any, moderate/severe, or daily hot flashes. Although women with tubal
sterilization were more likely to report hot flashes than were nonsterilized women, this association was largely
due to differences in characteristics between the women, particularly body mass. (Fertil Steril威 2004;82:
502– 4. ©2004 by American Society for Reproductive Medicine.)
Tubal sterilization is the most common form of surgical sterilization in the United States (1) and is one of
the most common surgeries performed in women (2). As such, an extensive amount of research has been
dedicated to elucidating the short- and long-term consequences of the procedure. Although there is consistent
evidence that tubal sterilization is associated with a reduced risk for ovarian cancer (3–5) and an increased risk
for hysterectomy (6 – 8), evidence is less consistent concerning the postulated increased risk of menstrual
abnormalities (9 –12). The mechanisms through which tubal sterilization may alter the risk of ovarian cancer,
menstrual problems, and hysterectomy are unknown, but some investigators propose that the procedure
impairs ovarian blood flow and that this leads to hormonal changes, ovarian dysfunction, and ovarian decline
(13–15). If tubal sterilization does lead to ovarian decline, it may in turn increase a woman’s risk for
menopausal hot flashes, the main reason that women seek medical attention during menopause (16). Few
studies have examined the relationship between tubal sterilization and hot flashes (17–19); none have
examined the relationship between tubal sterilization and more severe or frequent hot flashes. The purpose of
this study was to examine the association between tubal sterilization and any hot flashes, moderate and severe
hot flashes, and daily hot flashes.
A cross-sectional study of midlife women aged 40 to 60 years was conducted in 2001 among residents of
the Baltimore metropolitan region who reported their history of hot flashes and other information through a
mailed questionnaire. The University of Maryland institutional review board approved all aspects of the study.
Details of the study methods have been published elsewhere (20). Questionnaires were mailed to 2,999
women; 1,129 were returned completed. Questions were asked regarding demographic information, history of
tubal sterilization, pregnancy history, hormonal contraceptive use, menstrual history, menopausal symptoms,
hormone therapy use, medical and family history, health behaviors (smoking, alcohol use, vitamin use), and
attitudes toward menopause. Body mass index (BMI) was calculated in kilograms per meter squared from
self-reported height and weight at the time of the survey. A detailed hot flash history was obtained that
included information on occurrence of hot flashes, ages when hot flashes occurred, as well as frequency and
severity of hot flashes.
For analysis, exclusions included those with missing information regarding ever having hot flashes (n ⫽
1), menopausal status (n ⫽ 22), or current age (n ⫽ 5). Additionally, women reporting Turner’s syndrome (n
⫽ 2) or premature ovarian failure (n ⫽ 12) were excluded because they likely have different hormonal
disturbances and thus different risk factors for hot flashes than other women. Respondent numbers differ for
some analyses because of missing data for some questions.
The crude associations between tubal sterilization and each of three hot flash outcome variables (any
flashes, moderate and severe hot flashes, daily hot flashes) were assessed by unadjusted odds ratios (OR) with
95% confidence intervals (CI). Age, menopausal status, race, smoking, and BMI with the tubal sterilization
were examined as potential effect modifiers. Unconditional logistic regression was used to estimate the
association between tubal sterilization and the three hot flash outcome variables while adjusting for potential
confounders. Models were first fit adjusting for age and menopausal status. Factors then were included in the
models if they were associated with both tubal sterilization and hot flashes or if they were strongly associated
with hot flashes.
Almost one third of the study population (n ⫽ 335, 30.8%) reported having a tubal sterilization. The
average age at tubal sterilization was 32.7 (standard deviation ⫽ 5.1). Women were more likely to report a
tubal sterilization if they were older, black, or had less education. Women who were premenopausal were less
likely to report a tubal sterilization than were perimenopausal or postmenopausal women. Higher parity,
younger age at first birth, past oral contraceptive use, and ever use of hormone therapy or herbal supplements
were also associated with tubal sterilization. Additionally, smoking, higher BMI, and not currently using
alcohol were associated with reporting a tubal sterilization.
 TABLE 1

Association between tubal sterilization and reporting of any, moderate and severe, and daily hot flashes.

% Unadjusted Model 1a Model 2b

Reporting
Variable n hot flashes OR 95% CI OR 95% CI OR 95% CI

Any hot flashes

Tubal sterilization: yes 335 63.6 1.63 1.25, 2.21 1.44 1.06, 1.96 1.08 0.77, 1.52
Tubal sterilization: no 748 51.7 1.00 Ref 1.00 Ref 1.00 Ref
Moderate/severe hot flashes
Tubal sterilization: yes 333 46.6 1.51 1.16, 1.96 1.36 1.03, 1.79 1.06 0.77, 1.44
Tubal sterilization: no 741 36.6 1.00 Ref 1.00 Ref 1.00 Ref
Daily hot flashes
Tubal sterilization: yes 310 24.2 1.52 1.10, 2.10 1.33 0.94, 1.88 1.11 0.76, 1.63
Tubal sterilization: no 696 17.4 1.00 Ref 1.00 Ref 1.00 Ref
Note: Ref ⫽ reference group.
a
Adjusted for age and menopausal status.
b
Adjusted for age, menopausal status, smoking status, BMI, race, hormone therapy use, herbal supplement use, and nulliparity.
Whiteman. Tubal sterilization and hot flashes. Fertil Steril 2004.

A greater proportion of women who had a tubal sterilization
reported hot flashes (63.6%) than those who did not report a tubal
sterilization (51.7%; Table 1). This association was significant
when adjusted for age and menopausal status (OR ⫽ 1.44; 95% CI
⫽ 1.06, 1.96) but was no longer significant when controlling for
additional confounders, including smoking status, BMI, hormone
therapy use, herbal supplement use, and nulliparity (adjusted OR ⫽
1.08, 95% CI ⫽ 0.77, 1.52). Additional analysis indicated that BMI
was the main confounder of the association between tubal steril-
ization and hot flashes. Similarly, a greater proportion of women
who had a tubal sterilization reported moderate and severe or daily
hot flashes than those who did not report tubal sterilization (Table
1). These associations were also significant when adjusted for age
and menopausal status but were no longer significant when adjusted
for additional confounders.
There was a suggestion that the association between tubal ster-
ilization and any hot flashes differed by age (P interaction ⫽ 0.02).
Although ORs were higher for younger women (ages 40 –50 years)
than for older women (50 – 60 years), none of the fully adjusted
ORs were statistically significant.
In this study population, women who had a tubal sterilization
were more likely to report the occurrence of any, moderate and
severe, and daily hot flashes than were women who did not have a
tubal sterilization. However, tubal sterilization was no longer sig-
nificantly associated with hot flashes after adjustment for potential
confounders, particularly BMI. Our findings are consistent with
those of some (18), but not all previous, studies (17, 19). Previous
studies that suggested an association between tubal sterilization and
hot flashes or menopausal symptoms, however, did not control for
BMI (17, 19).
Our study is subject to several limitations. As a cross-sectional
study, we cannot be certain that the risk factors of interest tempo-
rally preceded the occurrence of hot flashes. Yet, for certain vari-
ables including tubal sterilization, the ages that these exposures
occurred were recorded, as were the ages that hot flashes occurred.
Thus, with reasonable certainty, it can be assumed that many of the
factors examined preceded the occurrence of hot flashes. However,
because the underlying biological changes that lead to hot flashes
are unknown, it is difficult to comment on whether the exposures of
interest occurred before these biological changes. Another limita-
tion was the lack of information on the reasons for sterilization or
the type of surgical procedure. Finally, all of the information in this
study is based on self-report, though if there is poor recall, it is
likely to be nondifferential, affecting both sterilized and nonsteril-
ized women.
Our data suggest that although women who undergo tubal
sterilization are more likely than those who have not undergone
tubal sterilization to report any, moderate and severe, or daily hot
flashes, much of this association is explained by differences in
certain characteristics between the groups, mainly BMI. In this
study, women with a high BMI were more likely to report a tubal
sterilization than were women with a low BMI. Additionally, our
previous work indicates that BMI may be a risk factor for hot
flashes (20). Thus, it is possible that the women who undergo tubal
sterilization are often the same women who are at increased risk for
hot flashes (i.e., those with high BMI). Further study is needed to
confirm these findings. Future studies should consider the effect of
BMI on any association between tubal sterilization and hot flashes.
Acknowledgment: The authors thank Lynn Lewis, M.A., for her help with
this project.
Maura K. Whiteman, Ph.D.
Kimberly P. Miller, Ph.D.
Dragana Tomic, M.D.
Patricia Langenberg, Ph.D.
Jodi A. Flaws, Ph.D.
Department of Epidemiology and Preventive Medicine,
University of Maryland School of Medicine, Baltimore,
Maryland

FERTILITY & STERILITY威 503

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Vol. 82, No. 2, August 2004