In the US, hysterectomy is the second most commonly performed surgery among women after cesarean section; around 1 in 3 will undergo the procedure by the age of 60. But according to a new study, 1 in 5 women in the US may not need to.
Hysterectomy involves the surgical removal all or part of the uterus, and some patients may also have their cervix or ovaries removed. Women who undergo a hysterectomy can no longer have periods or become pregnant.
A hysterectomy may be recommended by a health care professional to treat one of many medical conditions. Around 68% of hysterectomies for benign conditions are done to treat abnormal uterine bleeding, uterine fibroids and endometriosis.
Rates of hysterectomy in the US are falling, with one study reporting a 36.4% reduction in the number of hysterectomies carried out between 2003 and 2010.
Still, more than 400,000 hysterectomies are carried out in the US every year, and the researchers of this latest study - including Dr. Daniel Morgan of the Department of Obstetrics and Gynecology at the University of Michigan Medical School - note that concerns about the appropriateness of hysterectomy remain.
Guidelines from the American College of Obstetricians and Gynecologists state that health care professionals should recommend that patients with benign gynecologic disease undergo alternative treatments - such as hormonal therapies and endometrial ablation - before having a hysterectomy.
For their study - published in the American Journal of Obstetrics and Gynecology - Dr. Morgan and colleagues set out to analyze the use of such alternative treatments prior to a hysterectomy among women with benign conditions, and whether the pathology following a hysterectomy supported the need for the surgery.
Almost 40% of women were not offered alternative treatments prior to a hysterectomy
Over a 10-month period in 2013, the team analyzed the medical records of 3,397 women from 52 hospitals in Michigan who underwent a hysterectomy for benign gynecological disease, including uterine fibroids, abnormal uterine bleeding, endometriosis and pelvic pain.
- There are three types of hysterectomy: partial (removal of just the upper part of the uterus), total (removal of the uterus and cervix) and radical (removal of the whole uterus, the tissue on both sides of the cervix and the upper part of the vagina)
- A radical hysterectomy is most common when cancer is present
- Most women stay in the hospital for 1-2 days following surgery, although some may stay longer, often when the hysterectomy is done because of cancer.
The researchers found that 37.7% of women had no documentation indicating they underwent alternative treatment prior to undergoing a hysterectomy. What is more, the pathological findings following surgery among 18.3% women - almost 1 in 5 - did not support the need for a hysterectomy.
Less than 30% of women received medical therapy prior to a hysterectomy, according to the study, and 24% underwent minor surgical procedures beforehand.
Women under the age of 40 were more likely to receive alternative treatment, as were those with larger uteri.
Women under the age of 40, however, were also more likely to have unsupportive pathology; 37.8% of women under 40 years had pathology that did not support the need for a hysterectomy, compared with 12% of women aged 40-50 and 7.5% of women over 50.
Women with chronic pain or endometriosis were more likely to have unsupportive pathology.
According to Dr. Morgan, these findings "provide evidence that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for abnormal uterine bleeding, uterine fibroids, endometriosis or pelvic pain."
Dr. Jason Wright, chief of the Division of Gynecologic Oncology and Sol Goldman associate professor of Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, NY - who was not involved in the study - comments:
"Although quality in gynecologic surgery has focused on care after a procedure, these findings suggest that appropriateness of surgery could serve as an important quality metric in gynecology.
Reducing the number of procedures performed in women who may not necessarily require the procedure in the first place has the potential to have an even more meaningful impact in reducing adverse outcomes and cost than optimization of postoperative care. As reimbursement policies shift, appropriateness of surgery will likely become an even greater imperative from patients and payers."