Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer

Disclosures

Expert Rev of Obstet Gynecol. 2009;4(6):673-685. 

In This Article

Indications for Hysterectomy

There is considerable variation in policy concerning hysterectomy in healthcare centers and gynecological programs. Although hysterectomy rates in Western countries are diminishing owing to a generally more conservative approach, and this operation is still widely performed.[6] However, rates differ considerably between countries, ranging from a high of 5.4 per 1000 women in the USA[7] to intermediate rates, such as 3.7 per 1000 in Italy,[8] to a low of 1.2 per 1000 in Norway.[9] The hysterectomy rate in developing countries is lower. The incidence rate has dropped by approximately 1‰ every decade since 1980; even so, almost 20% of women in these countries will have a hysterectomy by the age of 55 years.[10–14]

The conditions that may lead to a hysterectomy cause discomfort and inconvenience rather than threaten life. The diversity of symptoms can have an immense influence on a woman's QoL, affecting aspects of her daily routine, general health and sense of wellbeing.[15] In most women who suffer gynecological disorders, QoL improves following a hysterectomy. Moreover, this surgery does not tend to produce any psychological disturbances in otherwise psychologically healthy women. In this way, most women who are undergoing this operation regain a so-called normal life.

Menorrhagia is the most frequent cause for hysterectomy in pre-menopausal women, with myomas and adenomyosis constituting the leading pathologies of the uterus. There is a 20–25% incidence of uterine fibroid tumor in women of fertile age[16] but, fortunately, these are usually asymptomatic. If a surgical approach is to be adopted, the reproductive desire of the patient must be taken into account. Thus, a conservative myomectomy should be the first recommendation in women without children and who are still capable of becoming mothers. If there is no intention of preserving fertility, hysterectomy is a definitive solution, unless other, more conservative, treatments can be offered, such as the levonorgestrel intrauterine device (LNG-IUD).

Another indication for hysterectomy is pelvic pain, mainly caused by endometriosis and/or adenomyosis. This condition can usually be managed with analgesic drugs (e.g., NSAIDS or paracetamol) and anovulatories; however, if necessary, surgery of the adnexa (endometrioma) is indicated. A hysterectomy may be proposed when more than one pathological circumstance is present. Uterine prolapse is also a common indication for hysterectomy, as it cannot be managed in a conservative manner. Hysterectomy is recommended unless a uterine-sparing desire is expressed, and accounts for 10% of the global rate of surgery. Vaginal surgery cannot be avoided when there is a prolapse, although it may be managed laparoscopically. Malignancy and postpartum hemorrhage are less frequent indications and account for only 10% of the total rate of hysterectomies.

Should Bilateral Salpingo-oophorectomy be Indicated?

Hysterectomy does not modify the risk of mortality from cardiovascular disease or cancer[17] but should be adequately evaluated in cases of concurrent bilateral oophorectomy, which is a considerably common situation among women. Many surgeons remove the ovaries in order to avoid a hypothetical ovarian cancer without giving sufficient thought to the impact it may have on the woman's health or its cost–effectiveness. Some years ago, it was estimated that 7.1% of future deaths would be prevented by concurrent salpingo-oophorectomy, mainly owing to avoiding the risk of ovarian cancer.[18] An age limit was set at 45 years old for carrying out this procedure while performing a hysterectomy. However, the evidence regarding this practice is inconclusive, as many contradictory results have been reported. Indeed, several studies have detected a reduced risk of ovarian cancer after hysterectomy and without bilateral oophorectomy.[19,20] Current scientific evidence suggests that elective oophorectomy is not advisable for the majority of women as it may lead to a higher risk of death from cardiovascular disease and hip fracture and a higher incidence of dementia and Parkinson's disease.[21] Recently, it has been concluded that preserving ovaries until at least the age of 65 years was associated with higher survival rates.[22,23]

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