Hysterectomy Overused for Benign Conditions

Laurie Barclay, MD

January 09, 2015

Alternatives to hysterectomy are underused in women with abnormal uterine bleeding (AUB) and other benign conditions, according to an analysis of perioperative hysterectomy data published online December 23, 2014, in the Journal of Obstetrics and Gynecology. When women with these conditions undergo hysterectomy, 18.3% have unsupportive pathology.

"The American Congress of Obstetricians and Gynecologists...supports the use of alternatives to hysterectomy including hormonal management, operative hysteroscopy, endometrial ablation, and use of the levonorgestrel intrauterine device (IUD) as primary management of these conditions in many cases," write Lauren E. Corona, BS, from Wayne State University School of Medicine, Detroit, Michigan, and colleagues. "Although use of these alternative treatments has recently led to a decrease in the utilization of hysterectomy, assessing the appropriateness of hysterectomy continues to be a target for quality improvement. Applying appropriateness criteria to hysterectomy, overutilization has been estimated to range from 16-70%."

Using data from 52 hospitals in the Michigan Surgical Quality Collaborative from January 1 through November 8, 2013, the researchers analyzed use of alternative treatments and pathology among women who underwent hysterectomy for benign indications, including uterine fibroids, AUB, endometriosis, or pelvic pain. AUB was the most common indication.

Of 6042 women who had hysterectomy during the study period, 3397 (56.2%) met inclusion criteria for analysis. More than one third of these (1281; 37.7%) had no documentation of alternative treatment before hysterectomy, and 621 (18.3%) had "unsupportive" pathology, meaning that hysterectomy showed no evidence of fibroids, endometriosis, endometrial hyperplasia, adenomyosis, adnexal pathology, or unexpected cancer.

Factors independently associated with receiving alternative treatment before hysterectomy, based on multivariable analysis, were larger uterine size and age younger than 40 years compared with ages 40 to 50 years and older than 50 years (68% vs 62% vs 56%; P < .001).

Factors independently associated with unsupportive pathology were smaller uterine size, indication of endometriosis or pain vs uterine fibroids and/or AUB, and younger age. Rates of unsupportive pathology were 37.8% in women younger than 40 years of age, 12.0% in those aged 40 to 50 years, and 7.5% in those older than 50 years (P < .001).

Limitations of this study include reliance on medical records, potential for selection bias, and lack of access to preoperative imaging.

"The fact that 18% of women did not have pathology supportive of the need for hysterectomy and that the majority of women consider at most 1 alternative treatment prior to hysterectomy indicates that there are opportunities to decrease the utilization of hysterectomy," the study authors conclude. "The levonorgestrel IUD, which is one of the most effective alternative treatments for AUB and pelvic pain, may be vastly underutilized. These are prime targets for quality improvement and cost savings by avoiding hysterectomy."

The Pelvic Floor Research Group receives research support from American Medical Systems, Johnson & Johnson, Kimberly Clark, and Proctor & Gamble through the University of Michigan. The authors have disclosed no relevant financial relationships.

J Obstet Gynecol. Published online December 23, 2014. Abstract

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