Just 20% of Hysterectomies for Pelvic Pain Find Endometriosis

Diana Swift

May 12, 2016

Fewer than one in four women having benign hysterectomy for chronic pelvic pain had confirmed endometriosis at time of surgery, according to a study published online May 4 and in the June issue of Obstetrics & Gynecology.

Even with a preoperative diagnosis of endometriosis, more than four in 10 of the women had no adhesions at the time of hysterectomy.

However, those with endometriosis at surgery were twice as likely to undergo oophorectomy at the same time, although only 22.4% presented with pathology-documented ovarian endometriomas.

"The low rate at which endometriosis is found among women undergoing major extirpative surgery for chronic pelvic pain is important to consider when counseling patients," write Erika L. Mowers, MD, an obstetrician-gynecologist at the University of Michigan and Women's Hospital in Ann Arbor, and colleagues in a retrospective study of 9622 women. This cohort had laparoscopic or abdominal hysterectomy for benign, noncancer, nonobstetrical indications in the Michigan Surgical Quality Collaborative between January 2013 and July 2014. They were studied by preoperative indications for surgery: chronic pelvic pain, suspected endometriosis, or both.

Some 15% to 17% of reproductive-age women suffer from endometriosis, one of the commonest drivers of chronic pelvic pain in this population, and of the 10% to 32% of hysterectomies performed for chronic pelvic pain, some 5% to 19% are for endometriosis. "Despite the large number of hysterectomies performed each year, we do not know how often endometriosis is identified during hysterectomy," Dr Mowers and colleagues write.

Noting that hysterectomy for chronic pelvic pain has not been shown to consistently lower the risk for recurrent pain even in those with endometriosis, the authors called the high oophorectomy rate in this cohort "concerning given the known health benefits of ovarian retention."

In the 9622 benign hysterectomies available for analysis, 15.2% (n = 1465) of patients had endometriosis at the time of surgery. Endometriosis prevalence varied according to indication: 21.4% (806/3768) of women with an indication of chronic pelvic pain, 57.2% (705/1232) with a preoperative indication of endometriosis, and 58.0% (484/835) with an indication of both showed visual or pathologic evidence of implants.

The most frequent sites of adhesions were the uterus, fallopian tubes, ovaries, or pelvis. Involvement of the bladder, ureter, and bowel, or implants outside of the pelvis or omentum, were less frequent.

The researchers note that those with surgically confirmed disease were more likely to have both moderate and severe adhesions. As well, they had a 2.03 (95% confidence interval, 1.71 - 2.40) greater odds ratio of having concurrent oophorectomy. In total, 47.4% (n = 773) of women with chronic pelvic pain found to have endometriosis underwent oophorectomy at time of surgery vs 33.3% (n = 2867) of those with chronic pelvic pain, but no evidence of endometriosis (P < .001).

Interestingly, unexpected endometriosis in the 5457 women with neither preoperative pain nor an indication of endometriosis was found in 8.0% of the women (n = 434).

In the 3786 patients whose preoperative indication was chronic pelvic pain, adhesions occurred more frequently in those of younger age (<45 years), white race, and lower parity and lower body mass index, as well as in those failing a prior treatment such as analgesics, hormone therapy, or a progesterone intrauterine device. Women with larger uteruses were less likely to have endometriosis.

"Further characterization of risk factors for endometriosis in women undergoing hysterectomy is needed to optimize surgical planning and patient counseling because hysterectomies involving endometriosis are often more technically challenging," Dr Mowers and coauthors write.

Those with a concurrent preoperative indication of abnormal uterine bleeding or fibroids had a lower likelihood of endometriosis. There was no association with alcohol or tobacco use and endometriosis.

Although the findings are consistent with those of other studies such as Howard's 1993 report, which found a 28% endometriosis prevalence in patients with chronic pelvic pain, the Michigan analysis differs by virtue of its restriction to intraoperative observations.

"Further investigations are needed to determine whether the preoperative risk factors for endometriosis in women with chronic pelvic pain are associated with persistent pain after hysterectomy or whether they affect patient satisfaction," Dr Mowers and coauthors write.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;127:1045-1053. Full text

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