The Loss of Vaginal Hysterectomy

Current and Future Trends in Performance of Vaginal Hysterectomy in the United States

OBJECTIVE

To describe the current and future use of vaginal hysterectomy in the United States for benign indications.

METHODS

In this retrospective cohort study using data from the PINC AI Healthcare Database, we analyzed patients who underwent hysterectomy for benign indications from 2006 to 2020. Hysterectomy was classified as abdominal, vaginal, or minimally invasive (laparoscopic or robotic-assisted). Demographic and clinical characteristics, as well as surgeon and hospital characteristics and practice settings associated with the performance of vaginal hysterectomy, were estimated using multivariable models. To examine trends in the route of hysterectomy for benign indications, we plotted a trajectory to 2030 estimated from the vector autoregressive moving average processes model.

RESULTS

A total of 1,558,107 patients-including 852,356 (54.7%) who underwent minimally invasive hysterectomy, 472,234 (30.3%) who underwent abdominal hysterectomy, and 233,517 (15.0%) who underwent vaginal hysterectomy-were identified. The rate of vaginal hysterectomy declined from 22.6% in January 2006 to 8.3% in December 2020. Vaginal hysterectomy was more commonly performed in hospitals with a high volume of prolapse and incontinence cases and by surgeons who performed a high number of hysterectomies for prolapse and incontinence and who are high-volume. The rate of vaginal hysterectomy was projected to decline to 7.3% by January 2030. By January 2030, vaginal hysterectomy was estimated to be used in 11.9% of patients undergoing hysterectomy for prolapse and in 3.5% of hysterectomies for other indications. For all indications, a minimally invasive hysterectomy will be the most common route of surgery.

CONCLUSION

The performance of vaginal hysterectomy has declined substantially and is expected to fall to fewer than 8% of hysterectomies by 2030.

Race, class, caste, disability, sterilisation and hysterectomy

This interdisciplinary historical paper focuses on the past and current state of diverse forms of surgical hysterectomy as a global phenomenon relating to population control and sterilisation. It is a paper grounded in historical inquiry but is unconventional relative to the norms of historical scholarship both in its wide geographical scope informed by the methodologies of global and intercultural history, in its critique of current clinical practices informed by recent feminist, race, biopolitical and disability studies, and by its engagement with scholarship in health sociology and medical anthropology which has focused on questions of gender and healthcare inequalities. The first part of the paper surveys existing medical, social-scientific and humanistic research on the racial, class, disability and caste inequalities which have emerged in the recent global proliferation of hysterectomy; the second part of the paper is about the diverse global rationales underlying radical gynaecological surgeries as a form of sterilisation throughout the long twentieth century. Radical gynaecological surgeries have been promoted for several different purposes throughout their history and, of course, are sometimes therapeutically necessary. However, they have often disproportionately impacted the most disadvantaged groups in several different global societies and have frequently been concentrated in populations that are already maligned on the basis of race, ethnicity, age, criminality, disability, gender deviation, lower class, caste or poverty. This heritage continues to inform current practices and contributes to ongoing global inequalities of healthcare.