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Singh SK, Chauhan K, Tripathi V. Key drivers of hysterectomy among women of reproductive age in three states in India: comparative evidence from NFHS-4 and NFHS-5. BMC Womens Health 2024; 24:107. [PMID: 38336664 PMCID: PMC10854047 DOI: 10.1186/s12905-024-02886-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states. MATERIAL AND METHODS We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model. RESULTS AND CONCLUSION The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals. RECOMMENDATIONS The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman's reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.
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Affiliation(s)
- Shri Kant Singh
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Kirti Chauhan
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra, India.
- Department of Biostatistics and Demography, International Institute for Population Sciences, Mumbai, Maharashtra, India.
| | - Vrijesh Tripathi
- Department of Mathematics and Statistics, The University of the West Indies, St. Augustine, Trinidad and Tobago
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Ripon RK, Rimti FH, Kercy M, Hossain S, Motahara U, Hossain MS, Sikder MT. A trend analysis of Black American women with cardiovascular disease and chronic medical conditions, sociodemographic factors from NHANES From 2011 to 2020. PLOS Glob Public Health 2023; 3:e0002521. [PMID: 38109309 PMCID: PMC10727433 DOI: 10.1371/journal.pgph.0002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 09/19/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Significant racial and gender differences exist in the prevalence of CVD in the United States. The goal of this study is to evaluate the prevalence of CVD among Black American women, the relationship between CVD and some medical conditions, and significant sociodemographic factors. METHODS The researchers in this study used data from four cycles of the NHANES, carried out by the NCHS. 2011 to 2012, 2013 to 2014, 2015 to 2016, and 2017 to 2020 were the cycles that were chosen. The researchers used the survey package in the R programming language to examine the data. RESULTS People with CVD problems 20 years of age and older were included in the analyses. Black American women experienced a considerable prevalence of CVD from 2011 to 2020. These women were more likely to report having completed no more schooling than the ninth grade, being widowed/divorced/separated, and having undergone a hysterectomy, as well as having a history of diabetes, asthma, obesity, arthritis, and depression. Black American women with CVD had a 3.8-fold increased risk of diabetes and a 5.6-fold increased risk of arthritis. CONCLUSION This study shows that Black American women with CVD are more likely to have chronic illnesses such as hysterectomy, diabetes, asthma, obesity, arthritis, and depression. Black American women's cardiovascular risk profiles can be updated using the data from this study.
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Affiliation(s)
- Rezaul Karim Ripon
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
- McHigher Center for Health Research, Boston, Massachusetts, United States of America
| | | | - Mickelder Kercy
- The City University of New York, New York, New York, United States of America
| | - Shahriar Hossain
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
- McHigher Center for Health Research, Boston, Massachusetts, United States of America
| | - Umma Motahara
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
| | - Md. Sharif Hossain
- McHigher Center for Health Research, Boston, Massachusetts, United States of America
- Division of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Md. Tajuddin Sikder
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
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Farland LV, Rice MS, Degnan WJ, Rexrode KM, Manson JE, Rimm EB, Rich-Edwards J, Stewart EA, Cohen Rassier SL, Robinson WR, Missmer SA. Hysterectomy With and Without Oophorectomy, Tubal Ligation, and Risk of Cardiovascular Disease in the Nurses' Health Study II. J Womens Health (Larchmt) 2023; 32:747-756. [PMID: 37155739 PMCID: PMC10354306 DOI: 10.1089/jwh.2022.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: Hysterectomy, oophorectomy, and tubal ligation are common surgical procedures. The literature regarding cardiovascular disease (CVD) risk after these surgeries has focused on oophorectomy with limited research on hysterectomy or tubal ligation. Materials and Methods: Participants in the Nurses' Health Study II (n = 116,429) were followed from 1989 to 2017. Self-reported gynecologic surgery was categorized as follows: no surgery, hysterectomy alone, hysterectomy with unilateral oophorectomy, and hysterectomy with bilateral oophorectomy. We separately investigated tubal ligation alone. The primary outcome was CVD based on medical-record confirmed fatal and nonfatal myocardial infarction, fatal coronary heart disease, or fatal and nonfatal stroke. Our secondary outcome expanded CVD to include coronary revascularization (coronary artery bypass graft surgery, angioplasty, stent placement). Cox proportional hazard models were used to calculate hazard ratios (HR) and 95% confidence intervals (CIs) and were adjusted a priori for confounding factors. We investigated differences by age at surgery (≤50, >50) and menopausal hormone therapy usage. Results: At baseline, participants were on average, 34 years old. During 2,899,787 person-years, we observed 1,864 cases of CVD. Hysterectomy in combination with any oophorectomy was associated with a greater risk of CVD in multivariable-adjusted models (HR hysterectomy with unilateral oophorectomy:1.40 [95% CI: 1.08-1.82]; HR hysterectomy with bilateral oophorectomy:1.27 [1.07-1.51]). Hysterectomy alone, hysterectomy with oophorectomy, and tubal ligation were also associated with an increased risk of combined CVD and coronary revascularization (HR hysterectomy alone: 1.19 [95% CI: 1.02-1.39]; HR hysterectomy with unilateral oophorectomy: 1.29 [1.01-1.64]; HR hysterectomy with bilateral oophorectomy: 1.22 [1.04-1.43]; HR tubal ligation: 1.16 [1.06-1.28]). The association between hysterectomy/oophorectomy and CVD and coronary revascularization risk varied by age at gynecologic surgery, with the strongest association among women who had surgery before age 50 years. Conclusion: Our findings suggest that hysterectomy, alone or in combination with oophorectomy, as well as tubal ligation, may be associated with an increased risk of CVD and coronary revascularization. These findings extend previous research finding that oophorectomy is associated with CVD.
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Affiliation(s)
- Leslie V. Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Megan S. Rice
- Clinical and Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William J. Degnan
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
- Department of Community, Environment, and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Kathryn M. Rexrode
- Divisions of Women's Health and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - JoAnn E. Manson
- Divisions of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Eric B. Rimm
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Rich-Edwards
- Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth A. Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
| | - Sarah L. Cohen Rassier
- Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
| | - Whitney R. Robinson
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stacey A. Missmer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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Shen R, Wang J, Tian Y, Wang R, Guo P, Shen S, Liu D, Zou T. Association between hysterectomy status and stroke risk and cause-specific and all-cause mortality: evidence from the 2005-2018 National Health and Nutrition Examination Survey. Front Neurol 2023; 14:1168832. [PMID: 37273708 PMCID: PMC10233142 DOI: 10.3389/fneur.2023.1168832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/25/2023] [Indexed: 06/06/2023] Open
Abstract
Background Prior research on women who had hysterectomies has shown mixed results on whether or not hysterectomies increased the incidence of stroke and cause-specific or all-cause mortality. Methods Using information from the Continuous National Health and Nutrition Examination Survey (NHANES) in the United States, including linked mortality follow-up files available for public access, a multicycle cross-sectional design mortality linkage study was performed. Results Conducted during the years 2005-2018, the study sample included 14,214 female participants ranging in age from 20 to 85 years. The relationship between the hysterectomy status and the risk of stroke and cause-specific and all-cause mortality was examined using a series of weighted logistic regressions and Cox proportional hazards regressions, respectively. The presence of a hysterectomy was consistently linked to an elevated risk of stroke using weighted logistic regression models. The hysterectomy status, however, consistently showed no effect on survival by adjusted weighted Cox regression analysis. Conclusion Our study found a significant association between hysterectomy and stroke, even after adjusting for other factors that could impact risk, such as the American Heart Association (AHA)'s Life's Simple 7 cardiovascular health score and variables of age, ethnicity, marital status, income, education, and depression severity.
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Affiliation(s)
- Ruihuan Shen
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Jia Wang
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Yuqing Tian
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Rui Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Peiyao Guo
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Shuhui Shen
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Donghao Liu
- Department of Cardiology, National Center of Gerontology, Institute of Geriatric Medicine, Beijing Hospital, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Tong Zou
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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Poorthuis MH, Yao P, Chen Y, Guo Y, Shi L, Li L, Chen Z, Clarke R, Yang L. Risks of Stroke and Heart Disease Following Hysterectomy and Oophorectomy in Chinese Premenopausal Women. Stroke 2022; 53:3064-3071. [PMID: 35862220 PMCID: PMC9508951 DOI: 10.1161/strokeaha.121.037305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the long-term risks of stroke and ischemic heart disease (IHD) in women who had a hysterectomy alone (HA) or with bilateral oophorectomy (HBO) for benign diseases, particularly in China where the burden of cardiovascular diseases (CVD) is high. We assessed mean levels of cardiovascular risk factors and relative risks of stroke and IHD in Chinese women who had a HA or HBO. METHODS A total of 302 510 women, aged 30 to 79 years were enrolled in the China Kadoorie Biobank from 2004 to 2008 and followed up for a mean of 9.8 years. The analysis involved premenopausal women without prior cardiovascular disease or cancer at enrollment. We calculated adjusted hazard ratios for incident cases of CVD and their pathological types (ischemic stroke, hemorrhagic stroke, and IHD) after HA and HBO. Analyses were stratified by age and region and adjusted for levels of education, household income, smoking status, alcohol consumption, physical activity, body mass index, systolic blood pressure, diabetes, self-reported health, and number of pregnancies. RESULTS Among 282 722 eligible women, 8478 had HA, and 1360 had HBO. Women who had HA had 9% higher risk of CVD after HA (hazard ratio, 1.09 [95% CI, 1.06-1.12]) and 19% higher risk of CVD after HBO (1.19 [95% CI, 1.12-1.26]) compared with women who did not. Both HA and HBO were associated with higher risks of ischemic stroke and IHD but not with hemorrhagic stroke. The relative risks of CVD associated with HA and HBO were more extreme at younger age of surgery. CONCLUSIONS Women who had either HA or HBO have higher risks of ischemic stroke and IHD, and these risks should be evaluated when discussing these interventions. Additional screening for risk factors for CVD should be considered in women following HA and HBO operations, especially if such operations are performed at younger age.
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Affiliation(s)
- Michiel H.F. Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Pang Yao
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Yiping Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (MRC PHRU) (Y.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Yu Guo
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing (Y.G.)
| | - Liya Shi
- The First Affiliated Hospital of Hainan Medical College, Haikou, Hainan, China (L.S.)
| | - Liming Li
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Sciences Center, Beijing, China (L.L.)
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Ling Yang
- Clinical Trial Service Unit and Epidemiological Studies Unit (M.H.F.P., P.Y., Y.C., Z.C., R.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (MRC PHRU) (Y.C., L.Y.), Nuffield Department of Population Health, University of Oxford, United Kingdom
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Ouh YT, Min KJ, Lee S, Hong JH, Song JY, Lee JK, Lee NW. Analysis of the Relationship between Socioeconomic Status and Incidence of Hysterectomy Using Data of the Korean Genome and Epidemiology Study (KoGES). Healthcare (Basel) 2022; 10:healthcare10060997. [PMID: 35742048 PMCID: PMC9223165 DOI: 10.3390/healthcare10060997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 02/05/2023] Open
Abstract
Hysterectomy remains a frequent gynecologic surgery, although its rates have been decreasing. The aim of this study was to investigate whether socioeconomic status affected the risk of hysterectomy in Korean women. This prospective cohort study used epidemiologic data from 2001 to 2016, from the Korean Genomic and Epidemiology Study (KoGES). Multivariate logistic regression analyses were performed to estimate the association between household income or education level and hysterectomy. Among 5272 Korean women aged 40−69 years, 720 who had a hysterectomy and 4552 controls were selected. Variable factors were adjusted using logistic regression analysis (adjusted model). Adjusted odds ratios (aORs) for insurance type and hysterectomy were not statistically significant. The aOR was 1.479 (95% confidence interval (CI): 1.018−2.146, p < 0.05) for women with education of high school or lower compared to college or higher. Women whose monthly household income was <KRW 4,000,000 had a higher risk of undergoing hysterectomy than women whose monthly household income was ≥KRW 4,000,000 (aOR: 2.193, 95% CI: 1.639−2.933, p < 0.001). Overall, the present study elucidated that lower socioeconomic status could increase the incidence of hysterectomy. Our results indicate that the implementation of stratified preventive strategies for uterine disease in those with low education and low income could be beneficial.
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Affiliation(s)
- Yung-Taek Ouh
- Department of Obstetrics and Gynecology, School of Medicine, Kangwon National University, Chuncheon 24289, Korea;
| | - Kyung-Jin Min
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Ansan 15355, Korea;
- Correspondence:
| | - Sanghoon Lee
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul 02841, Korea; (S.L.); (J.Y.S.)
| | - Jin-Hwa Hong
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Seoul 08308, Korea; (J.-H.H.); (J.-K.L.)
| | - Jae Yun Song
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul 02841, Korea; (S.L.); (J.Y.S.)
| | - Jae-Kwan Lee
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Seoul 08308, Korea; (J.-H.H.); (J.-K.L.)
| | - Nak Woo Lee
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Ansan 15355, Korea;
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Madueke-Laveaux OS, Elsharoud A, Al-Hendy A. What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review. J Clin Med 2021; 10:5335. [PMID: 34830617 DOI: 10.3390/jcm10225335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 12/29/2022] Open
Abstract
Hysterectomy is the most common treatment option in women with uterine fibroids, providing definitive relief from the associated burdensome symptoms. As with all surgical interventions, hysterectomy is associated with risk of complications, short-term morbidities, and mortality, all of which have been described previously. However, information on the potential long-term risks of hysterectomy is only recently becoming available. A systematic literature review was performed to identify studies published between 2005 and December 2020 evaluating the long-term impact of hysterectomy on patient outcomes. A total of 29 relevant studies were identified. A review of the articles showed that hysterectomy may increase the risk of cardiovascular events, certain cancers, the need for further surgery, early ovarian failure and menopause, depression, and other outcomes. It is important to acknowledge that the available studies examine possible associations and hypotheses rather than causality, and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow for preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs.
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Wang Z, Li X, Zhang D. Impact of hysterectomy on cardiovascular disease and different subtypes: a meta-analysis. Arch Gynecol Obstet. [DOI: 10.1007/s00404-021-06240-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
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Wang Z, Wu J, Zhang D. Hysterectomy and ischemic heart disease: An observational study using propensity score methods in NHANES 2007-2018. Atherosclerosis 2021; 327:5-12. [PMID: 34004485 DOI: 10.1016/j.atherosclerosis.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/01/2021] [Accepted: 04/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The association between hysterectomy and cardiovascular disease (CVD) remains controversial and research focusing on different types of CVD, especially ischemic heart disease, is scant. METHODS This observational study was conducted with the National Health and Nutrition Examination Survey (NHANES) 2007-2018 using propensity score matching, propensity score overlap weighting, and logistic regression. RESULTS Among 15,257 women, 3476 (22.78%) had hysterectomy. Compared with non-hysterectomized women, hysterectomized women are more likely to be older, obese, with lower education level, and lower annual family income. Less favorable outcomes often occurred in unadjusted analysis. In adjusted, matched, and weighted analyses, the associations between hysterectomy and all outcomes were consistent, including ischemic heart disease (ORunadjusted = 3.18[95%CI, 2.76-3.66]; ORadjusted = 1.38[95%CI, 1.09-1.73]; ORmatched = 1.37[95%CI, 1.07-1.75]; ORweighted = 1.38[95%CI, 1.12-1.71]), coronary heart disease (ORunadjusted = 3.31[95%CI, 2.71-4.05]; ORadjusted = 1.43[95%CI, 1.04-1.98]; ORmatched = 1.46[95%CI, 1.04-2.05]; ORweighted = 1.45[95%CI, 1.06-1.99]), heart attack (ORunadjusted = 3.04[95%CI, 2.51-3.68]; ORadjusted = 1.47[95%CI, 1.09-1.99]; ORmatched = 1.42[95%CI, 1.03-1.95]; ORweighted = 1.45[95%CI, 1.10-1.91]) and angina pectoris (ORunadjusted = 3.29[95%CI, 2.66-4.08]; ORadjusted = 1.34[95%CI, 0.95-1.89]; ORmatched = 1.30[95%CI, 0.91-1.87]; ORweighted = 1.33[95%CI, 0.98-1.81]). In hysterectomized women, there were no significant associations between bilateral ovariectomy and ischemic heart disease (ORunadjusted = 1.24[95%CI, 0.99-1.54]; ORadjusted = 1.05[95%CI, 0.80-1.38]; ORmatched = 1.16[95%CI, 0.86-1.55]; ORweighted = 0.93[95%CI, 0.68-1.27]), female hormones use and ischemic heart disease (ORunadjusted = 0.94[95%CI, 0.76-1.16]; ORadjusted = 0.81[95%CI, 0.62-1.07]; ORmatched = 0.89[95%CI, 0.66-1.20]; ORweighted = 1.14[95%CI, 0.88-1.49]). CONCLUSIONS Hysterectomy may increase the risk of ischemic heart disease, especially for coronary heart disease and heart attack, but not for angina pectoris. As for the hysterectomized women, bilateral ovariectomy and female hormones use do not affect ischemic heart disease.
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Affiliation(s)
- Zixuan Wang
- Department of Epidemiology and Health Statistics, The School of Public Health of Qingdao University, Qingdao, 266021, Shandong Province, China
| | - Jialong Wu
- Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Dongfeng Zhang
- Department of Epidemiology and Health Statistics, The School of Public Health of Qingdao University, Qingdao, 266021, Shandong Province, China.
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Zhu D, Chung HF, Dobson AJ, Pandeya N, Brunner EJ, Kuh D, Greenwood DC, Hardy R, Cade JE, Giles GG, Bruinsma F, Demakakos P, Simonsen MK, Sandin S, Weiderpass E, Mishra GD. Type of menopause, age of menopause and variations in the risk of incident cardiovascular disease: pooled analysis of individual data from 10 international studies. Hum Reprod 2020; 35:1933-1943. [PMID: 32563191 PMCID: PMC8453420 DOI: 10.1093/humrep/deaa124] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/22/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION How does the risk of cardiovascular disease (CVD) vary with type and age of menopause? SUMMARY ANSWER Earlier surgical menopause (e.g. <45 years) poses additional increased risk of incident CVD events, compared to women with natural menopause at the same age, and HRT use reduced the risk of CVD in women with early surgical menopause. WHAT IS KNOWN ALREADY Earlier age at menopause has been linked to an increased risk of CVD mortality and all-cause mortality, but the extent that this risk of CVD varies by type of menopause and the role of postmenopausal HRT use in reducing this risk is unclear. STUDY DESIGN, SIZE, DURATION Pooled individual-level data of 203 767 postmenopausal women from 10 observational studies that contribute to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE) consortium were included in the analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS Postmenopausal women who had reported menopause (type and age of menopause) and information on non-fatal CVD events were included. Type of menopause (natural menopause and surgical menopause) and age at menopause (categorised as <35, 35-39, 40-44, 45-49, 50-54 and ≥55 years) were exposures of interest. Natural menopause was defined as absence of menstruation over a period of 12 months (no hysterectomy and/or oophorectomy) and surgical menopause as removal of both ovaries. The study outcome was the first non-fatal CVD (defined as either incident coronary heart disease (CHD) or stroke) event ascertained from hospital medical records or self-reported. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CI for non-fatal CVD events associated with natural menopause and surgical menopause. MAIN RESULTS AND THE ROLE OF CHANCE Compared with natural menopause, surgical menopause was associated with over 20% higher risk of CVD (HR 1.22, 95% CI 1.16-1.28). After the stratified analysis by age at menopause, a graded relationship for incident CVD was observed with lower age at menopause in both types of natural and surgical menopause. There was also a significant interaction between type of menopause and age at menopause (P < 0.001). Compared with natural menopause at 50-54 years, women with surgical menopause before 35 (2.55, 2.22-2.94) and 35-39 years (1.91, 1.71-2.14) had higher risk of CVD than those with natural menopause (1.59, 1.23-2.05 and 1.51, 1.33-1.72, respectively). Women who experienced surgical menopause at earlier age (<50 years) and took HRT had lower risk of incident CHD than those who were not users of HRT. LIMITATIONS, REASONS FOR CAUTION Self-reported data on type and age of menopause, no information on indication for the surgery (e.g. endometriosis and fibroids) and the exclusion of fatal CVD events may bias our results. WIDER IMPLICATIONS OF THE FINDINGS In clinical practice, women who experienced natural menopause or had surgical menopause at an earlier age need close monitoring and engagement for preventive health measures and early diagnosis of CVD. Our findings also suggested that timing of menopause should be considered as an important factor in risk assessment of CVD for women. The findings on CVD lend some support to the position that elective bilateral oophorectomy (surgical menopause) at hysterectomy for benign diseases should be discouraged based on an increased risk of CVD. STUDY FUNDING/COMPETING INTEREST(S) InterLACE project is funded by the Australian National Health and Medical Research Council project grant (APP1027196). GDM is supported by Australian National Health and Medical Research Council Principal Research Fellowship (APP1121844). There are no competing interests.
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Affiliation(s)
- Dongshan Zhu
- The University of Queensland, Epidemiology and Biostatistics Division, School of Public Health, Brisbane, Queensland, Australia
| | - Hsin-Fang Chung
- The University of Queensland, Epidemiology and Biostatistics Division, School of Public Health, Brisbane, Queensland, Australia
| | - Annette J Dobson
- The University of Queensland, Epidemiology and Biostatistics Division, School of Public Health, Brisbane, Queensland, Australia
| | - Nirmala Pandeya
- The University of Queensland, Epidemiology and Biostatistics Division, School of Public Health, Brisbane, Queensland, Australia
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Eric J Brunner
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Diana Kuh
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Darren C Greenwood
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | | | - Janet E Cade
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Graham G Giles
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Fiona Bruinsma
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Panayotes Demakakos
- Department of Epidemiology and Public Health, University College London, London, UK
| | | | - Sven Sandin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, World Health Organisation, Lyon, France
| | - Gita D Mishra
- The University of Queensland, Epidemiology and Biostatistics Division, School of Public Health, Brisbane, Queensland, Australia
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Laughlin-Tommaso SK, Satish A, Khan Z, Smith CY, Rocca WA, Stewart EA. Long-term risk of de novo mental health conditions after hysterectomy with ovarian conservation: a cohort study. Menopause 2020; 27:33-42. [PMID: 31479034 PMCID: PMC7089568 DOI: 10.1097/gme.0000000000001415] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this research was to study the long-term risk of de novo mental health conditions in women who underwent hysterectomy with bilateral ovarian conservation compared with age-matched referent women. METHODS Using the Rochester Epidemiology Project records-linkage system, we identified a historical cohort of 2,094 women who underwent hysterectomy with ovarian conservation for benign indications at age ≥18 years and with an index date between 1980 and 2002 in Olmsted County, Minnesota. Each woman was age-matched (±1 y) to a referent woman residing in the same county who had not undergone hysterectomy or any oophorectomy before the index date. These two cohorts were followed historically to identify de novo mental health conditions. We estimated hazard ratios (HRs) and 95% confidence intervals (95% CIs) using Cox proportional hazards models adjusted for 20 preexisting chronic conditions and other potential confounders. We also calculated absolute risk increases (ARIs) and reductions (ARRs) at 30 years of follow-up. RESULTS Over a median follow-up of 21.9 years, women who underwent hysterectomy at any age experienced increased risks of de novo depression (adjusted HR 1.26; 95% CI, 1.12-1.41; ARI 6.6%) and anxiety (adjusted HR 1.22; 95% CI, 1.08-1.38; ARI 4.7%). The association for depression increased significantly with younger age at hysterectomy, but did not vary significantly by indication. Interactions were not significant for anxiety. CONCLUSIONS Hysterectomy, even with ovarian conservation, is associated with an increased long-term risk of de novo depression and anxiety, especially when performed in women who are younger. : Video Summary:http://links.lww.com/MENO/A465.
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Affiliation(s)
- Shannon K Laughlin-Tommaso
- Division of Gynecology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Anisha Satish
- Division of Gynecology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Carin Y Smith
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Walter A Rocca
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
- Department of Neurology, Mayo Clinic, Rochester, MN
| | - Elizabeth A Stewart
- Department of Surgery, Mayo Clinic, Rochester, MN
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
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Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study. Menopause 2018; 25:483-92. [PMID: 29286988 DOI: 10.1097/GME.0000000000001043] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine the long-term risk of cardiovascular disease and metabolic conditions in women undergoing hysterectomy with bilateral ovarian conservation compared with age-matched referent women. METHODS Using the Rochester Epidemiology Project records-linkage system, we identified 2,094 women who underwent hysterectomy with ovarian conservation for benign indications between 1980 and 2002 in Olmsted County, Minnesota. Each woman was age-matched (±1 y) to a referent woman residing in the same county who had not undergone prior hysterectomy or any oophorectomy. These two cohorts were followed historically to identify de novo cardiovascular or metabolic diagnoses. We estimated hazard ratios (HRs) and 95% CIs using Cox proportional hazards models adjusted for 20 preexisting chronic conditions and other potential confounders. We also calculated absolute risk increases and reductions from Kaplan-Meier estimates. RESULTS Over a median follow-up of 21.9 years, women who underwent hysterectomy experienced increased risks of de novo hyperlipidemia (HR 1.14; 95% CI, 1.05-1.25), hypertension (HR 1.13; 95% CI, 1.03-1.25), obesity (HR 1.18; 95% CI, 1.04-1.35), cardiac arrhythmias (HR 1.17; 95% CI, 1.05-1.32), and coronary artery disease (HR 1.33; 95% CI, 1.12-1.58). Women who underwent hysterectomy at age ≤35 years had a 4.6-fold increased risk of congestive heart failure and a 2.5-fold increased risk of coronary artery disease. CONCLUSIONS Even with ovarian conservation, hysterectomy is associated with an increased long-term risk of cardiovascular and metabolic conditions, especially in women who undergo hysterectomy at age ≤35 years. If these associations are causal, alternatives to hysterectomy should be considered to treat benign gynecologic conditions.
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Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: a national and state-level analysis of the Fourth National Family Health Survey (2015-2016). BJOG 2019; 126 Suppl 4:72-80. [PMID: 31309706 PMCID: PMC6772015 DOI: 10.1111/1471-0528.15858] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2019] [Indexed: 11/29/2022]
Abstract
Objective The National Family Health Survey‐4 in India provided the first nationally representative estimates of hysterectomy among women aged 15–49. This paper aims to examine the national and state‐level age‐specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state‐level indicators that may explain variation across states. Design Cross‐sectional, nationally representative household survey. Setting National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016. Population The survey covered 699 686 women between the ages of 15 and 49 years. Methods Descriptive analyses and multivariate logistic regression. Main outcome measures Women who reported ever having a hysterectomy and age at hysterectomy. Results Age‐specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15‐29; 3.59% (3.45,3.74) among women aged 30‐39; and 9.20% (8.94,9.46) among women 40‐49 years. There was considerable variation in prevalence by state. Four states reported age‐specific prevalence similar to high‐income settings. Approximately two‐thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P < 0.01) and higher wealth status were associated with higher odds of hysterectomy. Previously sterilised women had lower odds (AOR 0.64; 95% CI 0.61,0,68; P < 0.01) of reporting hysterectomy. Exploratory analyses suggest state‐level factors associated with prevalence of hysterectomy include caesarean section, female illiteracy, and women's employment. Conclusions Hysterectomy patterns among women aged 15–49 in India indicate the critical need to ensure treatment options for gynaecological morbidity and to address hysterectomy among young women in particular. Funding This study was part of the RASTA initiative of the Population Council's India country office under the Evidence Project supported by USAID. Tweetable abstract Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women. Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.
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Affiliation(s)
- S Desai
- Population Council, New Delhi, India
| | - A Shukla
- Population Council, New Delhi, India
| | - D Nambiar
- The George Institute India, New Delhi, India
| | - R Ved
- National Health Systems Resource Centre, New Delhi, India
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Karvinen S, Jergenson MJ, Hyvärinen M, Aukee P, Tammelin T, Sipilä S, Kovanen V, Kujala UM, Laakkonen EK. Menopausal Status and Physical Activity Are Independently Associated With Cardiovascular Risk Factors of Healthy Middle-Aged Women: Cross-Sectional and Longitudinal Evidence. Front Endocrinol (Lausanne) 2019; 10:589. [PMID: 31543865 PMCID: PMC6729112 DOI: 10.3389/fendo.2019.00589] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 08/12/2019] [Indexed: 12/21/2022] Open
Abstract
Cardiovascular disease (CVD) is the primary cause of mortality in women in developed countries. CVD risk rises with age, yet for women there is a rapid increase in CVD risk that occurs after the onset of menopause. This observation suggests the presence of factors in the middle-aged women that accelerate the progression of CVD independent of chronological aging. Leisure time physical activity (LTPA) is a well-established protective factor against CVD. However, its role in attenuating atherogenic lipid profile changes and CVD risk in post-menopausal women has not been well-established. The present study is part of the Estrogenic Regulation of Muscle Apoptosis (ERMA) study, a population-based cohort study in which middle-aged Caucasian women (47-55) were classified into pre-menopausal, peri-menopausal, and post-menopausal groups based on follicle stimulating hormone levels and bleeding patterns. Comprehensive questionnaires, laboratory visits, anthropometric measurements, and physical activity monitoring by accelerometers were used to characterize the menopausal groups and serum lipid profiles were analyzed to quantify CV (cardiovascular) risk factors. Based on our findings, LTPA may attenuate menopause-associated atherogenic changes in the serum CV risk factors of healthy middle-aged women. However, LTPA does not seem to entirely offset the lipid profile changes associated with the menopausal transition.
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Affiliation(s)
- Sira Karvinen
- Gerontology Research Center, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Matthew J Jergenson
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Matti Hyvärinen
- Gerontology Research Center, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Pauliina Aukee
- Pelvic Floor Research and Therapy Unit, Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Tuija Tammelin
- LIKES Research Centre for Physical Activity and Health, Jyväskylä, Finland
| | - Sarianna Sipilä
- Gerontology Research Center, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Vuokko Kovanen
- Gerontology Research Center, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Urho M Kujala
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Eija K Laakkonen
- Gerontology Research Center, Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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Wilson LF, Pandeya N, Byles J, Mishra GD. Hysterectomy status and all-cause mortality in a 21-year Australian population-based cohort study. Am J Obstet Gynecol 2019; 220:83.e1-83.e11. [PMID: 30312584 DOI: 10.1016/j.ajog.2018.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/22/2018] [Accepted: 10/01/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hysterectomy is a common surgical procedure, predominantly performed when women are between 30 and 50 years old. One in 3 women in Australia has had a hysterectomy by the time they are 60 years old, and 30% have both ovaries removed at the time of surgery. Given this high prevalence, it is important to understand the long-term effects of hysterectomy. In particular, women who have a hysterectomy/oophorectomy at younger ages are likely to be premenopausal or perimenopausal and may experience greater changes in hormone levels and a shortened reproductive lifespan than women who have a hysterectomy when they are older and postmenopausal. Use of menopausal hormone therapy after surgery may compensate for these hormonal changes. To inform clinical decisions about postsurgery management of women who have a hysterectomy prior to menopause (ie, average age at menopause 50 years), it is useful to compare women with a hysterectomy to women with no hysterectomy and to stratify the hysterectomy status by whether or not women have had a bilateral oophorectomy, or used menopausal hormone therapy. OBJECTIVE We sought to investigate whether women who had a hysterectomy with ovarian conservation or a hysterectomy and bilateral oophorectomy before the age of 50 years were at a higher risk of premature all-cause mortality compared to women who did not have this surgery before the age of 50 years. We also sought to explore whether use of menopausal hormone therapy modified these associations. STUDY DESIGN Women from the midcohort (born 1946 through 1951) of the Australian Longitudinal Study on Women's Health were included in our study sample (n = 13,541). Women who reported a hysterectomy (with and without both ovaries removed) before the age of 50 years were considered exposure at risk and compared with women who did not report these surgeries before age 50 years. To explore effect modification by use of menopausal hormone therapy we further stratified hysterectomy status by menopausal hormone therapy use. Risk of all-cause mortality was assessed using inverse-probability weighted Cox regression models. RESULTS During a median follow-up of 21.5 years, there were 901 (6.7%) deaths in our study sample. Overall, there was no difference in all-cause mortality between women who reported a hysterectomy with ovarian conservation (hazard ratio, 0.86; 95% confidence interval, 0.72-1.02) or women who reported a hysterectomy and bilateral oophorectomy (hazard ratio, 1.02; 95% confidence interval, 0.78-1.34) and women with no hysterectomy. When stratified by menopausal hormone therapy use, women with hysterectomy and ovarian conservation before the age of 50 years were not at higher risk of all-cause mortality compared to no hysterectomy, regardless of menopausal hormone therapy use status. In contrast, among nonusers of menopausal hormone therapy only, women who reported a hysterectomy-bilateral oophorectomy before the age of 50 years were at a higher risk of death compared to women with no hysterectomy (hazard ratio, 1.81; 95% confidence interval, 1.01-3.25). CONCLUSION Hysterectomy with ovarian conservation before the age of 50 years did not increase risk of all-cause mortality. Among nonmenopausal hormone therapy users only, hysterectomy and bilateral oophorectomy before the age of 50 years was associated with a higher risk of death.
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Affiliation(s)
- Louise F Wilson
- Center for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Brisbane, Australia.
| | - Nirmala Pandeya
- Center for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Brisbane, Australia; QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Julie Byles
- Research Center for Generational Health and Aging, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Gita D Mishra
- Center for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Brisbane, Australia
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Choi HG, Lee SW. Hysterectomy does not increase the risk of hemorrhagic or ischemic stroke over a mean follow-up of 6 years: A longitudinal national cohort study. Maturitas 2018; 117:11-16. [DOI: 10.1016/j.maturitas.2018.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/04/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022]
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Harnod T, Chen W, Wang JH, Lin SZ, Ding DC. Hysterectomies Are Associated with an Increased Risk of Depression: A Population-Based Cohort Study. J Clin Med 2018; 7:E366. [PMID: 30340333 DOI: 10.3390/jcm7100366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 01/11/2023] Open
Abstract
Using the National Health Insurance Research Database of Taiwan, we investigated whether undergoing a hysterectomy increases the risk of depression. A total of 7872 patients aged 30–49 years who underwent a hysterectomy from 2000 to 2013 were enrolled as the hysterectomy group. The comparison group was randomly selected from women who had never undergone a hysterectomy and was four times the size of the hysterectomy group. We calculated adjusted hazard ratios and 95% confidence intervals (CIs) for depression [The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 296.2, 296.3, 300.4, 311] in these cohorts after adjusting for age, comorbidities, oophorectomy, and hormone therapy. The overall incidence of depression was 1.02 and 0.66 per 100 person-years in the hysterectomy and comparison cohorts, respectively, yielding an adjusted hazard ratio of 1.35 (95% CI = 1.22–1.50) for depression risk. When we stratified patients by age, comorbidities, oophorectomy, and hormone use, hysterectomy increased the risk of depression. Hysterectomy, oophorectomy, and post-surgery hormone use were associated with an increased risk of depression when they occurred alone, but conferred a greater risk if they were considered jointly. Hysterectomy would be a predisposing factor for increased risk of subsequent depression. Our findings provide vital information for patients, clinicians, and the government for improving the treatment strategy in the future.
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Abstract
Uterine leiomyomas are common and life-altering for many women. Despite a wide range of symptoms, varying characteristics of the uterus and the leiomyomas themselves, and many alternatives, hysterectomy accounts for almost three fourths of all surgical therapy, yet there is increasing evidence for a variety of procedural therapies for symptomatic leiomyomas and a new generation of medical therapies under development. With increasing evidence of long-term risk from hysterectomy and new data regarding leiomyoma biology, individualized medical approaches to leiomyomas are likely in the near future. Key biological attributes that influence this disease process are common driver mutations and the new appreciation of the interaction of smooth muscle cells and fibroblasts. Additionally, the interaction between cell types and steroid hormone responsiveness likely plays a role in pathogenesis that can be leveraged in individualized therapy. However, given the independent clonal nature of leiomyomas within the same uterus, moving in the direction of biopsies for individual leiomyomas to understand the biology is unlikely to be fruitful. Use of advanced imaging will likely continue to evolve not only to accurately predict malignant disease, including sarcomas, but to predict leiomyoma subtypes, response to therapy, or both. We predict the continued evolution of therapy from excisional or interventional therapies to medical therapies and ultimately prediction of at-risk individuals. Ideally, individualized therapies will offer primary prevention for women at high risk of leiomyomas and secondary prevention after initial treatment.
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Affiliation(s)
- Shannon K. Laughlin-Tommaso
- Division of Gynecology, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Elizabeth A. Stewart
- Department of Surgery, Mayo Clinic, Rochester, MN
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
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Abstract
Hysterectomy is a common procedure for benign pathologies of the uterus. Reduced production of estrogen following hysterectomy has been reported. Yet the association between hysterectomy and coronary artery disease (CAD) risk remains controversial. The aim of this study was to investigate the effect of hysterectomy on the risk of CAD; calculations were adjusted for traditional risk factors.This study used a 1 million patient cohort of the Taiwan National Health Insurance database and included a total of 7331 women who received hysterectomy from 2000 to 2013. We randomly selected a control group composed of 29,324 women without hysterectomy by 1:4 matching the age (exact year) with the hysterectomy group.The mean (standard deviation) age was 43.5 ± 4.0 in the hysterectomy and 43.6 ± 4.0 in the control group. A total of 1986 CAD cases developed in both groups during a median follow-up of 7 years. Significant differences were observed in CAD incidence in the hysterectomy versus control group (9.82 vs. 7.17/1000 person-years, P < .001, adjusted hazard ratio = 1.31 [95% confidence interval: 1.18-1.45]).We found a significant association between hysterectomy and CAD, even after adjustment for baseline CAD risk factors.
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Affiliation(s)
- Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Institute of Medical Sciences, Tzu Chi University, Hualien
| | - I-Ju Tsai
- Management Office for Health Data, China Medical University Hospital
| | - Chung Y. Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Jen-Hung Wang
- Department of Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shinn-Zong Lin
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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Liu F, Pan Y, Liang Y, Zhang C, Deng Q, Li X, Liu M, He Z, Liu Y, Li J, Ning T, Guo C, Xu R, Zhang L, Cai H, Ke Y. The epidemiological profile of hysterectomy in rural Chinese women: a population-based study. BMJ Open 2017; 7:e015351. [PMID: 28667216 PMCID: PMC5734410 DOI: 10.1136/bmjopen-2016-015351] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Hysterectomy is one of the most common surgical procedures performed on women in developed countries; however, little is known about the epidemiology of hysterectomy in low-income to middle-income regions. This study seeks to evaluate the prevalence of hysterectomy and its risk factors in rural China. METHODS Questionnaires were collected from 3328 female adults aged 25â€"69 years in rural Anyang, China, in 2009â€"2011. Hysterectomy status was ascertained by the gynaecologist at the time of cytological test. Univariate and multivariate regression analyses were performed to assess the risk factors for hysterectomy. RESULTS The overall prevalence of hysterectomy was 3.31% (110/3328). Women above the age of 40 years had a higher prevalence of prior hysterectomy, compared with those aged 25â€"39 years (5.01% vs 0.33%). Obesity was marginally related with a higher risk of hysterectomy (adjusted OR=1.59; 95% CI 0.99 to 2.56; body mass index (BMI) ≥28.0 vs 18.5 ≤ BMI <24.0). History of prior pregnancy loss conferred a greater risk for hysterectomy (adjusted OR=1.51; 95% CI 1.02 to 2.23). Of the 75 (68.18%, 75/110) cases who provided further information on hysterectomy, 84.00% (63/75) had undergone total abdominal hysterectomy and 70.67% (53/75) had received surgery for leiomyoma. CONCLUSIONS Rural Chinese women had a relatively low prevalence of hysterectomy, and the majority of reported hysterectomies were performed abdominally for leiomyoma. Hysterectomy prevalence differed significantly by age, BMI and history of pregnancy loss. This study expands the current understanding of the epidemiology of hysterectomy in lower resource areas.
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Affiliation(s)
- Fangfang Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yaqi Pan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yongmei Liang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Chaoting Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Qiuju Deng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Xiang Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Mengfei Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Zhonghu He
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Ying Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jingjing Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Tao Ning
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Chuanhai Guo
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Ruiping Xu
- Administrative Department, Anyang Cancer Hospital, Anyang, China
| | - Lixin Zhang
- Administrative Department, Anyang Cancer Hospital, Anyang, China
| | - Hong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yang Ke
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Laboratory of Genetics, Peking University Cancer Hospital and Institute, Beijing, China
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Desai S, Campbell OM, Sinha T, Mahal A, Cousens S. Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India. Health Policy Plan 2016; 32:68-78. [PMID: 27497139 PMCID: PMC5886266 DOI: 10.1093/heapol/czw099] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 11/29/2022] Open
Abstract
Hysterectomy is a leading reason for use of health insurance amongst low-income women in India, but there are limited population-level data available to inform policy. This paper reports on the findings of a mixed-methods study to estimate incidence and identify predictors of hysterectomy in a low-income setting in Gujarat, India. The estimated incidence of hysterectomy, 20.7/1000 woman- years (95% CI: 14.0, 30.8), was considerably higher than reported from other countries, at a relatively low mean age of 36 years. There was strong evidence that among women of reproductive age, those with lower income and at least two children underwent hysterectomy at higher rates. Nearly two-thirds of women undergoing hysterectomy utilized private hospitals, while the remainder used government or other non-profit facilities. Qualitative research suggested that weak sexual and reproductive health services, a widespread perception that the post-reproductive uterus is dispensable and lack of knowledge of side effects have resulted in the normalization of hysterectomy. Hysterectomy appears to be promoted as a first or second-line treatment for menstrual and gynaecological disorders that are actually amenable to less invasive procedures. Most women sought at least two medical opinions prior to hysterectomy, but both public and private providers lacked equipment, skills and motivation to offer alternatives. Profit and training benefits also appeared to play a role in some providers’ behaviour. Although women with insecure employment underwent the procedure knowing the financial and physical implications of undergoing a major surgery, the future health and work security afforded by hysterectomy appeared to them to outweigh risks. Findings suggest that sterilization may be associated with an increased risk of hysterectomy, potentially through biological or attitudinal links. Health policy interventions require improved access to sexual and reproductive health services and health education, along with surveillance and medical audits to promote high-quality choices for women through the life cycle.
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Affiliation(s)
- Sapna Desai
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK .,Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India
| | - Oona Mr Campbell
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK
| | - Tara Sinha
- Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India
| | - Ajay Mahal
- Nossal Institute for Global Health, University of Melbourne, Carlton VIC 3053, Australia.,Monash University, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
| | - Simon Cousens
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK
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23
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Wilson LF, Mishra GD. Age at Menarche, Level of Education, Parity and the Risk of Hysterectomy: A Systematic Review and Meta-Analyses of Population-Based Observational Studies. PLoS One 2016; 11:e0151398. [PMID: 26963512 PMCID: PMC4786144 DOI: 10.1371/journal.pone.0151398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 02/26/2016] [Indexed: 12/13/2022] Open
Abstract
Background Although rates have declined, hysterectomy is still a frequent gynaecological procedure. To date, there has been no systematic quantification of the relationships between early/mid-life exposures and hysterectomy. We performed a systematic review and meta-analyses to quantify the associations between age at menarche, education level, parity and hysterectomy. Methods Eligible studies were identified by searches in PubMed and Embase through March 2015. Study-specific estimates were summarised using random effects meta-analysis. Heterogeneity was explored using sub-group analysis and meta-regression. Results Thirty-two study populations were identified for inclusion in at least one meta-analysis. Each year older at menarche was associated with lower risk of hysterectomy—summary hazard ratio 0.86 (95% confidence interval: 0.78, 0.95; I2 = 0%); summary odds ratio 0.88 (95% confidence interval: 0.82, 0.94; I2 = 61%). Low education levels conferred a higher risk of hysterectomy in the lowest versus highest level meta-analysis (summary hazard ratio 1.87 (95% confidence interval: 1.25, 2.80; I2 = 86%), summary odds ratio 1.51 (95% confidence interval: 1.35, 1.69; I2 = 90%)) and dose-response meta-analysis (summary odds ratio 1.17 (95% confidence interval: 1.12, 1.23; I2 = 85%) per each level lower of education). Sub-group analysis showed that the birth cohort category of study participants, the reference category used for level of education, the year the included article was published, quality of the study (as assessed by the authors) and control for the key variables accounted for the high heterogeneity between studies in the education level meta-analyses. In the meta-analyses of studies of parity and hysterectomy the results were not statistically significant. Conclusions The present meta-analyses suggest that the early life factors of age at menarche and lower education level are associated with hysterectomy, although this evidence should be interpreted with some caution due to variance across the included studies.
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Affiliation(s)
- Louise F. Wilson
- The University of Queensland, Centre for Longitudinal and Life Course Research, School of Public Health, Public Health Building, Herston Road, Herston, Queensland, 4006, Australia
- * E-mail:
| | - Gita D. Mishra
- The University of Queensland, Centre for Longitudinal and Life Course Research, School of Public Health, Public Health Building, Herston Road, Herston, Queensland, 4006, Australia
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24
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Ryan GL, Mengeling MA, Summers KM, Booth BM, Torner JC, Syrop CH, Sadler AG. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. Am J Obstet Gynecol 2016; 214:352.e1-352.e13. [PMID: 26475424 DOI: 10.1016/j.ajog.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/30/2015] [Accepted: 10/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population. OBJECTIVES The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population. STUDY DESIGN We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests. RESULTS Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V. CONCLUSION Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.
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Affiliation(s)
- Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA.
| | - Michelle A Mengeling
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA; Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City Veterans Affairs Health Care System, Iowa City, IA
| | - Karen M Summers
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brenda M Booth
- Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR
| | - James C Torner
- Department of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Craig H Syrop
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Anne G Sadler
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA
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