Prevalence corrected hysterectomy rates and probabilities in Utah

Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Quality of life and sexual function after abdominal versus laparoscopic hysterectomy: a prospective study

BACKGROUND

This study aimed to evaluate the quality of life (QoL) and sexual function of women who underwent total abdominal hysterectomy and total laparoscopic hysterectomy.

METHODS

In this prospective cohort study, a total of 121 patients who underwent total abdominal hysterectomy (N.=65) and total laparoscopic hysterectomy (N.=56) operations for benign indications were included. Sociodemographic features, obstetric histories, and clinical characteristics of the patients were noted. Quality of life assessment was conducted with the World Health Organization Quality of Life-BREF questionnaire, which has five domains: overall quality of life + health, physical health, psychological health, social relationships, and environment. Sexual function was assessed by the Golombok-Rust Inventory of Sexual Satisfaction Scale with subscales of infrequency, non-communication, avoidance, non-sensuality, dissatisfaction, vaginismus, and anorgasmia. The patients were asked to fill in both questionnaires before the operation and six months after the operation.

RESULTS

Of the 121 patients, 104 of them completed the postoperative surveys. In the total laparoscopic hysterectomy group, the individual improvements of the overall quality of life + health physical, and psychological health domains were statistically higher than the total abdominal hysterectomy group. In terms of sexual function, the total abdominal hysterectomy group had worse avoidance, non-sensuality, dissatisfaction, and vaginismus subscale scores and total score both in the preoperative and postoperative period compared to the total laparoscopic hysterectomy group. However, the individual differences and the number of patients exhibiting sexual dysfunction before and after surgery were not statistically significant in both groups.

CONCLUSIONS

Laparoscopic hysterectomy was superior to abdominal hysterectomy in improving the quality of life of the patients. Both abdominal and laparoscopic hysterectomies were not found to affect female sexuality.

Integrating Surveillance Data to Estimate Race/Ethnicity-specific Hysterectomy Inequalities Among Reproductive-aged Women: Who's at Risk?

BACKGROUND

Inequalities by race and ethnicity in hysterectomy for noncancerous conditions suggest that some subgroups may be shouldering an unfair burden of procedure-associated negative health impacts. We aimed to estimate race- and ethnicity-specific rates in contemporary hysterectomy incidence that address three challenges in the literature: exclusion of outpatient procedures, no hysterectomy prevalence adjustment, and paucity of non-White and non-Black estimates.

METHODS

We used surveillance data capturing all inpatient and outpatient hysterectomy procedures performed in North Carolina from 2011 to 2014 (N = 30,429). Integrating data from the Behavior Risk Factor Surveillance System and US Census population estimates, we calculated prevalence-corrected hysterectomy incidence rates and differences by race and ethnicity.

RESULTS

Prevalence-corrected estimates show that non-Hispanic (nH) Blacks (62, 95% confidence interval [CI] = 61, 63) and nH American Indians (85, 95% CI = 79, 93) per 10,000 person-years (PY) had higher rates, compared with nH Whites (45 [95% CI = 45, 46] per 10,000 PY), while Hispanic (20, 95% CI = 20, 21) and nH Asian/Pacific Islander rates (8, 95% CI = 8.0, 8.2) per 10,000 PY were lower than nH Whites.

CONCLUSION

Through strategic surveillance data use and application of bias correction methods, we demonstrate wide differences in hysterectomy incidence by race and ethnicity. See video abstract at, http://links.lww.com/EDE/B657.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Increasing minimally invasive hysterectomy: effect on cost and complications

OBJECTIVE

In a 3-year period, the main mode of access for hysterectomy at Brigham and Women's Hospital changed from abdominal to laparoscopic. We estimated potential effects of this shift on perioperative outcomes and costs.

METHODS

We compared the perioperative outcomes and the cost of care for all hysterectomies performed in 2006 and 2009 at an urban academic tertiary care center using the χ² test or Fisher's exact test for categorical variables and two-sided Student's t test for continuous variables. A multivariate regression analysis was also performed for the major perioperative outcomes across the study groups. Cost data were gathered from the hospital's billing system; the remainder of data was extracted from patients' medical records.

RESULTS

This retrospective study included 2,133 patients. The total number of hysterectomies performed remained stable (1,054 procedures in 2006 compared with 1,079 in 2009) but the relative proportions of abdominal and laparoscopic cases changed markedly during the 3-year period (64.7% to 35.8% for abdominal, P<.001; and 17.7% to 46% for laparoscopic cases, P<.001). The overall rate of intraoperative complications and minor postoperative complications decreased significantly (7.2% to 4%, P<.002; and 18% to 5.7%, P<.001, respectively). Operative costs increased significantly for all procedures aside from robotic hysterectomy, although no significant change was noted in total mean costs.

CONCLUSION

A change from majority abdominal hysterectomy to minimally invasive hysterectomy was accompanied by a significant decrease in procedure-related complications without an increase in total mean costs.

Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies

Complication rates did not vary significantly among minimally invasive methods of hysterectomy; however, patient costs were significantly influenced by the technique used for hysterectomy.

Background and Objectives:

To estimate the incidence of operative complications and compare operative cost and overall cost of different methods of benign hysterectomy including abdominal, vaginal, laparoscopic, and robotic techniques.

Methods:

We performed a retrospective cohort analysis (Canadian Task Force classification II-2) of all patients who underwent a hysterectomy for benign reasons in 2009 at a single urban academic tertiary care center using the χ² test and Student t test. A multivariate regression analysis was also performed for predictors of costs. Cost data were gathered from the hospital's billing system; the remainder of data was extracted from patient's medical records.

Results:

In 2009, 688 patients underwent a benign hysterectomy; 185 (26.9%) hysterectomies were abdominal, 135 (19.6%) vaginal, 352 (51.5%) laparoscopic, and 14 (2.0%) robotic. The rate of intraoperative complication was 1.7% for abdominal, 0.8% for vaginal, 0.3% for laparoscopic, and 0 for robotic. Mean total patient costs were $43,622 for abdominal, $31,934 for vaginal, $38,312 for laparoscopic, and $49,526 for robotic hysterectomies. Costs were significantly influenced by method of hysterectomy, operative time, and length of stay.

Conclusion:

Though complication rates did not vary significantly among minimally invasive methods of hysterectomy, patient costs were significantly influenced by the method of hysterectomy.

Is estrogen plus progestin menopausal hormone therapy safe with respect to endometrial cancer risk?

Given the strong link between use of unopposed estrogens and development of endometrial cancers, estrogens are usually prescribed with a progestin, particularly for women with intact uteri. Some studies suggest that sequential use of progestins may increase risk; however, the moderating effects of usage patterns or patient characteristics, including body mass index (BMI), are unknown. We evaluated menopausal hormone use and incident endometrial cancer (n = 885) in 68,419 postmenopausal women with intact uteri enrolled in the National Institutes of Health-American Association of Retired Persons Diet and Health study. Participants completed a risk factor questionnaire in 1996-1997 and were followed up through 2006. Hazard rate ratios (RRs) and 95% confidence intervals (CIs) were estimated using Cox regression. Among 19,131 women reporting exclusive estrogen plus progestin use, 176 developed endometrial cancer (RR = 0.88; 95% CI = 0.74-1.06). Long-duration (≥ 10 years) sequential (<15 days progestin per month) estrogen plus progestin use was positively associated with risk (RR = 1.88; 95% CI = 1.36-2.60], whereas continuous (>25 days progestin per month) estrogen plus progestin use was associated with a decreased risk (RR = 0.64; 95% CI = 0.49-0.83). Increased risk for sequential estrogen plus progestin was seen only among thin-to-normal weight women (BMI < 25 kg/m(2); RR = 2.53). Our findings support that specific categories of estrogen plus progestin use increases endometrial cancer risk, specifically long durations of sequential progestins, whereas decreased endometrial cancer risk was observed for users of short-duration continuous progestins. Risks were highest among thin-to-normal weight women, presumably reflecting their lower endogenous estrogen levels, suggesting that menopausal hormones and obesity increase endometrial cancer through common etiologic pathways.

Ovarian cancer and menopausal hormone therapy in the NIH-AARP diet and health study

Background:

Women using unopposed estrogens during menopause are at increased risk of ovarian cancer. It is uncertain whether oestrogen plus progestin therapy exerts similar effects.

Methods:

We evaluated menopausal hormone use and incident ovarian cancer (n=426) in 92 601 post-menopausal women enrolled in the National Institutes of Health-AARP (NIH-AARP) Diet and Health Study. Participants were administered questionnaires in 1996–1997 and followed through 2006. Hazard rate ratios (RR) and 95% confidence intervals (CIs) were estimated using Cox regression.

Results:

Increased risks were associated with long duration (10+ years) use of unopposed oestrogen (RR 2.15, 95% CI: 1.30–3.57 among women with a hysterectomy) and oestrogen plus progestin (RR 1.68, 95% CI: 1.13–2.49 among women with intact uteri) therapy. Similar risks were associated with progestins that were used sequentially (<15 days progestin per month) (RR 1.60, 95% CI: 1.10–2.33) or continuously (>25 days progestin per month) (RR 1.43, 95% CI: 1.032–2.01; P-value for heterogeneity=0.63).

Conclusion:

Our findings suggest that long duration use of both unopposed estrogens and oestrogen plus progestins are associated with increased risks of ovarian cancer, and that risk associated with oestrogen plus progestin use does not vary by regimen (sequential or continuous).

The impact of alternative treatment for abnormal uterine bleeding on hysterectomy rates in a tertiary referral center

STUDY OBJECTIVE

The purpose of this study was to estimate the influence of alternatives to hysterectomy for abnormal uterine bleeding (AUB) on hysterectomy rates.

DESIGN

Retrospective cohort study. Canadian Task Force II-2.

SETTING

University hospital.

PATIENTS

Premenopausal patients with AUB.

INTERVENTIONS

Medical records of all premenopausal patients treated for AUB in our university clinic between January 1, 1995, and December 31, 2004, were reviewed. Patients were identified based on (specific) diagnostic and therapy codes used in the registry system of the hospital. The total number of placements of levonorgestrel-releasing intrauterine device (LNG-IUD), hysteroscopic surgery, and hysterectomies performed/year was estimated. In addition, the course of treatment of each patient was assessed.

MEASUREMENTS AND MAIN RESULTS

A total of 640 patients received surgery and 246 LNG-IUDs were placed. The proportion of endometrial ablations decreased significantly over time (p <.001), whereas hysteroscopic polyp or myoma removal (p =.030) and insertion of LNG-IUD (p <.001) both increased. The proportion of patients receiving hysterectomy for AUB as their first therapy decreased significantly (p =.005) from 40.6% to 31.4%, although the total number of patients receiving hysterectomy remained similar (p =.449). The 5-year intervention-free percentage for LNG-IUD was 70.6% (SD = 3.3%), for hysteroscopic polyp or myoma removal 75.5% (SD = 3.3%), and for endometrial ablation 78.0% (SD = 4.3%; p =.067).

CONCLUSION

Despite the introduction of alternative therapies, the total hysterectomy rate in the management of AUB did not decrease in our clinic.

Patient clinical factors influencing use of hysterectomy in New York, 2001-2005

OBJECTIVE

To determine the effect of patient clinical factors on the utilization of hysterectomy and alternatives of hysterectomy.

STUDY DESIGN

The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months of May 2001-April 2005. Two hundred ninety-five thousand one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes.

RESULTS

One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, and 5,077 hysterectomy alternatives. The mean age of all patients encountered was 39.1 years. Patients undergoing a hysterectomy alternative or hysterectomy had mean ages of 46.0 and 49.7 years, respectively. Abnormal bleeding was associated with the most encounters, while leiomyomata was associated with the most hysterectomies performed.

CONCLUSION

Patients who undergo hysterectomy are, on average, older than those undergoing office management or hysterectomy alternatives. Procedures are most commonly associated with diagnosis of bleeding, leiomyomata, or cancer. Bleeding typically results in a hysterectomy alternative, while leiomyomata has the highest association with hysterectomy.

Effect of physician gender and specialty on utilization of hysterectomy in New York, 2001-2005

OBJECTIVE

The purpose of this study was to determine the effect of physician gender and specialty on the utilization of hysterectomy and alternatives to hysterectomy.

STUDY DESIGN

The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months May 2001-April 2005. Two hundred ninety-five thousand, one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes.

RESULTS

One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, as well as 5077 hysterectomy alternatives. These 7049 procedures represented 2.4% of all coded physician encounters. Male physicians utilize hysterectomy and hysterectomy alternatives at the same rate as female physicians. Physicians who practice gynecology-only or gynecologic oncology utilize laparoscopically assisted vaginal hysterectomy more often than their counterparts who practice obstetrics as well as gynecology.

CONCLUSION

Gender does not influence the rate of hysterectomy for similar clinical diagnoses. Subspecialty physicians utilize laparoscopic assisted vaginal hysterectomies more frequently than general obstetricians and gynecologists.

Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years

OBJECTIVE

To investigate incidence trends and demographic, social and health factors associated with the rate of hysterectomy and morbidity outcomes in Western Australia and compare these with international studies.

DESIGN

Population-based retrospective cohort study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy.

METHODS

Statistical analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Rates, rate ratios and odds ratios for incidence measures and length of stay in hospital and odds ratios for morbidity measures.

RESULTS

The age-standardised rate of hysterectomy adjusted for the underlying prevalence of hysterectomy decreased 23% from 6.6 per 1000 woman-years (95% CI 6.4-6.9) in 1981 to 4.8 per 1000 woman-years (95% CI 4.6-4.9) in 2003. Lifetime risk of hysterectomy was estimated as 35%. In 2003, 40% of hysterectomies were abdominal. The rate of hysterectomy to treat menstrual disorders fell from 4 per 1000 woman-years in 1981 to 1 per 1000 woman-years in 1993 and has since stabilised. Low socio-economic status, having only public health insurance, nonindigenous status and living in rural or remote areas were associated with increased risk of having a hysterectomy for menstrual disorders. Indigenous women had higher rates of hysterectomy to treat gynaecological cancers compared with nonindigenous women, particularly in rural areas. The odds of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures.

CONCLUSION

Western Australia has one of the highest hysterectomy rates in the world, although proportionally, significantly fewer abdominal hysterectomies are performed than in most countries.

Implementation of hysteroscopic surgery in The Netherlands

OBJECTIVE

This study was conducted to assess the degree of diffusion of hysteroscopic surgery in gynaecological practice in The Netherlands in order to guide further implementation. The diffusion was objectified by defining the percentage of hospitals performing hysteroscopic procedures and the number of different procedures performed per gynaecologist.

STUDY DESIGN

In 2003 all Departments of Gynaecology (n=102) in The Netherlands were sent a questionnaire. The questionnaire addressed the number and type of all hysteroscopic procedures that were performed in each hospital in 2002. Data from this study were compared to previously published data from 1997.

RESULTS

Responses were received from 80% of all gynaecological departments in The Netherlands. Diagnostic hysteroscopy was performed in almost all hospitals in both 1997 and 2002. The percentage of hospitals that adopted polypectomy, myomectomy and endometrial ablation increased to more than 90% in 2002. The number of teaching hospitals that integrated diagnostic hysteroscopy, polypectomy and myomectomy (procedures required for graduation) into their operative spectrum increased to 100%.

CONCLUSION

This survey indicates a growing trend of the diffusion of diagnostic and "basic" therapeutic hysteroscopic procedures in The Netherlands. However, figures upon more advanced hysteroscopic surgery are less optimistic.

Health economics of hysterectomy

Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.

Hysterectomy with or without unilateral oophorectomy and risk of ovarian cancer

OBJECTIVE

To analyze the role of hysterectomy, performed on benign indications, on the risk of developing ovarian cancer.

METHODS

Multicenter case-control study conducted in four Italian areas. Cases were 1031 women with epithelial ovarian cancer. Controls were 2411 women admitted to the same network of hospitals for a wide spectrum of acute non-neoplastic conditions, unrelated to known risk factors for ovarian cancer.

RESULTS

Compared to women with intact uterus and ovaries, the multivariate odds ratios (OR) was 0.6 (95% confidence interval 0.4-0.9) for women who reported hysterectomy. The OR was 0.5 > or =15 years after surgery. The OR was similar for women who had had pelvic surgery before age 45 and for those who had surgery later. No appreciable heterogeneity emerged across strata of parity and family history of ovarian/breast cancer.

CONCLUSION

Women who had undergone hysterectomy had a long-term reduced risk of epithelial ovarian cancer.

Effect of hysterectomy on incidence trends of endometrial and cervical cancer in Finland 1953-2010

The hysterectomy-corrected age-adjusted incidence rate of endometrial cancer was 29%, and for cervical cancer 11% higher than the uncorrected rate. Correction factors for such cancer sites are recommended for regular use. The levelling-off of the incidence of endometrial cancer appears to be an artefact caused by the increasing prevalence of hysterectomy.