It is estimated that one in three women in the United States will have had a hysterectomy by the age of 60. Although the numbers of hysterectomies are decreasing, a new study of more than three thousand women in Michigan who underwent hysterectomy for benign indications reveals that alternatives to hysterectomy are being underused and that treatment guidelines are often not followed. Post-surgical pathology showed that nearly one in five (18%) of hysterectomies that were done for benign indications were unnecessary, and that nearly two in five (37.8%) of women under 40 had unsupportive pathology, reports the American Journal of Obstetrics & Gynecology.
Over 400,000 hysterectomies are performed in the US each year. About 68% of surgeries for benign conditions are done because of abnormal uterine bleeding, uterine fibroids, and endometriosis. The American Congress of Obstetricians and Gynecologists recommends alternatives to hysterectomy, including hormonal and other forms of medical management, operative hysteroscopy, endometrial ablation, and use of the levonorgestrel intrauterine device as primary management of these conditions in many cases.
“Over the past decade, there has been a substantial decline in the number of hysterectomies performed annually in the United States,” observes senior investigator Daniel M. Morgan, MD, Associate Professor of Obstetrics and Gynecology at the University of Michigan. “An earlier study found a 36.4% decrease in number of hysterectomies performed in the U.S. in 2010 compared to 2002. However, despite the decrease in numbers of hysterectomies in the U.S., appropriateness of hysterectomy is still an area of concern and it continues to be a target for quality improvement.”
Investigators set out to assess how often alternatives to hysterectomy are being recommended to women with benign gynecologic disease before performing hysterectomy and how often the pathologic findings from the hysterectomy supported an indication for surgery. They examined the medical records of 3,397 women who underwent hysterectomies for benign conditions in Michigan with these goals in mind. Data were collected over a ten-month period in 2013 from 52 hospitals participating in the Michigan Surgery Quality Collaborative (MSQC). Indications for surgery included uterine fibroids, abnormal uterine bleeding, endometriosis, or pelvic pain.
Nearly 40% of women did not have documentation of alternative treatment before their hysterectomy. Fewer than 30% received medical therapy, while 24% underwent other minor surgical procedures before the hysterectomy. Alternative treatment was more likely to be considered among women under 40 years old and among women with larger uteri. About 68% of women under 40 received alternative treatment compared with 62% of those aged 40-50 and 56% of those aged 50 or above.
Nearly one in five women (18.3%) had postsurgical pathologic findings that did not support having undergone a hysterectomy. The rate of unsupportive pathology was highest among women under 40 years. Nearly two in five women under 40 (37.8%) had pathologic findings that did not support undergoing a hysterectomy versus those aged 40-50 (12%) and over 50 years (7.5%). The frequency of unsupportive pathology was highest among women with a pre-operative diagnosis of endometriosis or chronic pain.
“This study provides evidence that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for abnormal uterine bleeding, uterine fibroids, endometriosis, or pelvic pain,” says Dr. Morgan.
“Although quality in gynecologic surgery has focused on care after a procedure, these findings suggest that appropriateness of surgery could serve as an important quality metric in gynecology,” comments noted expert Jason D. Wright, MD, Chief of the Division of Gynecologic Oncology and Sol Goldman Associate Professor of Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York.
Dr. Wright adds: “Reducing the number of procedures performed in women who may not necessarily require the procedure in the first place has the potential to have an even more meaningful impact in reducing adverse outcomes and cost than optimization of postoperative care. As reimbursement policies shift, appropriateness of surgery will likely become an even greater imperative from patients and payers.”
