ANN ARBOR, Mich. — A University of Michigan-led study of nearly 3,400 women in Michigan shows that one in five who underwent a hysterectomy for benign conditions may not have needed it.
The findings, which appear in the American Journal of Obstetrics and Gynecology, indicate that alternatives to hysterectomy are being underused and that treatment guidelines are often not followed.
An estimated one in three women in the U.S. will have had a hysterectomy by the age of 60. Researchers found that although the numbers of hysterectomies are decreasing, nearly 18 percent of hysterectomies that were done for benign indications were unnecessary, and a pathology analysis for nearly two in five (38 %) of women under 40 did not support undergoing a hysterectomy.
“Over the past decade, there has been a substantial decline in the number of hysterectomies performed annually in the United States,” says senior author Daniel M. Morgan, M.D., associate professor in the Department of Obstetrics and Gynecology at the U-M Medical School.
“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.”
More than 400,000 hysterectomies are performed in the U.S. each year. About 68% of surgeries for benign conditions are done because of abnormal uterine bleeding, uterine leiomyomata (fibroids), and endometriosis. The American Congress of Obstetricians and Gynecologists recommends alternatives to hysterectomy, including hormonal management, a minimally invasive gynecological procedure called operative hysteroscopy, endometrial ablation (a procedure that destroys the uterine lining) and use of an intrauterine device as primary management of these conditions in many cases.
Researchers 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. Data were collected over a ten-month period in 2013 from 51 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 two in five women under 40 (38%) 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 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,” Morgan says.
Additional Authors: Lauren Elizabeth Corona, of Wayne State University; and Carolyn W Swenson, M.D.; Kyle H Sheetz; Gwendolyn Shelby, R.N.; Mitchell B. Berger, M.D.; Mark D. Pearlman, M.D.; John O DeLancey, M.D., all of U-M. Darrell A. Campbell, Jr., U-M’s former chief medical officer. Pearlman and Morgan are also members of the U-M Institute for Healthcare Policy and Innovation.
Funding: The MSQC is funded by the Blue Cross and Blue Shield of Michigan/ Blue Care Network
Reference: “Use of Other Treatments before Hysterectomy for Benign Conditions in a Statewide Hospital Collaborative,” American Journal of Obstetrics & Gynecology, January, 2015.