Health Services Research on Hysterectomy and Alternatives

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Hysterectomy is the second most frequently performed major surgery for women in the United States, with about half a million procedures performed each year. One in three woman have had a hysterectomy by age 60. Annual costs associated with this surgery exceed $5 billion, and there are wide variations in rates of hysterectomy in different parts of the country.

Following are summaries of new AHCPR-sponsored initiatives currently underway, as well as the findings of recently completed studies.

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Current Activities

• Do race and socioeconomic factors affect the decision to have a hysterectomy and outcomes of the procedure?

  This AHCPR-supported research is examining the extent to which a patient's race and other socioeconomic factors affect both the decisionmaking process of whether to have a hysterectomy and the outcomes of the surgery. Kristin Kjerulff, Principal Investigator (Grant No. HSO6865).

• Demonstration and evaluation of a strategy for implementing clinical practice recommendations for hysterectomy in physician group practices.

  This AHCPR-supported research is examining the effectiveness of a strategy for disseminating practice recommendations that combines education with the mobilization of social influence processes in physician groups. Results of a recruitment phase for the demonstration project showed markedly greater openness to practice recommendations among large multispecialty practices than among community hospitals. Accordingly, the demonstration is being conducted in nine medical group practices in Southern California, using practice recommendations developed by a physician expert panel, based on appropriateness criteria for hysterectomy. David Kanouse, Principal Investigator (Grant No. HS07095).

• Evaluation of alternatives to hysterectomy for treatment of fibroids and other benign conditions of the uterus.

  The Agency has made available funds for multi-year clinical trials which would assess the effectiveness and costs of alternatives to hysterectomy. In March 1996, AHCPR issued a Request for Applications (RFA) on "Medical Treatment Effectiveness Program Research on Noncancerous Uterine Conditions," to solicit studies directly comparing the effectiveness of hysterectomy to other common treatments for such conditions. Studies began in September 1996 and are expected to be completed within a 5-year period. In response to the RFA, three projects have been funded to date:

  1. The Surgical Treatment Outcomes Project for Dysfunctional Uterine Bleeding, a 5-year study designed to assess the effectiveness of hysterectomy compared with endometrial ablation (a conservative surgical procedure) for women with dysfunctional uterine bleeding who have failed medical management. Kay Dickersin, Principal Investigator, University of Maryland at Baltimore (Grant No. HS09506).
  2. Study on Hysterectomy and Dysfunctional Uterine Bleeding, a multi-center clinical trial of 375 patients to compare patient outcomes and relative costs of hysterectomy vs. endometrial ablation vs. gonadotropin releasing hormone and oral contraceptives for women with refractory dysfunctional uterine bleeding. Sarah Fowler, Principal Investigator, Henry Ford Health Sciences Center, Detroit (Grant No. HS09502).
  3. Medicine or Surgery? This clinical trial is comparing outcomes of medical and surgical treatment for abnormal uterine bleeding in premenopausal women with or without coexisting uterine leiomyomas (fibroids). The study will include a randomized trial to assess outcomes of supracervical vs. total abdominal hysterectomy. Researchers also will study patient preferences for hysterectomy and other options in a racially/ethnically diverse population. Findings will be used to develop a decision-assisting tool to help women of diverse backgrounds make informed choices that reflect their preferences regarding whether to undergo hysterectomy or alternative treatment. Stephen Hulley and Eugene Washington, Principal Investigators, University of California at San Francisco (Grant No. HS09478).

• Consumer brochure on treatment options is in development.

  The Agency is preparing a consumer brochure to help women with noncancerous uterine conditions understand that they may have treatment options other than hysterectomy. The brochure will address questions/issues women should consider in order to make fully informed decisions about their medical care.

Completed Initiatives/Findings

• Conference held to identify research issues.

  In May 1994, AHCPR sponsored the conference, "Treatment Effectiveness of Hysterectomy and Other Therapies for Common Noncancerous Uterine Conditions." The purpose of the conference was to assess the state of the science and to obtain advice from experts nationwide regarding the most important areas for effectiveness research. "Treatment of Common Noncancerous Uterine Conditions: Issues for Research," containing a summary of the conference, recommendations, and a comprehensive bibliography, was published by the Agency in July 1995.

• Nonmedical factors, including race, region, and sex of the patient's physician affect hysterectomy rates.

  By age 60, more than one-third of women in the United States have had a hysterectomy. A review article on indications for hysterectomy found that women who live in the Southern and Midwestern areas of the United States, African-American women, and women who have male gynecologists are more likely to undergo hysterectomies.

  Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med 328(12):856-860, 1993. (Grant No. HS06121).

• African-American women are more likely than white women to have a hysterectomy, are hospitalized longer, and are at higher risk for complications and death.

  Based on 1986 to 1991 hospital data from the State of Maryland, researchers found that African-American women are 25 percent more likely to have a hysterectomy than are white women of the same age. The study also indicated that African-American women undergoing the procedure are more likely to experience complications, remain hospitalized longer, and have a higher risk of death than white women.

  Kjerulff K, Guzinski G, Langenberg P, et al. Hysterectomy and race. Obstet Gynecol 82(5):757-764, 1993. (Grant No. HS06865).

• Hysterectomy improves quality of life for some women.

  In a study of 418 women, hysterectomy was found to be highly effective for relief of pelvic pain, fatigue, depression, sexual dysfunction, and other symptoms associated with nonmalignant conditions of the uterus. Researchers from the Maine Medical Assessment Foundation, Harvard Medical School, and Massachusetts General Hospital concluded that hysterectomy provided significant relief and an improved quality of life 1 year postoperatively. A limited number of women reported new problems, including hot flashes (13 percent), weight gain (12 percent), depression (8 percent), anxiety (6 percent), and lack of interest in sex (7 percent).

  Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study I: Outcomes of hysterectomy. Obstet Gynecol 83(4):556-572. (Grant No. HS06121).

• Hysterectomy for three nonmalignant gynecological conditions is associated with greater improvement in symptoms and quality of life than medication or "watchful waiting."

  In this component of the Maine Women's Health Study, the health outcomes of 380 women treated nonsurgically for conditions of the uterus—including uterine fibroids, abnormal bleeding, and/or chronic pain—were compared with those of 311 women who had hysterectomies for similar conditions. Even after controlling for age, reproductive history, and severity of symptoms, hysterectomy was the most highly correlated with a positive outcome at 1 year. Of the women treated nonsurgically at the outset, one-fourth underwent a hysterectomy within a year. Many of the women treated with medications experienced a significant reduction in abnormal bleeding and chronic pelvic pain, although problems continued in an appreciable number of others. Women with uterine fibroids whose physicians prescribed "watchful waiting" experienced no significant change in symptoms or decline in quality of life, providing some reassurance to women who are asymptomatic or have mild symptoms and choose to avoid surgery.

  Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study II: Outcomes of nonsurgical management of leiomyomas, abnormal bleeding, and chronic pelvic pain. Obstet Gynecol 83(4):556-572. (Grant No. HS06121).

• Hysterectomy is not associated with severe depression in older women.

  In a retrospective study of 1,074 upper-middle-class, older women interviewed between 1984 and 1987, findings suggest that bilateral oophorectomy (removal of both ovaries) is associated with only slight increases in depression scores. The authors recommend prospective studies to examine the risk of depression in response to hysterectomy, oophorectomy, and estrogen replacement therapy.

  Kritz-Silverstein D, Wingard DL, Barrett-Connor E, et al. Hysterectomy, oophorectomy, and depression in older women. Journal of Women's Health 3(4):255-263, 1994. (Grant No. HS06726).

AHCPR Publication No. 97-R021
Current as of August 1998