Hysterectomy: indications, alternatives and predictors

Author: Marcia G. Kramer, Robert C. Reiter
Date: Feb 15, 1997

Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased In recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.

Annual hospital costs associated with hysterectomy, the second most common major surgery performed in the United States, surpass $5 billion.[1] After peaking in 1975 at 725,000 per year, the number of hysterectomies performed each year has declined and is currently estimated to be 576,000 per year.[2]

The majority of hysterectomies are elective, and more than 90 percent of all procedures are performed in women with nonmalignant conditions.[3] Currently, appropriate indications for hysterectomy remain controversial among health care professionals. Besides the medical indications for hysterectomy, both patient and health care provider characteristics may influence hysterectomy rates.

This article reviews the current recommendations concerning common nonmalignant indications for hysterectomy, suggests alternative treatments and discusses nonmedical predictors of hysterectomy.

Medical Indications for Hysterectomy

UTERINE LEIOMYOMAS

Uterine leiomyomas are the most common indication for hysterectomy and are the reason given for 25 to 30 percent of hysterectomies.[3,4] Leiomyomas, or benign tumors composed of smooth muscle cells and fibrous connective tissue, arise most often in women 30 to 49 years of age and are typically slow-growing, multiple and variable in size. Although the precise etiology of leiomyomas is unknown, sex steroid hormones, specific enzymes and epidermal growth factor are believed to play a role in their development.[5]

Women with leiomyomas are usually asymptomatic. They may, however, have abnormal uterine bleeding, pelvic pain and pressure, lower urinary tract symptoms, infertility, spontaneous abortion and preterm labor.

Medical management of symptomatic uterine leiomyomas may involve hormonal therapy or nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve menorrhagia, dysmenorrhea or pelvic discomfort. Gonadotropin-releasing hormone (GnRH) agonists may induce a state of hypoestrogenemia, causing a reduction in tumor size.[6] However, use of GnRH agonist therapy is limited by the rapid regrowth of tumors following cessation of therapy, decreases in bone density and vasomotor symptoms.[7,8]

Myomectomy is a conservative surgical management option for uterine leiomyoma, is often performed laparoscopically on an outpatient basis, and appears to have good long-term effectiveness.[7] The advantages of hysteroscopic resection of leiomyomas include preservation of fertility, reduced postoperative discomfort and a relatively short recovery period.[9] Unfortunately, leiomyomas recur in an estimated 15 to 30 percent of patients following myomectomy, and operative risks increase with multiple myomectomies.[10]

Hysterectomy is the appropriate and definitive treatment for a woman who has finished childbearing and who has large, symptomatic uterine leiomyomas.[7] Table 1 summarizes the recommendations of the American College of Obstetricians and Gynecologists (ACOG) regarding hysterectomy for leiomyoma.[11] Experts, however, disagree on whether hysterectomy is justified for a woman with asymptomatic or minimally symptomatic fibroids.[12] Traditionally, indications for hysterectomy in a woman with asymptomatic leiomyomas include the following: (1) nonpalpable adnexa that interferes with the diagnosis of ovarian cancer; (2) prophylaxis against future symptoms; (3) avoidance of increased surgical morbidity from continued uterine enlargement, and (4) avoidance of the rare disorder leiomyosarcoma.[12,13] Available evidence challenges these traditional arguments, and current guidelines do not recommend hysterectomy for an enlarged uterus caused by asymptomatic leiomyomas.[12,13]

TABLE 1Criteria for Hysterectomy for LeiomyomasConfirmation of leiomyomas (presence of 1 or 2 or 3)1. Asymptomatic leiomyomas of such size that they are palpableabdominally and are a concern to the patient2. Excessive uterine bleeding evidenced by either of the following: a. Profuse bleeding with flooding or clots or repetitive periods lasting more than eight days b. Anemia due to acute or chronic blood loss3. Pelvic discomfort caused by myomas (presence of a or b or c) a. Acute and severe b. Chronic lower abdominal or low back pressure c. bladder pressure with urinary frequency not due to urinary tract infectionActions prior to procedure1. Confirm the absence of cervical malignancy2. Eliminate anovulation and other causes of abnormal bleeding3. When abnormal bleeding is present, confirm the absence ofendometrial malignancy4. Assess surgical risk from anemia and need for treatment5. Consider patient's medical and psychologic risks concerninghysterectomyContraindications1. Desire to maintain fertility, in which case myomectomy shouldbe considered2. Asymptomatic leiomyomas of size less than 12 weeks of gestationdetermined by physical examination or ultrasound examinationFrom Quality assessment and improvement in obstetrics andgynecology. Washington, D.C.: American College of Obstetriciansand Gynecologists, 1994. Used with permission.

[22.] Wood C, Maher P, Hill D. Biopsy diagnosis and conservative surgical treatment of adenomyosis. Aust N Z J Obstet Gynaecol 1993;33:319-21.

[23.] Reiter RC, Milburn A. Management of chronic pelvic pain. Postgrad Obstet Gynecol 1992;12:1-8.

[24.] Reiter RC, Milburn A. Exploring effective treatment for chronic pelvic pain. Contemp Ob Gyn 1994;39:84-103.

[25.] Peters AA, van Dorst E, Jellis B, van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740-4.

[26.] Gambone JC, Reiter RC. Nonsurgical management of chronic pelvic pain: a multidisciplinary approach. Clin Obstet Gynecol 1990;33:205-11.

[27.] Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988-1990. Obstet Gynecol 1994;83:549-55.

[28.] Bureau of Census. 1990 Census data. Des Moines: State Library of Iowa, 1991.

[29.] Graves EJ. Detailed diagnoses and procedures. National Hospital Discharge Survey, 1990. Vital Health Stat 1992;(113):1-225.

[30.] Coulter A, Peto V, Doll H. Patients' preferences and general practitioners' decisions in the treatment of menstrual disorders. Fam Pract 1994;11:67-74.

[31.] Bickell NA, Earp JA, Garrett JM, Evans AT. Gynecologists' sex, clinical beliefs, and hysterectomy rates. Am J Public Health 1994;84:1649-52.

[32.] Hall RE, Cohen MM. Variations in hysterectomy rates in Ontario: does the indication matter? Can Med Assoc J 1994;151:1713-9.

[33.] Gambone JC, Reiter RC, Lench JB, Moore JG. The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy. Am J Obstet Gynecol 1990;163:545-50.

The Authors

MARCIA G. KRAMER, M.P.A.S., P.A.-C is currently practicing medicine at Olympic Family Practice in Bremerton, Wash. She recently completed a master's degree in physician assistant studies from the University of Iowa College of Medicine, Iowa City.

ROBERT C. REITER, M.D. is associate professor and director of the General Women's Health Division in the Department of Obstetrics and Gynecology at the University of Iowa College of Medicine. Dr. Reiter earned a medical degree from the Baylor College of Medicine, Houston, Texas.

Address correspondence to Marcia G. Kramer, M.P.A.S., PA.-C, 3535 Malibu Country Dr., Malibu, CA 90265.

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