Today, hysterectomy is the second most frequent major operation performed on women in the United States, following only cesarean section. Over 600,000 hysterectomies are performed each year in the United States with an estimated annual cost of over $5 billion. The hysterectomy rate of the United States is among the highest in the developed world and approximately 23% of U.S. women have had a hysterectomy. Over the past several decades, new developments have been made in the surgical approaches to hysterectomy and in alternatives to hysterectomy for benign gynecologic conditions. This chapter will discuss the epidemiology of hysterectomy including the trends in hysterectomy rates over the last four decades and factors that influence these rates including both patient and physician factors. This chapter will also discuss the current indications for hysterectomy and their changing trends.
There has been a steady decline in the annual incidence of hysterectomy over the last four decades from a peak of about 10.4 per 1000 women in 1975 to 6.0 per 1000 in 1997 to approximately 5.4 per 1000 between 2000 and 2004 according to national estimates. From 1997 through 2005, U.S. hysterectomy rates have decreased approximately 1.9% per year. Decreasing rates have been highest in women 45 years and older and in the Northeast and South regions. A recent population-based study from Olmsted County, Minnesota noted that the overall rate of hysterectomy declined by 36% from 1965 to 2002; however, unlike national trends the decline was most pronounced among women aged 25 to 34 years. The explanation for the decline in hysterectomy rates over the last several decades is likely multifactorial including changing patient and physician attitudes toward hysterectomy and an increase in the number and effectiveness of alternative therapies for benign gynecologic conditions.
The estimated rate of hysterectomy and distribution of surgical approach in the United States from 2000 to 2004 is shown in Table 3-1 . Approximately two thirds of hysterectomies are performed abdominally in the United States and this has changed little over the last two decades in spite of clear benefits for the vaginal and laparoscopic approaches in terms of hospital stay, recovery time, and cost. The rate of laparoscopic hysterectomy has increased from approximately 0.3% in 1990 to 11.8% in 2003 largely at the expense of fewer vaginal hysterectomies. In approximately 5.5% of hysterectomies, the cervix is preserved (subtotal hysterectomy). For more details about the trends, benefits, and alternatives of the different routes of hysterectomy please refer to Chapter 4 .
|Year||Number of Procedures *||Rate per 1000 Woman-Years †||Abdominal (%)||Vaginal (%)||LAVH (%)|
Factors Influencing Hysterectomy Rate
Factors associated with increased risk of hysterectomy beyond medical indication include increasing parity, poor health, younger age at menarche, high body mass index, smoking, lower socioeconomic status, geography, and physician factors. Age also plays a considerable role in rates of hysterectomy. Although some studies have suggested racial differences in hysterectomy rates, the most recent Centers for Disease Control (CDC) data demonstrate no overall difference in hysterectomy rates between black and white women. However, black women do have significantly higher rates than white women between the ages of 35 and 44, with lower rates at other ages. This is likely explained by the increased prevalence of uterine leiomyoma seen in black women. Some studies suggest that Hispanic women have lower rates of hysterectomy compared to non-Hispanic white women. The reason for this is unclear.
Although the true relationship between the rate of hysterectomy and many of the preceding risk factors is unclear, a few warrant further consideration including age, geography, socioeconomic factors, and physician factors.
The prevalence of hysterectomy in the United States increases over much of the life span, peaking around age 75, then slightly decreasing ( Fig. 3-1 ). By the end of the reproductive period (age 18–44), 18% of women will have undergone a hysterectomy. By age 75, the rate is approximately 48%. Women age 40 to 44 have the highest incidence of hysterectomy (11.7/1000 woman-years) with 64% of all hysterectomies being performed on those between ages 35 and 54. At age 35, a woman has a 12.9% probability of undergoing a hysterectomy in the next 10 years. At age 45, the probability is 11.7%. All age groups have noted a decline in the rate of hysterectomy over the last two decades with the greatest decline noted in those age 45 to 64 (−3%) and ages 65 and older (−5%). A recent survey of almost 300,000 insurance claims in New York demonstrated that women who undergo hysterectomy are approximately 4 years older on average than women with similar diagnoses receiving nonhysterectomy alternatives (49.7 versus 46 years). Age also has a significant influence on indications for hysterectomy and this topic will be discussed further later in the chapter.
Rates of hysterectomy vary considerably between and within countries. Figure 3-2 compares the rates of hysterectomy across various countries. Rates of hysterectomy are highest in the United States and Australia, which have rates almost double those of Norway, Denmark, and Italy. There are also wide variations between countries in the route by which hysterectomy is performed. The proportion of hysterectomies performed by the abdominal route is lowest in Australia (46%–52%) whereas over 80% of hysterectomies in England are performed abdominally and over 90% of those performed in Turkey are by the abdominal route ( Fig. 3-3 ). Reasons for these geographic variations are unclear but are thought to be due to a combination of differing patient perceptions and demands, clinician preferences, and health care systems.
Within the United States, geographic region also appears to influence hysterectomy rates. Rates for women living in the South (6.5/1000) are significantly higher than for those in the West (4.8/1000) and Northeast (4.3/1000). Similarly, the average age at the time of hysterectomy is significantly younger for women living in the South than for those living in the Northeast (44 versus 49 years old). As previously noted, the South is among the regions with the greatest decline in hysterectomy rates over the last two decades; however, it still remains the region with the highest hysterectomy rate. The availability of gynecologists, the numbers of hospital beds per capita, the types of health care insurance available, and regional variations in patient and physician attitudes toward hysterectomy are thought to contribute to geographic variation within the United States.
Lower socioeconomic status has been associated with increased rates of hysterectomy in several studies. Similarly, level of education has also been found to be inversely related to hysterectomy rates. Additionally, obesity and smoking are factors associated with increased hysterectomy rates and are also associated with lower socioeconomic status. Socioeconomic status and education may influence risk of hysterectomy through their impact on health choices, access to medical care and alternative medical treatments, and other life circumstances.
Two recent studies suggest that the relationship between socioeconomic status and hysterectomy risk is complex, however. A comparison of three British cohorts found that hysterectomy risk and socioeconomic status was associated with childhood socioeconomic status but not adult economic circumstances ( ). Moreover, they found that among British women born in the 1940s and 1950s, those of lower socioeconomic status had a greater risk of hysterectomy than those of higher socioeconomic class. However, in an older cohort of British women, born in the 1920s and 1930s, the converse was found and women from more deprived socioeconomic backgrounds had a reduced risk of hysterectomy compared with those from less deprived backgrounds. A second study comparing cohorts in Britain and Australia confirmed these findings by noting an inverse association between indicators of socioeconomic status and hysterectomy in both Australian and British women born in 1946 or later ( ). In women born in the 1920s and 1930s there was no evidence of a relationship between adult socioeconomic status and rate of hysterectomy. This suggests that socioeconomic differentials in hysterectomy may be dynamic, varying over time. Further, it suggests that the socioeconomic impact on hysterectomy may be influenced by changes over time in access to medical care, women’s and doctors’ treatment preferences, the availability of alternative treatments, and trends in characteristics such as fertility, oral contraceptive use, and obesity.
A number of “physician factors” have been suggested to influence rates of hysterectomy including physician gender, practice type, and years in practice. Physician gender has been implicated as a factor influencing the hysterectomy rates in a number of studies, but the results have been conflicting, with some studies suggesting male gynecologists overutilize hysterectomy and others suggesting female gynecologists have higher hysterectomy rates. In 1994, a survey of practice patterns of surgeons in North Carolina found that male physicians with a primarily rural practice reported that they were more likely to perform hysterectomy ( P < .001) than other groups ( ). In contrast, a 1996 study of 3-year hospital discharge data from Arizona reported that female gynecologists were more likely than males to perform hysterectomy on patients hospitalized with a hysterectomy-associated diagnosis ( ). More recently, a survey of over 300,000 insurance claims from New York over a 4-year period found no gender difference in the utilization of hysterectomy or in the type of hysterectomy performed ( ). This survey did find differences in hysterectomy utilization by practice type, however. Gynecologic oncologists were more likely than physicians with a gynecology-only or a general obstetrics and gynecology practice to perform hysterectomies than alternatives to hysterectomies. Additionally, gynecologic oncologists and gynecology-only physicians were more likely to perform a laparoscopic hysterectomy than obstetrician-gynecologists. A number of studies suggest that greater years in practice are associated with higher hysterectomy rates; however, it is unclear if this is the result of changing referral patterns and patient mix as a physician’s practice matures or changing attitudes toward hysterectomy. A survey in the 1990s found that gynecologists were more likely to perform hysterectomy at higher rates if they were further from their training, practiced in areas with fewer gynecologists, or had more patients with abnormal bleeding or cancer. In a 2006 survey of the fellows of the American College of Obstetricians and Gynecologists, younger age of the physician and being in an academic practice were significantly associated with decreased choice of hysterectomy for their patients. Other physician factors that may influence hysterectomy rates include training, regional practice patterns, and local insurance mix, although these factors are less well studied.