Hysterectomy by indication

Hysterectomy is most commonly performed because of benign disease, such as fibroids, bleeding disorders, endometriosis, and uterine prolapse. In 2000–2004, hysterectomy caused by benign disease accounted for 90% of all hysterectomies in the United States; malignant disease, such as uterine cancer, cervical cancer, and ovarian cancer, accounted for the remaining 10%. Hysterectomy may also include the removal of both ovaries (bilateral oophorectomy). In 2000–2004, approximately 54% of women undergoing hysterectomy in the United States had both ovaries removed, whereas the rate was much lower in Australia (30% in 2004–2005), Germany (12% in 2005), and Denmark (22% in 1981).

The proportion of women undergoing bilateral oophorectomy concomitant with hysterectomy increases by age in most countries. In the United States, 37% of women aged 15–44 years had both ovaries removed concurrent with hysterectomy, and the highest proportion of concomitant oophorectomy was seen in women aged 50–54 years, peaking at 78%. However, these reports vary with regard to specification of whether bilateral oophorectomy was performed at hysterectomy because of both benign and malignant disease or because of benign disease only.

It would be valuable to introduce more systematic reporting to understand not only the proportion of total hysterectomies with concomitant bilateral oophorectomy but also the fraction removed prophylactically (ie, carriers of BRCA and other women with normal ovaries) vs therapeutically (ie, women having abnormal ovaries or gynecological cancer).

Surgical procedure

Hysterectomy can be performed vaginally or abdominally or by a laparoscopic approach. Most commonly, hysterectomy includes removal of the uterine cervix, but subtotal or supracervical hysterectomy, in which the cervix is left intact, is also an option. The latter approach is not a common procedure in the United States (7.5%), in the United Kingdom (4%), and in Germany (4.8%), whereas it has been more common in the Scandinavian countries such as Sweden and Denmark during the past 20 years. The percentage of subtotal hysterectomies in Denmark was 22% in the period 1988–1998, but since then the rate has declined to 15% in 2008 and to 8% in 2011. In Sweden 32% of hysterectomies were subtotal in 1987; thereafter the proportion declined to 18% in 2003.

Surgical procedure

Hysterectomy can be performed vaginally or abdominally or by a laparoscopic approach. Most commonly, hysterectomy includes removal of the uterine cervix, but subtotal or supracervical hysterectomy, in which the cervix is left intact, is also an option. The latter approach is not a common procedure in the United States (7.5%), in the United Kingdom (4%), and in Germany (4.8%), whereas it has been more common in the Scandinavian countries such as Sweden and Denmark during the past 20 years. The percentage of subtotal hysterectomies in Denmark was 22% in the period 1988–1998, but since then the rate has declined to 15% in 2008 and to 8% in 2011. In Sweden 32% of hysterectomies were subtotal in 1987; thereafter the proportion declined to 18% in 2003.

Hysterectomy incidence across countries

In the past years, several papers have been published on hysterectomy incidence rates in developed countries ( Table 1 ). The incidence rate is very high in countries such as the United States (510 per 100,000 in 2004), ranging from 430 of 100,000 for women living in the Northeast to 630 per 100,000 for those living in the South, whereas lower hysterectomy incidence rates have been reported in several European countries, including Denmark (173 per 100,000 in 2011).

The hysterectomy incidence increases with age until age 40–50 years in which the incidence seems to peak in most countries, including Finland, Denmark, Germany, and the United States. Hysterectomy incidence is cumulative with age, and it is estimated that approximately 50% of women in the United States will have undergone hysterectomy by the age of 70–75 years.

In some countries, the hysterectomy incidence rate has been reported to decline over time. The incidence rate has dropped in Australia (348 per 100,000 in 2000–2001 to 312 per 100,000 in 2004–2005) and in Denmark (from 205 per 100,000 in 1977–1981 to 173 of 100,000 in 2006–2011). In the United States, the incidence has declined more dramatically, from 710 per 100,000 in 1980 to 660 per 100,000 in 1987 and 510 per 100,000 in 2005. This decrease is presumably owing to increased use of ablative methods, hysteroscopic procedures, and the levenorgestrel-releasing intrauterine device for the treatment of abnormal bleeding disorders and myomas.

An increase in mean age at hysterectomy over the last decades has also been reported in some countries such as Denmark (from 46 years in 1977–1981 to 50 in 2006–2011) and Sweden (from 47.3 in 1987–1990 to 52.2 in 2001–2003). This may indicate that conservative treatment does not completely avert hysterectomy but, to some extent, postpones it until later ages.

The impact of hysterectomy and oophorectomy on gynecological cancer rates

The incidence rate of cervical cancer has declined significantly in developed countries after implementation of cervical cancer screening programs, but the same phenomenon has not been seen in uterine and ovarian cancer, presumably because of the lack of an efficient screening tool. Table 1 summarizes the incidence rate of cervical, uterine, and ovarian cancer in the United States, in Australia, and in 3 European countries. As shown, the cervical cancer incidence is higher in Denmark (12.7 per 100,000) compared with the United States (7.8 per 100,000) and Australia (7.1 per 100,000), whereas the incidence of uterine and ovarian cancer is highest in the United States (24.6 per 100,000) and in the United Kingdom (17.1 per 100,000), respectively.

Some studies have reported differences in the incidence of gynecological cancer when comparing hysterectomy or oophorectomy corrected and uncorrected incidence rates. Not surprisingly, all of the studies found that the hysterectomy or oophorectomy uncorrected incidence rates of gynecological cancers are lower than the corrected rates ( Table 2 ).

Table 2

Hysterectomy-corrected vs uncorrected incidence rate of cervical and uterine cancer

Variable					Cervical cancer			Uterine cancer
Author	Country	Years	Age range, y	Race	Uncorrected IR/100,000	Corrected IR/100,000	Relative change, %	Uncorrected IR/100,000	Corrected IR/100,000	Relative change, %
Redburn and Murphy	England and Wales	1961–1995	0–85+	All	12.6	14.4	14.3	13.4	16.2	20.9
Luoto et al	Finland	1953–2010	0–85+	All	3.8	4.2	10.5	14.6	18.8	28.8
Sherman et al	United States	1992–2000	30–74	All	NA	NA	NA	29.2	48.7	66.8
Merrill	United States	1998–2002	15–70+	White	11.1	15.3	37.8	32.8	56.7	72.9
				Black	14.2	22.8	60.6	24.2	46.8	93.4
				American Indians/Alaska Natives	7.3	10.6	45.2	15.9	29.6	86.2
				API	11.1	14.8	33.3	22.0	31.0	40.9
Jamison et al	United States	1992–2008	50+	White	NA	NA	NA	78.8	136	72.6
				Black				60.9	115.5	89.7
				API				47.5	67.4	41.9
				Hispanic				51.0	82.3	61.3
Stang	Germany	2003–2007	0–85+	All	9.6	12.3	28.1	17.9	26.1	45.8
Rositch et al	United States	2000–2009	0–85+	All	11.7	18.6	59.0	NA	NA	NA
Stang et al	United States	2007–2010	20–80+	White non-Hispanic	7.0	8.2	17.1	42.9	57.2	33.3
				Black non-Hispanic	13.8	22.1	60.1	37.3	66.6	78.6
				Hispanic	11.3	14.5	28.3	28.6	38.8	35.7

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