Hysterectomy is a highly effective treatment for many gynecologic disorders. Patient satisfaction is generally very high after hysterectomy and tends to be related to the initial indication for surgery and patient expectation. The Maine Women’s Health Study evaluated the effect of hysterectomy for nonmalignant disorders on quality of life ( ). The indications for surgery were similar to those reported from national statistics ( www.hcupnet.ahrq.gov , 2007; ). They documented a marked improvement abnormal uterine bleeding, pelvic pain, urinary symptoms, fatigue, and psychological and sexual symptoms at 1 year in the majority of patients. In the Maryland Women’s Health Study patients were followed for up to 2 years after hysterectomy for nonmalignant conditions ( ). Symptoms related to the underlying indication for surgery, as well as associated symptoms of depression and anxiety and quality of life, improved after hysterectomy ( Table 5-1 ). However, each study reported that about 8% of patients had new symptoms, such as depression and lack of interest in sex, or lack of improvement in quality of life ( Table 5-2 ). Although women with pelvic pain and depression did not show the same level of improvement as other groups, there was significant improvement over baseline ( ). Low socioeconomic status and concurrent bilateral oophorectomy also have been shown to lower the likelihood of satisfactory outcome in some studies ( ). found significant reductions in pelvic pain, abdominal pain, urinary frequency, and depression 5 years after hysterectomy in a prospective cohort of premenopausal women. Women 5 years after hysterectomy had similar bladder, bowel, and sexual function to a parallel cohort of women with normal menses who had not undergone a hysterectomy.
|Indicator||Before Hysterectomy||After Hysterectomy|
|6 mo ( n = 1225)||12 mo ( n = 1188||18 mo ( n = 1174)||24 mo ( n = 1162)|
|Quality of life|
|Limited physical function||47.7||28.1||23.6||24.4||23.3|
|Limited social function||23.1||6.8||5.1||5.9||4.9|
|Poor health perception||78.6||31.8||32.0||34.5||31.9|
|Problem Relieved||Problem Acquired|
|Quality of life|
|Limited physical function||63.4||12.9|
|Limited social function||88.6||3.6|
|Poor health perception||60.8||7.7|
† Problem relieved : problem no longer experienced at the “problematic-severe” level among women who did report having the problem at this level before hysterectomy. Problem acquired : problem reported at the “problematic-severe” level among women who did not have the problem at this level before hysterectomy.
This chapter will discuss in detail the symptom- and indication-based long-term outcomes of hysterectomy, reviewing both the positive and negative effects of this surgery on women. It will also compare the outcomes of subtotal (supracervical) hysterectomy to total hysterectomy and summarize the outcomes of hysterectomy relative to several nonhysterectomy alternatives for treatments of heavy menstrual bleeding and uterine fibroids ( Table 5-3 ). A more detailed discussion of short-term outcomes including perioperative complications and the relative risks and benefits of different routes of hysterectomy can be found elsewhere in this text ( Chapters 4 and 11 ).
|Alternative Treatment (Population)||No. of Trials ( n )||Bleeding||Quality of Life||Pain||Sexual Health||Bulk Symptoms||Satisfaction||Additional Tx||Adverse Events||Quality of Evidence|
|Endometrial ablation (DUB)||7 (1167)||Favors hyst||ND *||Favors hyst||ND||ND||ND||Favors hyst||Favors ablation||Low to moderate|
|Medications (DUB)||1 (57)||NA||ND||ND||ND||NA||ND||NA||Favors meds||Low|
|Uterine artery embolization (fibroids)||3 (391)||Favors hyst||ND||ND||ND||ND||ND||Favors hyst||ND||Moderate|
|LNG-IUS (mixed DUB and fibroids)||1 (236)||Favors hyst||ND||NA||Favors hyst||NA||NA||Favors hyst||Favors LNG-IUS||Moderate|
* Improvements in quality of life are similar overall for hysterectomy and for endometrial ablation; however, hysterectomy is favored for some domains (social functioning, energy, pain, and general health).
Hysterectomy always provides a definitive cure of irregular or excessive menstrual bleeding. The exception is subtotal (supracervical) hysterectomy, after which cyclic bleeding can be seen in 3% to 24% of patients postoperatively. Hysterectomy should be considered a second-line therapy in most cases of abnormal menstrual bleeding because it results in permanent loss of fertility and has greater risk, higher cost, and longer recovery than most alternative treatments. Hormonal therapies (such as oral contraceptive pills and oral or intramuscular medroxyprogesterone acetate), nonsteroidal anti-inflammatory medications (particularly mefenamic acid and naproxen sodium), and medicated intrauterine devices (IUDs) effectively treat abnormal menstrual bleeding in many patients. However, a significant proportion of patients eventually require further treatment, including hysterectomy. The Maine Women’s Health Study prospectively evaluated a cohort of women with abnormal uterine bleeding treated medically over a 1-year period ( ). Overall, they had a significant improvement in symptoms of pain and bleeding and in quality of life. However, 23% still underwent a hysterectomy in the 12-month follow-up period.
Few randomized clinical trials comparing medical therapy to hysterectomy for treatment of abnormal menstrual bleeding exist. One study by Kuppermann and associates (2004) randomized 63 premenopausal women who had failed previous treatment with medroxyprogesterone acetate for excessive menstrual bleeding to receive either hysterectomy or expanded medical therapy, typically oral contraceptive pills with or without nonsteroidal anti-inflammatory drugs (NSAIDs). At 6 months, women in the hysterectomy group had greater improvement in scores of mental health, and greater improvement in symptom resolution, interference with sex, sexual desire, health distress, sleep problems, and satisfaction with health. During the 2 years of follow-up, 53% of those who had received expanded medical treatment eventually requested and received hysterectomy, with resulting improvements in quality of life.
A large randomized trial of 236 women age 35 to 49 with excessive menstrual bleeding compared hysterectomy to a levonorgestrel-releasing intrauterine system (LNG-IUS) ( ). After 5 years of follow-up, both groups reported high (>90%) satisfaction with treatment. In those who received the LNG-IUS, 75% reported amenorrhea or minimal spotting; however, 42% of subjects eventually underwent a hysterectomy during the follow-up period.
Endometrial ablation is an effective alternative to hysterectomy for treatment of excessive menstrual bleeding. To date, there have been seven randomized trials with a total of 1192 participants comparing either abdominal or vaginal hysterectomy to endometrial ablation in women with abnormal uterine bleeding ( ). Compared to hysterectomy, endometrial ablation is associated with a shorter operative time, shorter recovery period, and lower postoperative complication rate. However, although hysterectomy eliminates menstrual bleeding, endometrial ablation results in amenorrhea in only 45% of patients and recurrent excessive bleeding is seen in 15% to 25% of cases. Approximately 9% to 34% of patients who receive endometrial ablation subsequently undergo hysterectomy. A systematic review performed by the Cochrane Collaboration found that hysterectomy had a significant advantage over endometrial ablation for the improvement in anemia as well as overall satisfaction and general health for up to 4 years after surgery ( ). Although many quality-of-life scales reported no differences between surgical groups, there was some evidence of a greater improvement in some health domains (social functioning, energy, pain, and general health) for hysterectomy patients. Most adverse events were significantly more likely to occur after hysterectomy and before discharge from hospital. However, after discharge from hospital, the only difference was a lower rate of infection among those receiving endometrial ablation (odds ratio [OR] = 0.2, confidence interval [CI] 0.1–0.5). The overall cost of endometrial ablation was lower than that of hysterectomy, but the cost differences narrow over time because of the need for eventual hysterectomy in a proportion of those who receive ablation, or re-treatment with other alternatives to hysterectomy including uterine fibroid embolization and myomectomy. The relative advantages and disadvantages of these therapies are discussed in Chapter 12 .
Uterine fibroid embolization (UFE) offers an alternative to hysterectomy in women with symptomatic uterine fibroids, particularly those with uterine fibroids and heavy menstrual bleeding. Women with symptomatic uterine fibroids who are of reproductive age but who are not interested in childbearing are candidates for UFE. Three randomized clinical trials including a total of 391 women have compared UFE to hysterectomy for the treatment of heavy menstrual bleeding in women with uterine fibroids. Overall, hysterectomy offers better control of bleeding than UFE and requires fewer additional treatments but demonstrates no differences in quality of life, sexual health, or frequency of adverse events. The EMMY trial randomized 177 patients with uterine fibroids and menorrhagia to UFE ( n = 88) or hysterectomy ( n = 89) ( ). Of those who received UFE, 62% reported resolution of menorrhagia at 24 months and 4% described their menorrhagia as being unchanged. In both groups hemoglobin levels increased significantly compared to baseline (at 24 months: UFE, +1.37 g/dL; hysterectomy, +2.03 g/dL; p < .001 for each) with the increase in hemoglobin being significantly greater for hysterectomy patients ( p = .037). Two years after treatment, 23.5% of UFE patients had undergone a hysterectomy for inadequate symptom control. This finding is similar to the REST trial, in which 20% of patients receiving UFE required invasive procedure (hysterectomy or repeat UFE) within 2 years after the procedure for continued or recurrent symptoms compared with none in those who received a hysterectomy ( ).
For simple dysfunctional uterine bleeding, a short trial of oral contraceptives followed by second-generation ablation is the most cost-effective strategy. Hysterectomy is more cost-effective for achieving amenorrhea, which likely improves with more follow-up time. Patient preferences of treatment also play an important role ( ).