Objective
The purpose of this study was to describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation.
Study Design
This multicenter, cross-sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms who were being examined for initial urogynecologic evaluation. Before meeting the physician, the women completed a questionnaire that asked them to indicate their prolapse treatment preference (uterine preservation vs hysterectomy) for scenarios in which the efficacy of treatment varied. Patient characteristics that were associated with preferences were determined, and predictors for uterine preservation preference were identified with multivariable logistic regression.
Results
Two hundred thirteen women participated. Assuming outcomes were equal between hysterectomy and uterine preservation, 36% of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. If uterine preservation was superior, 46% of the women preferred uterine preservation, and 11% of the women preferred hysterectomy. If hysterectomy was superior, 21% of the women still preferred uterine preservation, despite inferior efficacy. On multivariable logistic regression, women in the South had decreased odds of preferring uterine preservation compared with women in the Northeast (odds ratio [OR], 0.17; 95% CI, 0.05–0.66). Women with at least some college education (OR, 2.87; 95% CI, 1.08–7.62) and those who believed that the uterus is important for their sense of self (OR, 28.2; 95% CI, 5.00–158.7) had increased odds for preferring uterine preservation.
Conclusion
A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation.
The number of women who will seek care for pelvic organ prolapse (POP) in the United States is expected to increase over the next decades. Effective nonsurgical treatment options for women with POP are available and include pelvic floor muscle training and pessary, but many women choose surgical therapy. Surgical treatment for POP historically has included hysterectomy; up to 13% of all hysterectomies that are performed in the United States occur for POP. There has been increasing interest in the role of surgical treatment options that allow uterine preservation; however, the long-term efficacy of these procedures remains unclear.
Determination of the best surgical treatment options involves consideration of a patient’s values and preferences for uterine preservation vs hysterectomy. Although many women undergo hysterectomy for POP, little is known about women’s preferences for either uterine preservation or hysterectomy. A recent study that described women with POP at a single center showed that most women who were evaluated would decline hysterectomy in the absence of substantial benefit. Predictors of patient preference for uterine preservation or hysterectomy in women with POP are not well-described.
The primary objective of this study was to describe patient preferences for uterine preservation and hysterectomy in women with POP symptoms who were seen by a urogynecologist for initial evaluation. The secondary objective was to describe potential predictors of preference for uterine preservation.
Materials and Methods
We conducted a multicenter, cross-sectional survey study through the Fellows’ Pelvic Research Network of the Society of Gynecologic Surgeons. A total of 9 study sites participated. Each study site had a Female Pelvic Medicine and Reconstructive Surgery fellow who participated in the research network. All 4 US geographic regions, as defined by the US Census Bureau, were represented in this study. Institutional review board approval was obtained from all participating sites.
Women with prolapse symptoms who were seen for a new patient evaluation by a urogynecologist at one of the study sites between May 2011 and October 2012 were eligible. We defined prolapse symptoms as an affirmative response to question 3 from the Pelvic Floor Distress Inventory (Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?). We excluded women who reported hysterectomy and women who were unable to complete the written questionnaires in English because of language barrier or cognitive impairment.
Patients were screened for eligibility and approached before meeting the physician. If the patient was eligible and agreed to participate, she completed a 35-item questionnaire that assesses patient preferences and attitudes regarding treatment options for prolapse before seeing the physician. Our questionnaire included the following domains: (1) patient preferences for uterine preservation vs hysterectomy, (2) attitudes regarding the potential benefits and risks of uterine preservation, and (3) basic knowledge about POP. The questionnaire was reviewed by clinical experts from the advisory board to the Fellows’ Pelvic Research Network and piloted on 10 patients before use.
We asked women what their preferences would be for prolapse treatment under 3 conditions: (1) hysterectomy and uterine preservation treatment outcomes are equal; (2) uterine preservation is superior to hysterectomy, and (3) hysterectomy is superior to uterine preservation.
Specifically, we used the following question: “Suppose there are 2 treatments for your prolapse symptoms that are equal. One treatment involves keeping your uterus. The other treatment involves hysterectomy (removal of your uterus). Which of the following most accurately describes your preference for treatment?” We altered the efficacy of each procedure in subsequent questions. Possible responses included (a) “I prefer/strongly prefer to keep my uterus,” (b) “I prefer/strongly prefer to have my uterus removed (hysterectomy),” and (c) “No strong preference.” Additional clinical and demographic information was also collected.
Descriptive statistics were used to describe the demographic and clinical characteristics of our patient population. Differences in participant characteristics and preferences for treatment were compared with the use of the chi-squared, Fisher exact, or analysis of variance tests. A multivariable logistic regression was performed to identify predictors of preference for uterine preservation. We selected potential predictors for our regression model based on results of our univariate analyses ( P < .1). Data analysis was performed with SAS statistical software (version 9.2; SAS Institute Inc, Cary, NC).
Results
A total of 244 women were eligible to participate: 26 women declined enrollment, and 218 women participated in the study. Four women were later excluded for completing questionnaires after seeing the physician; 1 woman was excluded for incorrectly reporting no hysterectomy. A total of 213 women were included in the final analysis with 43% from the Northeast, 20% the South, 27% the Midwest, and 10% from the West region. The mean age was 58.9 ± 14.1 years; 24% of the women were premenopausal, and 3% of the women expressed a desire for future fertility. Eighty-six percent of the women were white; 6% of the women were black; 4% of the women were other races; 4% of the women did not report race, and 11% of the women reported Latina ethnicity. Most of the women (65%) had received some college education or more. Twenty-five percent of the women reported previous treatment for prolapse, and 27% of them previously had seen a urogynecologist or urologist for prolapse. Five percent of the women had stage 0-1 prolapse; 48% of the women had stage 2 prolapse, and 47% of the women had stage 3 or 4 prolapse on Pelvic Organ Prolapse Quantification examination.
Table 1 shows patient characteristics by treatment preference under the condition that treatment outcomes for prolapse were equal between hysterectomy and uterine preservation. Thirty-six percent of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. Women who preferred uterine preservation were similar in age, race, prolapse stage and proportion of uterine prolapse, previous treatment for prolapse, and level of basic knowledge about prolapse compared with those women who preferred hysterectomy or had no strong preference. Compared with women with a high school education or less, a higher proportion of women with at least some college education preferred uterine preservation (75%) vs hysterectomy (48%) or no strong preference (65%; P = .01).
| Variable | Uterine preservation (n = 77) | Hysterectomy (n = 42) | No strong preference (n = 94) | P value |
|---|---|---|---|---|
| Age, y a | 58.5 ± 16.4 | 56.0 ± 11.9 | 60.5 ± 12.7 | .21 |
| Race, n (%) | .77 | |||
| White | 66 (89.2) | 35 (89.7) | 82 (91.1) | |
| Black | 4 (5.4) | 3 (7.7) | 5 (5.6) | |
| Other | 4 (5.4) | 1 (2.6) | 3 (3.3) | |
| Ethnicity, n (%) | .06 | |||
| Latina | 8 (10.5) | 9 (21.4) | 7 (7.4) | |
| Not Latina | 68 (89.5) | 33 (78.6) | 89 (95.6) | |
| Region, n (%) | .01 | |||
| Northeast | 36 (46.7) | 12 (28.6) | 43 (45.7) | |
| South | 12 (15.6) | 14 (33.3) | 18 (19.1) | |
| Midwest | 16 (20.8) | 15 (35.7) | 26 (27.7) | |
| West | 13 (16.9) | 1 (2.4) | 7 (7.5) | |
| Education level, n (%) | .01 | |||
| High school/GED or less | 19 (25.3) | 22 (52.4) | 33 (35.1) | |
| Some college or higher degree | 56 (74.7) | 20 (47.6) | 61 (64.9) | |
| Income level, n (%) | .01 | |||
| <$20,000 | 10 (14.5) | 14 (33.3) | 15 (16.5) | |
| $20,001-40,000 | 9 (13.0) | 13 (30.9) | 23 (25.3) | |
| $40,001-60,000 | 14 (20.3) | 7 (16.7) | 11 (12.1) | |
| $60,001-80,000 | 7 (10.1) | 2 (4.8) | 12 (13.2) | |
| >$80,000 | 30 (42.0) | 6 (14.3) | 30 (33.0) | |
| Parity, median (range) b | 2 (0-6) | 3 (0-6) | 2 (0-9) | .16 |
| Menopausal status, n (%) | .36 | |||
| Premenopausal | 22 (28.6) | 11 (26.2) | 17 (18.1) | |
| Menopausal | 11 (14.3) | 8 (19.1) | 12 (12.8) | |
| Postmenopausal | 44 (57.1) | 23 (54.8) | 65 (69.1) | |
| Sexually active, n (%) | 36 (46.7) | 21 (50.0) | 46 (49.5) | .92 |
| Previous prolapse treatment, n (%) | 23 (29.9) | 9 (21.4) | 21 (22.3) | .44 |
| Previous specialist visit for prolapse, n (%) | 26 (33.8) | 9 (21.4) | 22 (23.4) | .21 |
| Pelvic organ prolapse quantification system stage, n (%) | .25 | |||
| 0-1 | 5 (7.0) | 4 (9.8) | 2 (2.2) | |
| 2 | 31 (43.7) | 17 (41.4) | 48 (53.9) | |
| 3-4 | 35 (49.3) | 20 (48.8) | 39 (43.8) | |
| Belief that uterus is important for a sense of self, n (%) | < .001 | |||
| Yes | 34 (44.2) | 2 (4.8) | 8 (8.5) | |
| No | 28 (36.4) | 35 (83.3) | 65 (69.2) | |
| Unsure | 15 (19.5) | 5 (11.9) | 21 (22.3) |
Table 2 shows how changes in the efficacy of treatment options impacted treatment preferences. Under the condition in which uterine preservation was superior, the proportion of the women who preferred uterine preservation increased to 46% from 36% when efficacy was equal ( P = .02). Eleven percent of the women still preferred hysterectomy, despite inferior efficacy. Under the condition that hysterectomy was superior, the proportion of the women who preferred hysterectomy increased to 36% from 20% when efficacy was equal ( P < .001). Twenty-one percent of the women still preferred uterine preservation, despite inferior efficacy.
| Variable | Uterine preservation, % | Hysterectomy, % | No preference, % | P value |
|---|---|---|---|---|
| Treatment outcomes equal | 36 | 20 | 44 | < .001 |
| Uterine preservation superior | 46 | 11 | 43 | < .001 |
| Hysterectomy superior | 21 | 36 | 43 | < .001 |
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