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Hysterectomy is the second most frequently performed major surgery for
women in the United States, with about half a million procedures performed
each year. One in three woman have had a hysterectomy by age 60. Annual
costs associated with this surgery exceed $5 billion, and there are wide
variations in rates of hysterectomy in different parts of the country.
Following are summaries of new AHCPR-sponsored initiatives currently
underway, as well as the findings of recently completed studies.
Do race and socioeconomic factors affect the decision to have a
hysterectomy and outcomes of the procedure?
This AHCPR-supported research is examining the extent to which a
patient's race and other socioeconomic factors affect both the
decisionmaking process of whether to have a hysterectomy and the outcomes of
the surgery. Kristin Kjerulff, Principal Investigator (Grant No.
Demonstration and evaluation of a strategy for implementing clinical
practice recommendations for hysterectomy in physician group practices.
This AHCPR-supported research is examining the effectiveness of a
strategy for disseminating practice recommendations that combines education
with the mobilization of social influence processes in physician groups.
Results of a recruitment phase for the demonstration project showed markedly
greater openness to practice recommendations among large multispecialty
practices than among community hospitals. Accordingly, the demonstration is
being conducted in nine medical group practices in Southern California,
using practice recommendations developed by a physician expert panel, based
on appropriateness criteria for hysterectomy. David Kanouse, Principal
Investigator (Grant No. HS07095).
- Evaluation of alternatives to hysterectomy for treatment of fibroids
and other benign conditions of the uterus.
The Agency has made available funds for multi-year clinical trials which
would assess the effectiveness and costs of alternatives to hysterectomy. In
March 1996, AHCPR issued a Request for Applications (RFA) on "Medical
Treatment Effectiveness Program Research on Noncancerous Uterine
Conditions," to solicit studies directly comparing the effectiveness of
hysterectomy to other common treatments for such conditions. Studies began
in September 1996 and are expected to be completed within a 5-year period.
In response to the RFA, three projects have been funded to date:
- The Surgical Treatment Outcomes Project for Dysfunctional Uterine
Bleeding, a 5-year study designed to assess the effectiveness of
hysterectomy compared with endometrial ablation (a conservative surgical
procedure) for women with dysfunctional uterine bleeding who have failed
medical management. Kay Dickersin, Principal Investigator, University of
Maryland at Baltimore (Grant No. HS09506).
- Study on Hysterectomy and Dysfunctional Uterine Bleeding, a
multi-center clinical trial of 375 patients to compare patient outcomes and
relative costs of hysterectomy vs. endometrial ablation vs. gonadotropin
releasing hormone and oral contraceptives for women with refractory
dysfunctional uterine bleeding. Sarah Fowler, Principal Investigator, Henry
Ford Health Sciences Center, Detroit (Grant No. HS09502).
- Medicine or Surgery? This clinical trial is comparing outcomes of
medical and surgical treatment for abnormal uterine bleeding in
premenopausal women with or without coexisting uterine leiomyomas
(fibroids). The study will include a randomized trial to assess outcomes of
supracervical vs. total abdominal hysterectomy. Researchers also will study
patient preferences for hysterectomy and other options in a
racially/ethnically diverse population. Findings will be used to develop a
decision-assisting tool to help women of diverse backgrounds make informed
choices that reflect their preferences regarding whether to undergo
hysterectomy or alternative treatment. Stephen Hulley and Eugene Washington,
Principal Investigators, University of California at San Francisco (Grant
Consumer brochure on treatment options is in development.
The Agency is preparing a consumer brochure to help women with
noncancerous uterine conditions understand that they may have treatment
options other than hysterectomy. The brochure will address questions/issues
women should consider in order to make fully informed decisions about their
Conference held to identify research issues.
In May 1994, AHCPR sponsored the conference,
"Treatment Effectiveness of Hysterectomy and Other
Therapies for Common Noncancerous Uterine Conditions."
The purpose of the conference was to assess the state of the science and to
obtain advice from experts nationwide regarding the most important areas for
effectiveness research. "Treatment of Common Noncancerous Uterine
Conditions: Issues for Research," containing a summary of the conference,
recommendations, and a comprehensive bibliography, was published by the
Agency in July 1995.
Nonmedical factors, including race, region, and sex of the patient's
physician affect hysterectomy rates.
By age 60, more than one-third of women in the United States have had a
hysterectomy. A review article on indications for hysterectomy found that
women who live in the Southern and Midwestern areas of the United States,
African-American women, and women who have male gynecologists are more
likely to undergo hysterectomies.
Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N
Engl J Med 328(12):856-860, 1993. (Grant No. HS06121).
African-American women are more likely than white women to have a
hysterectomy, are hospitalized longer, and are at higher risk for
complications and death.
Based on 1986 to 1991 hospital data from the State of Maryland,
researchers found that African-American women are 25 percent more likely to
have a hysterectomy than are white women of the same age. The study also
indicated that African-American women undergoing the procedure are more
likely to experience complications, remain hospitalized longer, and have a
higher risk of death than white women.
Kjerulff K, Guzinski G, Langenberg P, et al. Hysterectomy and race.
Obstet Gynecol 82(5):757-764, 1993. (Grant No. HS06865).
Hysterectomy improves quality of life for some women.
In a study of 418 women, hysterectomy was found to be highly effective
for relief of pelvic pain, fatigue, depression, sexual dysfunction, and
other symptoms associated with nonmalignant conditions of the uterus.
Researchers from the Maine Medical Assessment Foundation, Harvard Medical
School, and Massachusetts General Hospital concluded that hysterectomy
provided significant relief and an improved quality of life 1 year
postoperatively. A limited number of women reported new problems, including
hot flashes (13 percent), weight gain (12 percent), depression (8 percent),
anxiety (6 percent), and lack of interest in sex (7 percent).
Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study
I: Outcomes of hysterectomy. Obstet Gynecol 83(4):556-572. (Grant
Hysterectomy for three nonmalignant gynecological conditions is
associated with greater improvement in symptoms and quality of life than
medication or "watchful waiting."
In this component of the Maine Women's Health Study, the health outcomes
of 380 women treated nonsurgically for conditions of the uterus—including
uterine fibroids, abnormal bleeding, and/or chronic pain—were compared with
those of 311 women who had hysterectomies for similar conditions. Even after
controlling for age, reproductive history, and severity of symptoms,
hysterectomy was the most highly correlated with a positive outcome at 1
year. Of the women treated nonsurgically at the outset, one-fourth underwent
a hysterectomy within a year. Many of the women treated with medications
experienced a significant reduction in abnormal bleeding and chronic pelvic
pain, although problems continued in an appreciable number of others. Women
with uterine fibroids whose physicians prescribed "watchful waiting"
experienced no significant change in symptoms or decline in quality of life,
providing some reassurance to women who are asymptomatic or have mild
symptoms and choose to avoid surgery.
Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study
II: Outcomes of nonsurgical management of leiomyomas, abnormal bleeding,
and chronic pelvic pain. Obstet Gynecol 83(4):556-572. (Grant No.
Hysterectomy is not associated with severe depression in older
In a retrospective study of 1,074 upper-middle-class, older women
interviewed between 1984 and 1987, findings suggest that bilateral
oophorectomy (removal of both ovaries) is associated with only slight
increases in depression scores. The authors recommend prospective studies to
examine the risk of depression in response to hysterectomy, oophorectomy,
and estrogen replacement therapy.
Kritz-Silverstein D, Wingard DL, Barrett-Connor E, et al. Hysterectomy,
oophorectomy, and depression in older women. Journal of Women's Health
3(4):255-263, 1994. (Grant No. HS06726).
AHCPR Publication No. 97-R021
Current as of August 1998