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Women's Health

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Hysterectomy is often recommended for indications judged inappropriate by established criteria

Hysterectomy is second only to cesarean section as the most common major operation performed on U.S. women, and there have long been concerns about its overuse. A new study of women enrolled in nine managed care organizations (MCOs) in Southern California seems to support this concern. According to the study's findings, almost three-fourths (70 percent) of hysterectomies performed between 1993 and 1995 on 497 women enrolled in these MCOs were recommended inappropriately. These cases did not meet the level of care recommended by an expert panel. What's more, 76 percent of women who underwent the operation for endometriosis, chronic pelvic pain, or premenopausal abnormal bleeding, indications for which criteria sets have been developed by the American College of Obstetricians and Gynecologists (ACOG), did not meet ACOG criteria for performing hysterectomy.

Overall, the most common indications for hysterectomy were benign tumors (leiomyomata, often called fibroid tumors, 60 percent of hysterectomies), pelvic relaxation (11 percent), pain (9 percent), and bleeding (8 percent). The most common reasons that recommendations for hysterectomy were considered to be inappropriate were inadequate diagnostic evaluation and failure to try alternative treatment before hysterectomy. For example, neither a laparoscopy nor a laparotomy was done before hysterectomy on 77 percent of women with pelvic pain to exclude other causes of pain that might be resolved without a hysterectomy. Also, 45 percent of women with abnormal uterine bleeding did not have endometrial sampling (usually done to rule out cancer) before hysterectomy.

In addition, 21 percent of women with pain or bleeding did not receive (or were not offered) a trial of medical treatment for the problem first. Finally, 14 percent of the women had clinical characteristics such that, regardless of diagnostic or therapeutic steps taken before surgery, the panel would have considered the procedure inappropriate (for example, surgery for pelvic relaxation in a woman with first-degree uterine prolapse and no incontinence or pain). This research was supported in part by the Agency for Healthcare Research and Quality (HS07095).

See "The appropriateness of recommendations for hysterectomy," by Michael S. Broder, M.D., David E. Kanouse, Ph.D., Brian S. Mittman, Ph.D., and Steven J. Bernstein, M.D., M.P.H., in the February 2000 Obstetrics & Gynecology 95(2), pp. 199-205.

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