Chance Of Hysterectomy Predicted By Multi-year Study

Results from a four-year study of 762 women with various symptoms of uterine distress, such as chronic pelvic pain, abnormal bleeding or fibroids, are reported in the April 2007 issue of the "Journal of the American College of Surgeons." 

The findings confirm a widely held, but untested, belief in gynecology that the more symptoms of discomfort a woman has, as well as the longer she has tried alternative therapies unsuccessfully, the more likely she is to have a hysterectomy, said lead investigator Lee Learman, MD, a professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

"In the past, we were never entirely sure which symptoms were most likely to lead to a hysterectomy and which were most likely to be controlled with conservative treatments, so women received differing advice from individual doctors across the country," he added. "Now, for the first time, we have easily-measured, clinical characteristics that we can assess and use to accurately counsel patients on their options."

That, in turn, means women with a high likelihood of hysterectomy can avoid years of pain and discomfort while trying other options first and women with a low likelihood of hysterectomy can explore other options with more confidence of their success, Learman said.

The study found three independent predictors of a patient's chance of having a hysterectomy: a combination of symptoms, such as pelvic pain and bleeding, or fibroids with bleeding or pressure; a lack of symptom resolution despite prior treatments; and previous use of gonadotropin-releasing hormone agonist, known as GNRH agonist and the so-called "medical menopause" that doctors sometimes prescribe to alleviate severe symptoms.

One symptom alone, such as pelvic pain or bleeding, results in only a 20 percent chance of undergoing a hysterectomy within four years, the study found. Yet a combination of symptoms as well as the two other predictors -- a lack of symptom resolution and previous use of GNRH agonist -- led to a 95 percent chance.

Subgroups with a combination of these predictors showed an escalating risk of hysterectomy with each additional risk factor.

This study was the first part of an ongoing UCSF research project on hysterectomies, called the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives, or SOPHIA. The project is tracking nearly 1,500 premenopausal women, including those in this study, for four to eight years to understand not only their rate of hysterectomy, but also predictions of their quality of life over time.

Hysterectomy is the most common operation performed on U.S. women other than childbirth and affects more than 600,000 patients per year. Prior to this study, little has been known about how non-cancerous uterine conditions lead to hysterectomy, Learman said. The rate of hysterectomy also has varied widely across the nation and worldwide, raising questions of the appropriateness of the procedure.

This study recruited women seeking care for abnormal uterine bleeding, chronic pelvic pain, or symptomatic uterine fibroids and ascertained their hysterectomy status during four years of surveillance. The team also collected baseline socio-demographic and clinical data, as well as patient age.

The 99 hysterectomies observed in the population reflected a cumulative 13.5 percent hysterectomy rate.

For the past decade, Learman said, most studies have shown that women who do undergo a hysterectomy have a far better quality of life after the surgery, yet most women postpone the procedure as long as possible to try other options first.

"It's the best-kept secret in gynecology," Learman said. "Ten years ago, we had to say we didn't know whether women were better off or not, but now we do know. When women have a hysterectomy because of bleeding, pain or bulky fibroids, we now know that they do extremely well."

Those who don't do as well often started with baseline depression or other conditions, he said.

Co-authors of the study are principal investigator Miriam Kuppermann, PhD, MPH; Elena Gates, MD; Steven E. Gregorich, PhD; and A. Eugene Washington, MD, MSc, all from the UCSF Medical Effectiveness Research Center for Diverse Populations, UCSF School of Medicine; and James Lewis, MD, Kaiser Permanente Medical Group, San Francisco, CA.

The study was funded by the U.S. Agency for Healthcare Research and Quality and the National Institute on Aging and Office of Research in Women's Health, National Institutes of Health.