Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965-2002

Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Long-term risk of de novo mental health conditions after hysterectomy with ovarian conservation: a cohort study

OBJECTIVE

The aim of this research was to study the long-term risk of de novo mental health conditions in women who underwent hysterectomy with bilateral ovarian conservation compared with age-matched referent women.

METHODS

Using the Rochester Epidemiology Project records-linkage system, we identified a historical cohort of 2,094 women who underwent hysterectomy with ovarian conservation for benign indications at age ≥18 years and with an index date between 1980 and 2002 in Olmsted County, Minnesota. Each woman was age-matched (±1 y) to a referent woman residing in the same county who had not undergone hysterectomy or any oophorectomy before the index date. These two cohorts were followed historically to identify de novo mental health conditions. We estimated hazard ratios (HRs) and 95% confidence intervals (95% CIs) using Cox proportional hazards models adjusted for 20 preexisting chronic conditions and other potential confounders. We also calculated absolute risk increases (ARIs) and reductions (ARRs) at 30 years of follow-up.

RESULTS

Over a median follow-up of 21.9 years, women who underwent hysterectomy at any age experienced increased risks of de novo depression (adjusted HR 1.26; 95% CI, 1.12-1.41; ARI 6.6%) and anxiety (adjusted HR 1.22; 95% CI, 1.08-1.38; ARI 4.7%). The association for depression increased significantly with younger age at hysterectomy, but did not vary significantly by indication. Interactions were not significant for anxiety.

CONCLUSIONS

Hysterectomy, even with ovarian conservation, is associated with an increased long-term risk of de novo depression and anxiety, especially when performed in women who are younger. : Video Summary:http://links.lww.com/MENO/A465.

Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study

OBJECTIVE

The aim of the study was to determine the long-term risk of cardiovascular disease and metabolic conditions in women undergoing hysterectomy with bilateral ovarian conservation compared with age-matched referent women.

METHODS

Using the Rochester Epidemiology Project records-linkage system, we identified 2,094 women who underwent hysterectomy with ovarian conservation for benign indications between 1980 and 2002 in Olmsted County, Minnesota. Each woman was age-matched (±1 y) to a referent woman residing in the same county who had not undergone prior hysterectomy or any oophorectomy. These two cohorts were followed historically to identify de novo cardiovascular or metabolic diagnoses. We estimated hazard ratios (HRs) and 95% CIs using Cox proportional hazards models adjusted for 20 preexisting chronic conditions and other potential confounders. We also calculated absolute risk increases and reductions from Kaplan-Meier estimates.

RESULTS

Over a median follow-up of 21.9 years, women who underwent hysterectomy experienced increased risks of de novo hyperlipidemia (HR 1.14; 95% CI, 1.05-1.25), hypertension (HR 1.13; 95% CI, 1.03-1.25), obesity (HR 1.18; 95% CI, 1.04-1.35), cardiac arrhythmias (HR 1.17; 95% CI, 1.05-1.32), and coronary artery disease (HR 1.33; 95% CI, 1.12-1.58). Women who underwent hysterectomy at age ≤35 years had a 4.6-fold increased risk of congestive heart failure and a 2.5-fold increased risk of coronary artery disease.

CONCLUSIONS

Even with ovarian conservation, hysterectomy is associated with an increased long-term risk of cardiovascular and metabolic conditions, especially in women who undergo hysterectomy at age ≤35 years. If these associations are causal, alternatives to hysterectomy should be considered to treat benign gynecologic conditions.

Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy

OBJECTIVE

In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two- (2D) and three- (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).

METHODS

This was a prospective observational study performed between October 2008 and November 2011 in a tertiary referral laparoscopic unit. All women scheduled to undergo LH were included and underwent detailed preoperative transvaginal US. Uterine volumes were calculated using 2D-US measurements (ellipsoid formula), and using Virtual Organ Computer-aided AnaLysis (VOCAL™) having acquired 3D-US volumes of the uterus. Age, parity, need to morcellate and final uterine dry weight at histology were recorded. The estimated uterine volumes were then incorporated into a previously published logistic regression model to predict the need to morcellate for both nulliparous and parous women. The probability threshold cut-off of 0.14 (95% sensitivity) was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LRs). The performance of the models incorporating 2D- and 3D-US calculations were compared with 2D- and 3D-US-generated volumes alone, using receiver-operating characteristics (ROC) curves.

RESULTS

Of 76 women who underwent LH during the study period, 79% (n = 60) had complete background and 3D-US data. Their mean age was 43.7 years, 91.7% were parous and 35% underwent morcellation. The greatest uterine volume that did not require morcellation was 404 mL estimated using 3D-US, which corresponded to a uterine volume of 688.8 mL using 2D-US. The smallest uterine volume that required morcellation was 118.9 mL using 3D-US, which corresponded to a uterine volume of 123.4 mL using 2D-US. The 3D-US uterine volume for parous women with a sensitivity of 95% based on ROC-curve analysis was approximately 120 mL, which equated to a predicted probability of morcellation cut-off of 0.14. For this cut-off, specificity was 55.00%, PPV was 51.35%, NPV was 95.65%, LR+ was 2.11 and LR- was 0.09. Areas under the ROC curves for the morcellation logistic regression model were 0.769 (95% CI, 0.653-0.886) and 0.586 (95% CI, 0.419-0.753) using uterine volumes obtained by 3D-US and by 2D-US, respectively, and they were 0.938 (95% CI, 0.879-0.996) and 0.815 (95% CI, 0.681-0.948) using 3D-US and 2D-US volumes alone.

CONCLUSIONS

The need to morcellate can be predicted preoperatively using 3D-US uterine volumes obtained by transvaginal US with a fair degree of accuracy. Uteri with volumes smaller than 120 mL at 3D-US are very unlikely to require morcellation. The incorporation of 3D-US-estimated uterine volume into the previously published logistic regression model does not seem to confer any significant improvement when compared with 3D-US uterine volume alone to predict the need to morcellate in women undergoing total LH. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cardiovascular risk factors and diseases in women undergoing hysterectomy with ovarian conservation

OBJECTIVE

This study aims to determine the association of preexisting cardiovascular risk factors and cardiovascular diseases with hysterectomy with bilateral ovarian conservation using a case-central design.

METHODS

Using the Rochester Epidemiology Project records-linkage system, we identified all Olmsted County, MN women who underwent hysterectomy with ovarian conservation between January 1, 1965 and December 31, 2002 (cases). Each case was age-matched (± 1 y) with a randomly selected woman who resided in the county and did not undergo hysterectomy or oophorectomy before the index date (date of hysterectomy in her matched case). Using electronic codes, we identified cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, obesity, metabolic syndrome, and polycystic ovary syndrome) and cardiovascular diseases (coronary artery disease, congestive heart failure, myocardial infarction, and stroke) that occurred before the index date. Analyses were stratified by age at hysterectomy and indication for surgical operation.

RESULTS

During the study period, 3,816 women underwent hysterectomy with ovarian conservation for a benign indication. Preexisting hyperlipidemia, obesity, and metabolic syndrome were significantly more frequent in cases than in controls in univariable analyses. In multivariable analyses, obesity remained significantly associated overall, for nearly all age groups, and across all indications. Stroke was significantly more frequent in cases than in controls among women younger than 36 years. Congestive heart failure and stroke were significantly less common in cases than in controls among women older than 50 years.

CONCLUSIONS

Hysterectomy with ovarian conservation is associated with cardiovascular risk factors, particularly obesity. Obesity may contribute to underlying gynecologic conditions leading to hysterectomy; however, surgical selection may also play a role.

Estimation of uterine volume: A comparison between Viewpoint and 3D ultrasound estimation in women undergoing laparoscopic hysterectomy

Objectives: To assess the three‐dimensional (3D) tool, Virtual Organ Computed‐aided AnaLysis™ (VOCAL) in the calculation of pre‐operative uterine volume and to correlate the measurements with those obtained with Viewpoint, using uterine dry weight (UDW) as the gold standard.

Methods: Prospective observational study of women consented for a laparoscopic hysterectomy (LH) at Nepean Hospital between October 2008 and November 2011. All women underwent detailed transvaginal scan (TVS) at the pre‐operative assessment. Two‐dimensional (D) images of the uterus were obtained both in the mid‐sagittal and transverse planes. 3D volumetric acquisitions were also obtained for each uterus in the mid‐sagittal plane. 2D measurements of the uterus in millimetres (Anterio‐Posterior, longitudinal and transverse) were recorded in Viewpoint software package (GE Healthcare ViewPoint, Germany); which then generated an estimated uterine volume (ml) using the ellipsoid formula. The 3D uterine volumetric datasets were reviewed using SonoView Pro and uterine volumes were estimated with off‐line processing using VOCAL™. The gold standard for comparison was UDW in grams (g), measured by the histopathologist at the time of analysis of the LH specimens. The relationship between the estimated uterine volumes and actual UDW was evaluated using correlation analysis. P‐values were calculated to ascertain the significance of these findings; P values &< 0.05 represented statistical significance.

Results: 76 women underwent LH during the study period. Complete data were available in 96% (74/76) of cases. The mean age of the women was 43.7 years and 92% were multiparous. The mean Viewpoint uterine volume was 283 ml, the mean VOCAL™ uterine volume was 249 ml and the mean UDW was 295 g. There was a significant correlation between UDW and estimated uterine volumes both for Viewpoint (R = 0.83, P < 0.001) and VOCAL™ (R = 0.97, P < 0.001), respectively. Viewpoint systematically overestimated weight by 43.1 g, whereas VOCAL™ underestimated by an average of 42.4 g, and this difference was statistically significant (P < 0.001). In terms of absolute values, the mean prediction error for VOCAL™ was −18.0 g and for Viewpoint it was 27.6 g (P &< 0.0001). Conclusion: VOCAL™ was found to be significantly more accurate than Viewpoint in the estimation of uterine volumes, and it was better correlated with UDW.

Risk of oophorectomy after hysterectomy

OBJECTIVE

To compare the risk of subsequent oophorectomy among women who underwent hysterectomy for benign indications and those who did not.

METHODS

Using Rochester Epidemiology Project resources, we compared the risk of oophorectomy through December 31, 2008, among 4,931 women in Olmsted County, Minnesota, who underwent ovary-sparing hysterectomy for benign indications (case group) between 1965 and 2002, with 4,931 age-matched women who did not undergo hysterectomy (referent group). The cumulative incidence of subsequent oophorectomy was estimated by the Kaplan-Meier method, and comparisons were evaluated by Cox proportional hazard models using age as the time scale to allow for complete age adjustment.

RESULTS

The median follow-up times for case group and referent group participants were 19.6 and 19.4 years, respectively. At 10, 20, and 30 years after hysterectomy, the respective cumulative incidences of subsequent oophorectomy were 3.5%, 6.2%, and 9.2% among case group participants and 1.9%, 4.8%, and 7.3% among referent group participants. The overall risk of subsequent oophorectomy among case group participants was significantly higher than among referent group participants (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.02-1.42; P=.03). Furthermore, among case group participants, the risk of subsequent oophorectomy was significantly higher (HR 2.15, 95% CI 1.51-3.07; P<.001) in women who had both ovaries preserved compared with those who initially had one ovary preserved.

CONCLUSION

The incidence of oophorectomy after hysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentage points higher than the incidence of oophorectomy in referent women with intact reproductive organs.

LEVEL OF EVIDENCE

II.

Transversus abdominis plane infiltration and quality of recovery after laparoscopic hysterectomy: a randomized controlled trial

OBJECTIVE

To examine the effect of a preoperative transversus abdominis plane infiltration on postoperative quality of recovery and analgesia in patients undergoing laparoscopic hysterectomy.

METHODS

The study was a randomized, double-blinded, placebo-controlled trial. Seventy-five healthy women were randomized to receive a preoperative infiltration with 0.5% ropivacaine, 0.25% ropivacaine, or saline. Postoperative quality of recovery score (QoR-40), pain, and opioid consumption were assessed up to 24 hours after the surgical procedure. Data were analyzed using Kruskal-Wallis test. Post hoc pair-wise comparisons were made using Dunn test. P<.05 was required to reject the null hypothesis.

RESULTS

Sixty-six patients completed the study. Patients' baseline characteristics and surgical factors were not different between groups. The ropivacaine group experienced a better quality recovery and less postoperative pain than the saline group. The median difference (99.2% confidence interval) in global recovery scores at 24 hours after surgery was 28 (QoR score 4-39, P=.001) for ropivacaine 0.5% and 28 (QoR score 10-43, P<.001) for ropivacaine 0.25% compared with saline, respectively. The 0.5% ropivacaine group also had less pain, lower opioid consumption, and faster postanesthesia care unit discharge than the saline group. Linear regression demonstrated an inverse relationship between opioid consumption and global quality of recovery at 24 hours (P<.001).

CONCLUSION

The transversus abdominis plane infiltration improves quality of recovery. There was an inverse linear relationship between postoperative opioid consumption and quality of recovery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01074229.

LEVEL OF EVIDENCE

I.

Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy

Laparoscopic supracervical hysterectomy demonstrated fewer preoperative complications and lower postoperative costs compared to laparoscopic-assisted vaginal hysterectomy in this report.

Objectives:

To compare the incidence of perioperative complications and postoperative healthcare utilization and costs in laparoscopic supracervical hysterectomy (LSH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) patients.

Methods:

Women ≥18 years with LSH or LAVH were extracted using a large national commercial claims database from 1/1/2007 through 9/30/2008. Outcome was perioperative complications and gynecologic-related postoperative resource use and costs. Multivariate analysis was performed to compare postsurgical outcomes between the cohorts.

Results:

The final sample consisted of 6,198 LSH patients and 14,181 LAVH patients. LSH patients were significantly more likely to have dysfunctional uterine bleeding and leiomyomas and less likely to have endometriosis and prolapse as the primary diagnosis, and also significantly more likely to have a uterus that weighed >250 grams than LAVH patients. Compared with LAVH patients, LSH patients had significantly lower overall infection rates (7.4% versus 6.2%, P=.002) and lower total gynecologic-related postoperative costs ($252 versus $385, P<.001, within 30 days of follow-up and $350 versus $569, P<.001, within 180 days of follow-up). Significant cost differences remained following multivariate adjustment for patient characteristics.

Conclusions:

LSH patients demonstrated fewer perioperative complications and lower GYN-related postoperative costs compared to LAVH patients.

Menopausal characteristics and physical functioning in older adulthood in the National Health and Nutrition Examination Survey III

OBJECTIVE

We hypothesized that natural menopause would be related to better physical functioning compared with surgical menopause and that later age at menopause would be related to better physical functioning.

METHODS

Our sample comprised 1,765 women 60 years or older who participated in the National Health and Nutrition Examination Survey III, a cross-sectional study representative of the US population. Women recalled age at final menstrual period and age at removal of the uterus and ovaries and reported age, race and ethnicity, height, weight, educational attainment, smoking status, number of children, and use of estrogen therapy. Respondents completed a walk trial and chair rises and reported functional limitations.

RESULTS

Women with surgical menopause had chair rise times that were an average of 4.4% slower than did those of women with natural menopause (95% CI, 0.56-8.27). Women with natural menopause at age 55 years or more had an average walking speed of 0.05 meters/second (95% CI, 0.01-0.10) faster than did women with natural menopause at age less than 45 years. Later ages at natural and surgical menopause were also related to lower self-reported functional limitation. Women with surgical menopause at age 55 years or more had odds of functional limitation 0.52 times (95% CI, 0.29-0.95) that of women with surgical menopause at age less than 40 years, with similar patterns for natural menopause.

CONCLUSIONS

Women with surgical menopause and earlier age at menopause had worse physical function in older adulthood. These groups of women may benefit from interventions to prevent functional decline.

Alternatives to hysterectomy: focus on global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound

The aim of this study was to inform the clinician of alternatives to hysterectomy through a critical evaluation of three treatment options: global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound. Studies published in English-language, peer-reviewed journals were systematically searched using Cochrane and Medline. Keywords used included "alternatives to hysterectomy," "endometrial ablation," "uterine fibroid embolization," "uterine artery embolization," and "focused ultrasound." Articles meeting the inclusion criteria were reviewed and analyzed for themes and similarities. All three alternative methods of treatment reviewed are currently approved for use in the United States and abroad. In fact, five different global endometrial ablation devices are approved by the Food and Drug Administration for treatment of menorrhagia. Patient satisfaction scores after endometrial ablation are high (90%-95%), but amenorrhea rates are much lower (15%-60%). Data from randomized trials demonstrate that uterine fibroid embolization results in a shorter hospital stay and quicker return to work as compared with abdominal hysterectomy for leiomyomas, but after embolization, up to 20% of women need a second procedure. Ex-ablative therapy of leiomyomas with focused ultrasound is the newest of the three methods. It has a special set of patient selection criteria and is only available at less than 20 medical centers in the United States. Leiomyoma symptom relief after focused ultrasound therapy at 1 year post-procedure is high (85%-95%). There are many effective alternatives to hysterectomy in women with menorrhagia and/or symptomatic leiomyomas. However, because these procedures are performed by individuals from different subspecialists, primarily gynecologists and interventional radiologists, clinicians must consider using a multidisciplinary approach to find the best procedure for a given patient. There are no randomized trials comparing uterine fibroid embolization to vaginal hysterectomy, laparoscopic hysterectomy, or laparoscopic myomectomy.

Type and timing of menopause and later life mortality among women in the Iowa Established Populations for theEpidemiological Study of the Elderly (EPESE) cohort

BACKGROUND

The relationship between menopausal characteristics and later life mortality is unclear. We tested the hypotheses that women with surgical menopause would have increased all-cause and cardiovascular mortality compared with women with natural menopause, and that women with earlier ages at natural or surgical menopause would have greater all-cause and cardiovascular mortality than women with later ages at menopause.

METHODS

Women who participated in the Iowa cohort of the Established Populations for the Epidemiologic Study of the Elderly (n=1684) reported menopausal characteristics and potential confounding variables at baseline and were followed up for up to 24 years. Participants were aged 65 years or older at baseline and lived in rural areas. We used survival analysis to examine the relationships between menopausal characteristics and all-cause and cardiovascular mortality.

RESULTS

A total of 1477 women (87.7% of respondents) died during the study interval. Women with an age at natural menopause ≥55 years had increased all-cause and cardiovascular disease mortality compared with women who had natural menopause at younger ages. Type of menopause and age at surgical menopause were not related to mortality. These patterns persisted after adjustment for potential confounding variables.

CONCLUSIONS

Among an older group of women from a rural area of the United States, later age at natural menopause was related to increased all-cause and cardiovascular mortality. Monitoring the cardiovascular health of this group of older women may contribute to improved survival times.

Comparison of the clinical and economic outcomes between open and minimally invasive appendectomy and colectomy: evidence from a large commercial payer database

BACKGROUND

Appendectomy and colectomy are commonly performed surgical procedures. Despite evidence demonstrating advantages with the minimally invasive surgical (MIS) approach, open procedures occur with greater prevalence. Therefore, there is still controversy as to whether the MIS approach is safer or more cost effective.

METHODS

A retrospective analysis was performed using a large commercial payer database. The data included information on 7,532 appendectomies and 2,745 colectomies. Data on the distribution of patient demographic and comorbidity characteristics associated with the MIS and open approaches were reviewed. The corresponding complication rates and expenditures were analyzed. Summary statistics were compared using chi-square tests, and generalized linear models were constructed to estimate expenditures while controlling for patient characteristics.

RESULTS

The patients undergoing MIS and open colectomy showed no significant variations in age distribution or marginal age differences for appendectomy. Significantly more patients experienced an infection postoperatively, and procedure-specific complications were more common in the open group for both procedures (P\0.05). The postsurgical hospital stay was longer for the patients treated using the open techniques, differing an average of half a day for appendectomies and significantly more (4 days) for colectomy (P\0.05). Readmission rates differed little between the two approaches. Procedures performed through an MIS approach were associated with lower expenditures than for the open technique, with differences ranging from $700 for appendectomy patients (P\0.05) to $15,200 for colectomy patients (P\0.05).

CONCLUSIONS

Minimally invasive appendectomy and colectomy were associated with lower infection rates, fewer complications, shorter hospital stays, and lower expenditures than open surgery.

Timing of births and endometrial cancer risk in Swedish women

While a protective long-term effect of parity on endometrial cancer risk is well established, the impact of timing of births is not fully understood. We examined the relationship between endometrial cancer risk and reproductive characteristics in a population-based cohort of 2,674,465 Swedish women, 20-72 years of age. During follow-up from 1973 to 2004, 7,386 endometrial cancers were observed. Compared to uniparous women, nulliparous women had a significantly elevated endometrial cancer risk (hazard ratio [HR] = 1.32, 95% confidence interval [CI], 1.22-1.42). Endometrial cancer risk decreased with increasing parity; compared to uniparous women, women with > or =4 births had a HR = 0.66 (95% CI, 0.59-0.74); p-trend < 0.001. Among multiparous women, we observed no relationship of risk with age at first birth after adjustment for other reproductive factors. While we initially observed a decreased risk with later ages at last birth, this appeared to reflect a stronger relationship with time since last birth, with women with shorter times being at lowest risk. In models for multiparous women that included number of births, age at first and last birth, and time since last birth, age at last birth was not associated with endometrial cancer risk, while shorter time since last birth and increased parity were associated with statistically significantly reduced endometrial cancer risks. The HR was 3.95 (95% CI; 2.17-7.20; p-trend = <0.0001) for women with > or =25 years since a last birth compared to women having given birth within 4 years. Our findings support that clearance of initiated cells during delivery may be important in endometrial carcinogenesis.

Risk factors for pelvic floor repair after hysterectomy

OBJECTIVE

Having demonstrated that prior history of prolapse was a risk factor for pelvic floor repair procedures after hysterectomy, the objective of this study was to assess medical risk factors for pelvic floor repair after hysterectomy.

METHODS

Using the Rochester Epidemiology Project database of 8,220 Olmsted County, Minnesota, women who had hysterectomy for benign indications from 1965-2002, we conducted a nested case-control study in 144 pairs, comparing women who underwent pelvic floor repair after hysterectomy (case group) with women matched for known risk factors (ie, age, pelvic floor disorders at baseline, year and type of hysterectomy, and pelvic floor repair during hysterectomy) (control group).

RESULTS

The median duration between hysterectomy and pelvic floor repair was 13 years. Chronic pulmonary disease (odds ratio [OR] 14.3, 95% confidence interval [CI] 1.2-178), but not obstetric history, obesity, indication for hysterectomy, or chronic constipation, was associated with an increased risk of pelvic floor repair after hysterectomy. Between the hysterectomy and subsequent pelvic floor repair, overall pelvic organ prolapse severity changed by one grade or less in 54 case patients (38%, group A) but increased by two or more grades in 72 case patients (50%, group B). In group A, but not group B, uterine prolapse (OR 25, 95% CI 2.1-300) and chronic pulmonary disease (OR 22, 95% CI 1.5-328) at baseline remained risk factors for pelvic floor repair after hysterectomy.

CONCLUSION

In this matched case-control study, chronic pulmonary disease was the only risk factor for pelvic floor repair after hysterectomy for benign indications, underscoring the need to address pulmonary status before surgery.

Utilization of surgical procedures for pelvic organ prolapse: a population-based study in Olmsted County, Minnesota, 1965-2002

To describe trends in the utilization of surgical procedures for pelvic organ prolapse among women in Olmsted County, MN, we retrospectively identified all county residents undergoing pelvic organ prolapse repair from January 1, 1965 through December 31, 2002. From 1965 to 2002, 3,813 women had pelvic organ prolapse surgeries: 3,126 had hysterectomy combined with pelvic floor repair (PFR) procedures and 687 had PFR alone. The age-adjusted utilization of hysterectomy plus PFR and of PFR alone decreased by 62% (P < 0.001) and 32% (P = 0.02), respectively. In both groups, utilization decreased in all age groups over time except in women aged 80 years and older undergoing hysterectomy plus PFR and women aged 70 years and older undergoing PFR only. The most common indication for PFR was uterovaginal prolapse. Among women in the community, the rate of utilization and age distribution of pelvic organ prolapse surgery changed substantially between 1965 and 2002.

Incidence of pelvic floor repair after hysterectomy: A population-based cohort study

OBJECTIVE

The objective of the study was to assess the incidence of and risk factors for pelvic floor repair (PFR) procedures after hysterectomy.

STUDY DESIGN

Using the Rochester Epidemiology Project database, we tracked the incidence of PFRs through June 2006 among 8220 Olmsted County, MN, women who had a hysterectomy for benign indications between 1965 and 2002.

RESULTS

The cumulative incidence of PFR after hysterectomy was 5.1% by 30 years. This risk was not influenced by age at hysterectomy or calendar period. Future PFR was more frequently required in women who had prolapse, whether they underwent a hysterectomy alone (eg, vaginal [hazard ratio (HR) 4.3; 95% confidence interval (CI) 2.5 to 7.3], abdominal [HR 3.9; 95% CI 1.9 to 8.0]) or a hysterectomy and PFR (ie, vaginal [HR 1.9; 95% CI 1.3 to 2.7] or abdominal [HR 2.9; 95% CI 1.5 to 5.5]).

CONCLUSION

Compared with women without prolapse, women who had a hysterectomy for prolapse were at increased risk for subsequent PFR.

Influence of hysterectomy on long-term fracture risk

OBJECTIVE

To assess long-term fracture risk after hysterectomy, with or without oophorectomy.

DESIGN

Population-based, cohort study.

SETTING

Olmsted County, Minnesota.

PATIENT(S)

Women residing in Olmsted County (n = 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age- and sex-matched community controls.

INTERVENTION(S)

Observational study of the effect of hysterectomy for various indications on subsequent fractures.

MAIN OUTCOME MEASURE(S)

Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community.

RESULT(S)

Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98-1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98-1.15).

CONCLUSION(S)

Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention.