Hysterectomy and disability among U.S. women

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study

BACKGROUND

Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking.

OBJECTIVE

This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years.

STUDY DESIGN

This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group.

RESULTS

Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group.

CONCLUSION

Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review

OBJECTIVE

To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022.

METHODS OF STUDY SELECTION

The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies.

TABULATION, INTEGRATION, AND RESULTS

Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy.

CONCLUSION

Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021234511.

A Mixed Methods Study of Hysterectomy in a U.S. Sample of Deaf Women Who Use American Sign Language

Background: Hysterectomy is one of the most common procedures performed in the United States. Yet, we know nothing about deaf women's experiences with hysterectomy. The study aims to establish a prevalence of hysterectomy among deaf women and provide insight into the experiences of those who have undergone hysterectomy.

Materials and Methods: Quantitative data (n = 195; 27% Black, Indigenous, People of Color) were collected through a bilingual online patient-reported outcomes survey and reproductive health questions from the National Health and Nutrition Examination Survey (NHANES) between November 2019 and March 2020. Semistructured interviews were conducted between March and April 2021 with a smaller sample of deaf women who underwent hysterectomy. A multivariable logistic regression model identified the relationship between health care history and sociodemographic factors, while qualitative interview data were used to understand deaf women's experiences with hysterectomy.

Results: Of the 195 deaf respondents, 34% underwent hysterectomy (n = 67). Results indicated that the odds of hysterectomy increased for higher age (per year), being African American/Black or Latinx, being married or living with a partner, being overweight or obese, and if communicating with the doctor through English writing or others. Qualitative interviews were conducted with eight women who provided consent to participate. Although all women reported improved quality of life posthysterectomy, patient-centered experience and decision making before hysterectomy were highly dependent on access to communication, information sources, and social support.

Conclusions: Prioritizing the needs of deaf women leading up to, during, and after hysterectomy has the potential to improve overall experience with hysterectomy and patient–clinician communication.

Prevalence of Hysterectomy by Self-Reported Disability Among Canadian Women: Findings from a National Cross-Sectional Survey

Introduction: Our objective was to investigate differences in prevalence of hysterectomy by self-reported disability status among Canadian women.

Materials and Methods: We analyzed cross-sectional data from the Canadian Community Health Survey 2012 on 30,170 women aged ≥20 years. Disability was defined as reports of sometimes or often (vs. never) experiencing functional limitations or reduction in daily activities at home, school, or work. Frequency of these limitations was used as a proxy for disability severity. The outcome was self-reported hysterectomy status. Modified Poisson regression was used to quantify the prevalence ratio (PR) and 95% confidence interval (CI) for hysterectomy according to any, functional, or activity-limiting disability, after adjustment for household income, employment, education, ethnicity, and marital status. Results were stratified by age at time of data collection, categorized as childbearing (20–44 years), perimenopausal (45–59 years), and postmenopausal (60 years and older).

Results: Disability was significantly and consistently associated with higher prevalence of hysterectomy in women. The strength of association was inversely related to age category, and PRs for a given age category were similar across disability types and severity levels. PRs for the association between any disability and hysterectomy were 2.18 (95% CI 1.36–3.50) for childbearing-aged women, 1.48 (95% CI 1.21–1.80) for perimenopausal women, and 1.12 (95% CI 1.02–1.24) for postmenopausal women.

Conclusions: Prevalence of hysterectomy is disproportionately higher among women with self-reported disabilities compared with women without disabilities, with these differences most pronounced in women of childbearing age.

Complications following hysterectomy in women with intellectual and developmental disabilities

BACKGROUND

Limited data exist on complications following hysterectomy among women with intellectual and developmental disabilities (IDD).

OBJECTIVE

The objective was to assess the frequencies of postoperative complications in women with IDD following hysterectomy.

METHODS

The National Inpatient Sample from 2014 to 2017 was queried using codes from the International Classification of Disease 9th and 10th revisions to identify women over 15 years of age with a diagnosis of an IDD undergoing hysterectomy. Comparisons were made to women without IDD undergoing the same procedure. Logistic regression analysis was performed to examine between group differences in the frequency of clinical post-surgical complications while adjusting for potential confounding variables.

RESULTS

Of eligible women undergoing hysterectomy, 1,370 were identified as having IDD and 624,700 did not. Compared to controls, women with IDD were significantly younger (45 vs. 50 years, p < 0.001). Women with IDD were also more likely to have had governmental health insurance (83% vs. 34%, p < 0.001), an open hysterectomy approach (78% vs. 69%, p = 0.002), and longer hospital stays (4 vs. 3 days, p < 0.001). After adjusting for potential confounders, women with IDD had greater odds of postoperative urinary complications (OR 3.74, 95% CI 1.18-11.83) and complications related to decubitus ulcer formation (OR 8.97, 95% CI 2.10-38.36).

CONCLUSIONS

Women with IDD have increased odds having urinary and decubitus ulcer complications following hysterectomy, compared to women without IDD. These results inform surgical decision-making and anticipatory guidance for these women and their caregivers.

Long-Acting Reversible Contraception: Specific Issues for Adolescents

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.

The effects of salpingectomy on the serum level of anti-Müllerian hormone: A single-blind randomized controlled trial

OBJECTIVES

Concerns exist over the effects of salpingectomy on ovarian function. This study aimed to assess the effects of salpingectomy on the serum level of anti-Müllerian hormone.

MATERIALS AND METHODS

This single-blind randomized controlled trial was conducted in 2017-2018 on 86 candidates for hysterectomy. Participants were randomly allocated to undergo either hysterectomy without salpingectomy (control group) or hysterectomy with salpingectomy (intervention group). Serum anti-Müllerian hormone level was measured both before and three months after surgery. Data were analyzed through the Mann-Whitney U test, the Chi-square test, the analysis of covariance, and the linear regression analysis.

RESULTS

The mean value of Serum anti-Müllerian hormone level did not significantly change in the study groups (P>0.05). After removing the effects of confounders, study groups did not significantly differ from each other respecting the posttest mean value of serum anti-Müllerian hormone level (P=0.868).

CONCLUSION

Salpingectomy does not significantly affect serum anti-Müllerian hormone level and ovarian function.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.

Female Sterilization and Cognitive Disability in the United States, 2011-2015

OBJECTIVE

To compare female sterilization among three mutually exclusive groups of females: 1) those without any self-reported disability, 2) those with noncognitive disabilities (sensory or physical disabilities), and 3) those with cognitive disabilities.

METHODS

We conducted a secondary analysis of nationally representative data from the National Survey of Family Growth 2011-2015, which surveyed individuals aged 15-44 years in the U.S. civilian population. Disability status (self-reported) was ascertained using a standard set of questions about hearing, vision, cognitive, ambulatory, self-care, and independent living difficulties. Regression models were used to calculate odds of female sterilization, hysterectomies, and age of sterilization while accounting for sociodemographic differences.

RESULTS

Female sterilization rates were higher among females with cognitive (22.1% [n=272]) and noncognitive disabilities (24.7% [n=150]) than among those without disabilities (14.8% [n=1,132]). After adjusting for sociodemographic covariates, females with cognitive disabilities had significantly higher odds of female sterilization (adjusted odds ratio [OR] 1.54, 95% CI 1.19-1.98, P<.01) and hysterectomy (adjusted OR 2.64, 95% CI 1.53-4.56, P<.001) than those without cognitive disabilities. Females with cognitive disabilities also underwent sterilization at significantly younger ages (27.3 years, 95% CI 27.0-27.6) than those with noncognitive disabilities (28.3 years, 95% CI 27.9-28.8) and those without any disability (29.8 years, 95% CI 29.5-30.0).

CONCLUSION

U.S. females with cognitive disabilities were more likely to have undergone female sterilizations and hysterectomies and at younger ages than those with other disabilities or without disabilities. Drivers of these disability-related differences in female sterilization patterns must be explored.

Planning for motherhood: fertility attitudes, desires and intentions among women with disabilities

CONTEXT

An estimated 10% of U.S. women of reproductive age report a current disability; however, the relationship between disability, motherhood attitudes and fertility intentions among these women is largely unknown.

METHODS

Data from the 2006-2010 National Survey of Family Growth were used to examine attitudes toward motherhood and fertility intentions among 10,782 U.S. women aged 15-44. A series of regression models assessed, separately for mothers and childless women, associations between disability status and women's attitudes and intentions.

RESULTS

Women with and without disabilities held similar attitudes toward motherhood. Among women without children, women with and without disabilities were equally likely to want a child and equally likely to intend to have one. However, childless women with disabilities who wanted and intended to have a child were more likely to report uncertainty about those intentions than were childless women without disabilities (odds ratio, 1.7). Mothers with disabilities were more likely to want another child (1.5), but less likely to intend to have a child (0.5), than were mothers without disabilities.

CONCLUSIONS

Deepening understanding of the reproductive health desires, needs and challenges of women with disabilities is essential if the highest quality reproductive health services are to be provided for all.