Hysterectomy prevalence by Hispanic ethnicity: evidence from a national survey

Connections between reproductive health and cognitive aging among women enrolled in the HCHS/SOL and SOL-INCA

INTRODUCTION

Reproductive health history may contribute to cognitive aging and risk for Alzheimer's disease, but this is understudied among Hispanic/Latina women.

METHODS

Participants included 2126 Hispanic/Latina postmenopausal women (44 to 75 years) from the Study of Latinos-Investigation of Neurocognitive Aging. Survey linear regressions separately modeled the associations between reproductive health measures (age at menarche, history of oral contraceptive use, number of pregnancies, number of live births, age at menopause, female hormone use at Visit 1, and reproductive span) with cognitive outcomes at Visit 2 (performance, 7-year change, and mild cognitive impairment [MCI] prevalence).

RESULTS

Younger age at menarche, oral contraceptive use, lower pregnancies, lower live births, and older age at menopause were associated with better cognitive performance. Older age at menarche was protective against cognitive change. Hormone use was linked to lower MCI prevalence.

DISCUSSION

Several aspects of reproductive health appear to impact cognitive aging among Hispanic/Latina women.

Unplanned hysterectomy: a comprehensive analysis of race, ethnicity, sociodemographic factors, pregnancy complications, and cardiovascular disease risk factors

OBJECTIVE

To understand the risk of unplanned hysterectomy (UH) in pregnant women better in association with maternal sociodemographic characteristics, cardiovascular disease (CVD) risk factors, and current pregnancy complications.

DESIGN

Using Florida birth data from 2005 to 2014, we investigated the possible interactions between known risk factors of having UH, including maternal sociodemographic characteristics, maternal medical history, and other pregnancy complications. Logistic regression models were constructed. Adjusted odds ratios and 95% confidence intervals were reported.

RESULTS

Several interactions were observed that significantly affected odds of UH. Compared to non-Hispanic White women, Hispanic minority women were more likely to have an UH. The overall risk of UH for women with preterm birth (<37 weeks) and concurrently had premature rupture of membranes (PRoM), uterine rupture, or a previous cesarean delivery was significantly higher than women who delivered to term and had no pregnancy complications. Women who delivered via cesarean who also had preeclampsia, PRoM, or uterine rupture had an overall increased risk of UH. Significantly decreased risk of UH was seen for Black women less than 20 years old, women of other minority races with either less than a high school degree or a college degree or greater, women of other minority races with PRoM, and women with preterm birth and diabetes compared to respective reference groups.

CONCLUSIONS

Maternal race, ethnicity, CVD risk factors, and current pregnancy complications affect the risk of UH in pregnant women through complex interactions that would not be seen in unadjusted models of risk analysis.

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.

Hysterectomy, bilateral oophorectomy, and breast cancer risk in a racially diverse prospective cohort study

BACKGROUND

Gynecologic surgery is hypothesized to reduce risk of breast cancer; however, associations may be modified by subsequent hormone use. Our objective was to examine the association between gynecologic surgery and breast cancer incidence considering the use of hormone therapy.

METHODS

The Sister Study is a prospective cohort of initially breast cancer-free women aged 35-74 years with a sister who had breast cancer. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between gynecologic surgery (no surgery, hysterectomy only, bilateral oophorectomy with or without hysterectomy) and incident breast cancer among 50 701 women.

RESULTS

History of gynecologic surgery was common, with 13.8% reporting hysterectomy only and 18.1% reporting bilateral oophorectomy with or without hysterectomy. During follow-up (median = 11.4 years), 3948 cases were diagnosed. Compared with no surgery, bilateral oophorectomy was inversely associated with breast cancer (HR = 0.91, 95% CI = 0.83 to 1.00), and hysterectomy alone was positively associated (HR = 1.12, 95% CI = 1.02 to 1.23). Compared with no surgery and no hormone therapy, bilateral oophorectomy combined with estrogen only therapy (HR = 0.83, 95% CI = 0.74 to 0.94) was inversely associated with breast cancer, while hysterectomy combined with estrogen plus progestin therapy was positively associated with breast cancer (HR = 1.25, 95% CI = 1.01 to 1.55).

CONCLUSIONS

We observed an inverse association between bilateral oophorectomy and breast cancer risk. The positive association between hysterectomy and breast cancer may be due to concomitant estrogen plus progestin therapy.

Transgender Males as Potential Donors for Uterus Transplantation: A Survey

Uterus transplantation is a new treatment for patients with absolute uterine infertility that is conducted in order to enable them to carry their own pregnancy. One of the limitations for its development is donor availability. Some transgender males undergo a hysterectomy in the gender-affirming surgery process, and might be interested in donating their uterus for transplantation. In this manuscript, we report the results of a survey designed to determine the attitudes of such individuals regarding donation of their uterus for this purpose. Over 32 years (January 1989-January 2021), 348 biological women underwent hysterectomy at our hospital as part of gender-affirming surgery. The survey was sent to 212 of the 348 prospective participants (for 136, we lacked postal or email addresses). Among the 212 surveys sent, we obtained responses from 94 individuals (44%): 83 (88.3%) stated they would agree to donate, of whom 44 would do so for altruism, 23 for the usefulness of the gesture and 16 out of understanding of the desire to have a child; 63 (75.5%) wanted to know the recipient and 45 (54.2%) wanted to know the result of the donation. According to this survey, a high proportion of transgender males surveyed would be interested in donating their uterus for uterus transplantation.

Trends and predictors of hysterectomy prevalence among women in the United States

BACKGROUND

Hysterectomy is the most common nonobstetrical medical procedure performed in US women. Evaluating hysterectomy prevalence trends and determinants is important for estimating gynecologic cancer rates and management of uterine conditions.

OBJECTIVE

This study aimed to assess hysterectomy prevalence trends and determinants using the Behavioral Risk Factor Surveillance System (2006-2016).

STUDY DESIGN

We estimated crude hysterectomy prevalences and multivariable-adjusted odds ratios and 95% confidence intervals for associations of race or ethnicity, age group (5-year), body mass index (categorical), smoking status, education, insurance, income, and US region with hysterectomy. Missing data were imputed. The number of women in each survey year ranged from 220,302 in 2006 to 275,631 in 2016.

RESULTS

Although overall hysterectomy prevalence changed little between 2006 and 2016 (21.4% and 21.1%, respectively), hysterectomy prevalence was lower in 2016 than in 2006 among women aged ≥40 years, particularly among non-Hispanic Black and Hispanic women. Current smoking (odds ratio, 1.38; 95% confidence interval, 1.35-1.41), increasing age (odds ratio, 1.40; 95% confidence interval, 1.39-1.40), living in the South compared with the Midwest (odds ratio, 1.36; 95% confidence interval, 1.34-1.39), higher body mass index (odds ratio, 1.26; 95% confidence interval, 1.25-1.27), Black race compared with White (odds ratio, 1.10; 95% confidence interval, 1.07-1.13), and having insurance compared with being uninsured (odds ratio, 1.26; 95% confidence interval, 1.22-1.30) were most strongly associated with increased prevalence. Hispanic ethnicity and living in the Northeast were most strongly associated with decreased prevalence (odds ratio, 0.73; 95% confidence interval, 0.70-0.76; odds ratio, 0.67; 95% confidence interval, 0.65-0.69).

CONCLUSION

Nationwide hysterectomy prevalence decreased among women aged ≥40 years from 2006 to 2016, particularly among non-Hispanic Black and Hispanic women. Age, non-Hispanic Black race, having insurance, current smoking, and living in the South were associated with increased odds of hysterectomy, even after accounting for possible explanatory factors. Further research is needed to better understand associations of race and ethnicity and region with hysterectomy prevalence.

Integrating Surveillance Data to Estimate Race/Ethnicity-specific Hysterectomy Inequalities Among Reproductive-aged Women: Who's at Risk?

BACKGROUND

Inequalities by race and ethnicity in hysterectomy for noncancerous conditions suggest that some subgroups may be shouldering an unfair burden of procedure-associated negative health impacts. We aimed to estimate race- and ethnicity-specific rates in contemporary hysterectomy incidence that address three challenges in the literature: exclusion of outpatient procedures, no hysterectomy prevalence adjustment, and paucity of non-White and non-Black estimates.

METHODS

We used surveillance data capturing all inpatient and outpatient hysterectomy procedures performed in North Carolina from 2011 to 2014 (N = 30,429). Integrating data from the Behavior Risk Factor Surveillance System and US Census population estimates, we calculated prevalence-corrected hysterectomy incidence rates and differences by race and ethnicity.

RESULTS

Prevalence-corrected estimates show that non-Hispanic (nH) Blacks (62, 95% confidence interval [CI] = 61, 63) and nH American Indians (85, 95% CI = 79, 93) per 10,000 person-years (PY) had higher rates, compared with nH Whites (45 [95% CI = 45, 46] per 10,000 PY), while Hispanic (20, 95% CI = 20, 21) and nH Asian/Pacific Islander rates (8, 95% CI = 8.0, 8.2) per 10,000 PY were lower than nH Whites.

CONCLUSION

Through strategic surveillance data use and application of bias correction methods, we demonstrate wide differences in hysterectomy incidence by race and ethnicity. See video abstract at, http://links.lww.com/EDE/B657.

Postoperative Risks for Hispanic Patients Undergoing Hysterectomy for Benign Indications

BACKGROUND

Hispanic patients have previously been shown to have relatively lower odds of complication following hysterectomy compared with non-Hispanic white patients, but little is known about specific risks for this group. Our primary objective was to identify differences in proportions of specific complications experienced by Hispanic patients following hysterectomy for benign indications as compared with non-Hispanic white patients.

DESIGN

Retrospective cohort study examining differences in complication rates following benign hysterectomy between Hispanic and non-Hispanic white patients in NSQIP-participating hospitals from 2012 to 2016.

MEASUREMENTS AND MAIN RESULTS

A total of 102,051 women were included. A total of 15.0% were Hispanic and 85.0% were non-Hispanic white. Hispanic patients were more likely to have class 1 or 2 obesity (59.7 vs 49.8%), diabetes (10.9 vs 6.7%), and anemia (hematocrit < 33: 14.1 vs 6.5%); p < 0.01 for all. Hispanic patients were more likely to undergo abdominal hysterectomy (30.0 vs 19.1%, p < 0.01) and to remain inpatient for 2-6 days (38.8 vs 24.0%, p < 0.01). After adjustment for possible confounders including anemia, an increased odds of requiring blood transfusion persisted only in the laparoscopic and vaginal groups. Hispanic patients had a decreased or equal odds for all other examined complications.

CONCLUSIONS

Compared with non-Hispanic white patients, Hispanic women had a higher odds of requiring blood transfusion even when undergoing minimally invasive laparoscopic and vaginal approaches to hysterectomy. Despite a higher proportion of open surgery, Hispanic patients had a decreased or equal odds of postoperative complications.

Factors Predicting Type II Histology in Endometrial Biopsies Among Postmenopausal Minority Women at a Safety-Net Hospital

Background: Rates of type II endometrial cancers (EC) are increasing in the United States, especially in minority women. The purpose of this project was to examine a primarily minority and low socioeconomic status patient population in a public hospital to identify risk factors associated with the finding of type II histology in endometrial biopsies (EMBs). Materials and Methods: A retrospective chart review was performed of patients who underwent an EMB between 2010 and 2016. Included patients were postmenopausal women older than 50 years with biopsy-proven EC. Basic demographic data were analyzed, along with indication for EMB and ultrasound findings. Statistics were completed using analysis of variance and logistic regression with significance set at p < 0.05. Results: Four hundred sixty-one EMB results were reviewed. Around 17.4% (n = 80) resulted in a diagnosis of EC, with 45% (n = 36) being type II histology. Average age was 62.5 (standard deviation [SD] = 7.63), and the majority (64%) were Hispanic. Type II malignancies were diagnosed in 17% of Caucasians, 41% of Hispanics, and 61% of blacks/Haitians (p = 0.03). Factors associated with type II tumors in univariable models included older age (odds ratio [OR] 1.10 [confidence interval; CI 1.03-1.18], p = 0.007), black/Haitian (vs. Caucasian) race (OR 8.75 [CI 0.86-88.70], p = 0.066), obesity (OR 0.39 [0.15-0.98], p = 0.044), and number of years since menopause (OR 1.06 [CI 1.01-1.12], p = 0.027), although none remained independently predictive in the multivariable analysis. Conclusion: This minority population of postmenopausal women with EC had a greater prevalence of type II histologies. Understanding this pattern may be helpful in expediting the workup for abnormal symptoms in these women and prompt a higher level of suspicion for EC.

Age at Menarche, Level of Education, Parity and the Risk of Hysterectomy: A Systematic Review and Meta-Analyses of Population-Based Observational Studies

Background

Although rates have declined, hysterectomy is still a frequent gynaecological procedure. To date, there has been no systematic quantification of the relationships between early/mid-life exposures and hysterectomy. We performed a systematic review and meta-analyses to quantify the associations between age at menarche, education level, parity and hysterectomy.

Methods

Eligible studies were identified by searches in PubMed and Embase through March 2015. Study-specific estimates were summarised using random effects meta-analysis. Heterogeneity was explored using sub-group analysis and meta-regression.

Results

Thirty-two study populations were identified for inclusion in at least one meta-analysis. Each year older at menarche was associated with lower risk of hysterectomy—summary hazard ratio 0.86 (95% confidence interval: 0.78, 0.95; I² = 0%); summary odds ratio 0.88 (95% confidence interval: 0.82, 0.94; I² = 61%). Low education levels conferred a higher risk of hysterectomy in the lowest versus highest level meta-analysis (summary hazard ratio 1.87 (95% confidence interval: 1.25, 2.80; I² = 86%), summary odds ratio 1.51 (95% confidence interval: 1.35, 1.69; I² = 90%)) and dose-response meta-analysis (summary odds ratio 1.17 (95% confidence interval: 1.12, 1.23; I² = 85%) per each level lower of education). Sub-group analysis showed that the birth cohort category of study participants, the reference category used for level of education, the year the included article was published, quality of the study (as assessed by the authors) and control for the key variables accounted for the high heterogeneity between studies in the education level meta-analyses. In the meta-analyses of studies of parity and hysterectomy the results were not statistically significant.

Conclusions

The present meta-analyses suggest that the early life factors of age at menarche and lower education level are associated with hysterectomy, although this evidence should be interpreted with some caution due to variance across the included studies.

Human uterus transplantation in focus

INTRODUCTION

Uterus transplantation (UTx) is introduced as the first treatment for absolute uterine factor infertility (AUFI), affecting 1:500 fertile aged women. This review presents potential patients, research and human UTx cases.

SOURCES OF DATA

Published articles and our research experience.

AREAS OF AGREEMENT

The first UTx live births in 2014 established UTx as a possible treatment for AUFI. This was proceeded by 15 years of systematic research.

AREAS OF CONTROVERSY

Is a deceased donor UTx as effective as the proven successful live donor UTx?.

GROWING POINTS

Human UTx trials will accumulate data on risks, effectiveness and long-term consequences for donors, recipients and children. These should also include aspects of quality of life, psychological well-being and cognitive/neuropsychiatric development of children.

AREAS TIMELY FOR DEVELOPING RESEARCH

All new activities in human UTx within the coming years should be conducted as prospective observational studies, and data should also be collected within an international registry.

Factors associated with hysterectomy among older women from Latin America and the Caribbean

To identify factors associated with hysterectomy, data collected from 1999-2000 were assessed from seven cities of the Health, Well-Being and Aging in Latin America and the Caribbean Study on 6,549 women, aged 60 years and older. Hysterectomy prevalence ranged from 12.8% in Buenos Aires (Argentina) to 30.4% in Bridgetown (Barbados). The median age for having had a hysterectomy ranged from 45 to 50 years across the cities and was 47 years in the pooled sample. Ethnic differences in hysterectomy rates were partially explained by differences across cities. Factors significantly associated with lower odds for hysterectomy included older age, household crowding conditions, and having public/military or no health insurance, compared to having private health insurance. Women who had three or more children were less likely to have had a hysterectomy, a finding that differs from most previous studies. Socioeconomic position related to rates of hysterectomy in late life rather than hysterectomies earlier in life. However, the nature of these differences varied across birth cohorts. The findings suggested that adverse socioeconomic factors were most likely related to hysterectomy risk by affecting access to health care, whereas parity was most likely acting through an effect on decision-making processes.

Hysterectomy and disability among U.S. women

CONTEXT

Hysterectomies are the second most common surgery performed on women in the United States, and most are done for elective reasons. Although women with disabilities appear to have an increased risk of undergoing the procedure, little research has evaluated the relationship between disability and hysterectomy.

METHODS

Data on 42,842 women aged 18 or older from the 2000, 2005 and 2010 National Health Interview Surveys were used to evaluate the relationship between disability and the risk of having a hysterectomy over the life course. Piecewise exponential event history models were estimated to identify associations between timing of disability onset, type of disability, and the occurrence and timing of hysterectomy.

RESULTS

Women with multiple disabilities experienced a higher risk of undergoing a hysterectomy than women with no disability (hazard ratio, 1.3), and this heightened risk was concentrated at younger ages. During their 20s, 30s and early 40s, women who had multiple disabilities were more likely to have had a hysterectomy than were their same-age counterparts with no or one disability (1.3-2.4). Women with a single type of disability, as well as most women who had multiple disabilities and were aged 46 or older, were not at increased risk of having had a hysterectomy.

CONCLUSIONS

Additional research is needed to investigate why young women with multiple disabilities appear to face an increased risk of having a hysterectomy, especially because it is major surgery that can carry significant health risks.

Factors related to hysterectomy in women with physical and mobility disabilities

This paper aims to identify self-report data for hysterectomy prevalence and to explore its correlated factors among women with physical and mobility disabilities in Taiwan. This paper was part of a larger study, "Survey on Preventive Health Utilizations of People with Physical and Mobility Disability in Taiwan", which is a cross-sectional survey conducted in 2009. We recruited 502 women aged ≧15 years who were officially registered as having physical and mobility disabilities. The results show that 11.3% of women with physical and mobility disabilities accepted hysterectomy surgery and that hysterectomy prevalence was increasing by age: 7% (45-49 years), 9.7% (50-54 years), 26.3% (55-59 years), 31% (60-64 years) and 17.6% (≧65 years). Multilevel logistic regression analyses revealed that being ≧50 years or older (OR=4.65, 95% CI=1.79-12.064), having had cervical cancer (OR=17.2, 95% CI=3.5-84.47) and not having a Pap smear test within the last 3 years (OR=2.79, 95% CI=1.194-6.561) were more likely to accept a hysterectomy operation than their counterparts. This study suggests that future studies should analyze hospital data and assesses long-term changes to understand an area's hysterectomy profile and correlated factors for these types of vulnerable populations.

Gynecological history in chronic fatigue syndrome: a population-based case-control study

BACKGROUND

Chronic fatigue syndrome (CFS) affects disproportionately more women than men, and the condition is more common at perimenopause. We examined gynecological history events as risk factors for CFS.

METHODS

In a case-control study from a randomly selected population sample from Wichita, Kansas, 36 women with CFS and 48 nonfatigued controls, of similar age, race, and body mass index (BMI), answered a structured gynecological history questionnaire.

RESULTS

CFS cases and controls had the same mean age (51 years) and age at menarche (12 years). Overall, a greater proportion of women with CFS than controls reported pelvic pain unrelated to menstruation (22.2% vs. 1.7%, p = 0.004), endometriosis (36.1% vs. 16.7, %, p = 0.046), and periods of amenorrhea (53.9 % vs. 46.2%, p = 0.06). Compared to controls, women in the CFS group had a higher mean number of pregnancies (2.8 vs 2.0, p = 0.05) and gynecological surgeries (1.8 vs. 1.1, p = 0.05). Similar proportions of the CFS (69.4%) and control (72.9%) groups were menopausal. Although menopausal women in the CFS and control groups had similar mean age (55.5 and 55.8, respectively), menopause occurred about 4.4 years earlier in the CFS group (41.7 years vs. 46.1 years, respectively, p = 0.11). Among menopausal women, 76% of the CFS group reported hysterectomy vs. 54.6% of controls (p = 0.09), and 56% of women with CFS reported oophorectomy vs. 34.3% of controls (p = 0.11).

CONCLUSIONS

The higher prevalence of gynecological conditions and gynecological surgeries in women with CFS highlights the importance of evaluating gynecological health in these patients and the need for more research to clarify the chronologic and the pathophysiological relationships between these conditions and CFS.

Racial and ethnic disparities in benign gynecologic conditions and associated surgeries

Common gynecologic conditions and surgeries may vary significantly by race or ethnicity. Uterine fibroid tumors are more prevalent in black women, and black women may have larger, more numerous fibroid tumors that cause worse symptoms and greater myomectomy complications. Some, but not all, studies have found a higher prevalence of endometriosis among Asian women. Race and ethnicity are also associated with hysterectomy rate, route, and complications. Overall, the current literature has significant deficits in the identification of racial and ethnic disparities in the incidence of fibroid tumors, endometriosis, and hysterectomy. Further research is needed to better define racial and ethnic differences in these conditions and to examine the complex mechanisms that may result in associated health disparities.

Breast cancer risk and hysterectomy status: the Multiethnic Cohort study

OBJECTIVE

The main objective was to examine the association between simple hysterectomy (without bilateral oophorectomy) and breast cancer risk. Because hysterectomy prevalence varies by ethnicity, the secondary objective was to examine whether inclusion of women with hysterectomies affects the estimates of breast cancer risk by ethnicity.

METHODS

The Multiethnic Cohort study was assembled between 1993 and 1996 and included 68,065 women from Hawaii and Los Angeles, aged 45-75 years, without any missing information or bilateral oophorectomy. Hysterectomy status was self-reported. After 7.7 years median follow-up, 1,862 cases of invasive breast cancer were identified. Proportional hazards models were used to estimate relative risks (RR) while controlling for known risk factors.

RESULTS

Prevalence of simple hysterectomy varied from 12% to 29% among the ethnic groups (White, African American, Native Hawaiian, Japanese American, and Latina). Overall, hysterectomy was not associated with breast cancer risk (RR = 0.98). Although the RRs were nonsignificantly elevated by 15% in White women and nonsignificantly reduced by 15% in Latinas of non-US origin, the variation by ethnicity was not significant (p(interaction) = 0.48). The breast cancer risk associated with ethnicity was very similar when estimated with and without women with hysterectomies.

CONCLUSIONS

This study suggests that simple hysterectomy status does not alter breast cancer risk. Therefore, inclusion of women with simple hysterectomies does not substantially change estimated risk of breast cancer by ethnicity.

Factors associated with undergoing bilateral salpingo-oophorectomy at the time of hysterectomy for benign conditions

OBJECTIVE

To identify possible factors associated with undergoing bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy among women with benign conditions.

METHODS

This was a cross-sectional analysis using the 2005 Nationwide Inpatient Sample. Women aged 18 years or older who underwent hysterectomy with BSO or hysterectomy only for a benign condition were included. We examined a broad range of factors associated with undergoing BSO in multivariable analyses.

RESULTS

Fifty-two percent of 461,321 hysterectomies included BSO, with a mean age of 49 years compared with 43 years in the hysterectomy-only group (P<.001). The odds of BSO were two times higher in the Midwest and South and 1.67 times higher in the West as compared with the Northeast (P<.001). Women who were uninsured or had Medicaid were more likely to undergo BSO compared with those with private insurance (odds ratio 1.86, 95% confidence interval 1.14-3.04 for "no charge/charity," odds ratio 1.21, 95% confidence interval 1.08-1.35 for Medicaid) Although BSO was more common among white women than African-American, Latina, and Asian women (P<.001), lower income was associated with BSO among African-American and white women only, not among Asian and Latina women (P=.007 for test for interaction). BSO was eight times as likely with a laparoscopic hysterectomy and 12 times as likely with an abdominal hysterectomy compared with a vaginal approach (P<.001). Women who had endometriosis, pelvic infection, or an ovarian cyst were more likely to undergo BSO (P<.001) compared with women who did not have these diagnoses.

CONCLUSION

There is significant nationwide variation in the practice of BSO. Age, route of hysterectomy, and diagnosis at surgery affect BSO rates. Nonclinical factors such as race or ethnicity, insurance status, income, and geographic location are also associated with BSO practice.

LEVEL OF EVIDENCE

II.

Leiomyomata uteri: hormonal and molecular determinants of growth

OBJECTIVE

To review the available English literature that examines the biology of leiomyoma uteri in African-American women and other ethnic groups. Factors that influence the growth and development of leiomyomas are examined to understand the basis for larger myomas in African-American women.

DESIGN

Literature review of 176 articles regarding the pathobiology of leiomyoma in various ethnic groups.

RESULTS

The initiating factor(s) associated with the transformation of a normal myometrial cell into a leiomyoma cell remain(s) to be determined. Epidemiological studies have confirmed that different ethnic groups develop leiomyomas. However, African-American ethnicity is a risk factor for the development of leiomyomas. Studies have examined diet, genetics, hormonal, growth, enzymatic and molecular determinants of myoma biology, with critical advances in some of these areas. The best radiological tools to identify and monitor leiomyomas are ultrasonography and/or magnetic resonance imaging. Evidence supports progesterone and growth factors (e.g., transforming growth factor-B), have significant impact on the development of leiomyomas.

CONCLUSIONS

Early monitoring and intervention should become standard for African-American women who are at greater risk for developing leiomyomas. There are plausible biological mechanisms that explain the predisposition for developing larger leiomyomas in African-American women as compared with other ethnic groups.

The roles of biologic and nonbiologic factors in cultural differences in vasomotor symptoms measured by surveys

OBJECTIVE

To review evidence of cultural differences in both biologic and nonbiologic factors as possible explanations for variation across cultures in self-reported vasomotor symptoms from surveys.

DESIGN

Literature review and cross-sectional and longitudinal comparisons of ethnic groups with respect to patterns of symptom reporting from the Study of Women's Health Across the Nation (SWAN).

RESULTS

The evidence to date indicates that cultural differences in vasomotor symptom reporting on surveys reflect both differences in the underlying biology, which ar likely to influence vasomotor symptom occurrence, and differences in nonbiologic sociocultural factors such as attitudes toward menopause, which are likely to be related to vasomotor symptom perception and reporting,

CONCLUSIONS

It is important to consider interactions of culture and biology in studies of vasomotor symptoms. Recommendations for future studies include using both open- and closed-ended questions, including measurements of objective indicators such as reproductive hormone concentrations, measuring both culturally related biologic and nonbiologic factors related to vasomotor symptom occurrence or reporting, and using the same general study protocol for multiple cultural groups being compared.

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

OBJECTIVE

The purpose of this study was to assess temporal trends for hysterectomy among Olmsted County, Minnesota women.

STUDY DESIGN

Using the Rochester Epidemiology Project database, we identified all county residents undergoing a hysterectomy in 1965-2002. Temporal changes in the utilization (incidence) rate, type, diagnostic indications, and age at surgery were assessed.

RESULTS

Between 1965 and 2002, 6152 women had a hysterectomy alone, whereas 3126 women had, in addition, a pelvic floor repair; the age-adjusted utilization rate for hysterectomy alone and for combined procedures declined (P < .0001) by 13% and 63%, respectively. Except for subjects aged 75-85 years, this decline affected every age group. The distribution of vaginal (56%) and abdominal (44%) procedures differed across indications. Uterine leiomyomata, precancerous conditions, and genital prolapse accounted for 28%, 23%, and 12% of all procedures, respectively.

CONCLUSION

Among community women, the utilization rate, age distribution, and indications for a hysterectomy changed substantially between 1965 and 2002.

Predictors of hysterectomy in women with common pelvic problems: a uterine survival analysis

BACKGROUND

Comprising over 600,000 patients per year, hysterectomy is the most common nonobstetrical operation performed in US women. Little is known about the natural history of the noncancerous uterine conditions leading to hysterectomy. We followed a prospective cohort of women with common pelvic problems to determine whether simple clinical characteristics could predict a subsequent hysterectomy.

STUDY DESIGN

We recruited 762 women seeking care for abnormal uterine bleeding, chronic pelvic pain, or symptomatic uterine fibroids and ascertained their hysterectomy status during 4 years of surveillance. We collected baseline patient-reported sociodemographic and clinical data and fit Cox models to predict the effects of covariates on hysterectomy across patient age.

RESULTS

There were 99 hysterectomies, resulting in 0.044 hysterectomies per person-year of observation and a 13.5% cumulative hysterectomy rate. Hysterectomy was independently predicted by multiple pelvic symptoms or symptomatic fibroids (hazard ratio [HR], 1.97; 95% CI, 1.18-3.28), previous use of a gonadotropin-releasing hormone agonist (HR, 2.54; 95% CI, 1.53-4.24), and an absence of symptom resolution (HR, 2.24; 95% CI, 1.46-3.44). Survival curves plotted for subgroups with combinations of these predictors showed an escalating risk of hysterectomy with each additional risk factor. Predicted hysterectomy rates ranged from 20%, if all 3 predictors were absent, to 95%, if all 3 were present.

CONCLUSIONS

For women with common pelvic problems, three easily measured clinical characteristics (symptom combination, degree of resolution, and earlier use of a gonadotropin-releasing hormone agonist) predict the likelihood of subsequent hysterectomy and can be used to inform counseling about the likely success of alternative treatments.

Premature menopause in survivors of childhood cancer: a report from the childhood cancer survivor study

BACKGROUND

Childhood cancer survivors who retain ovarian function after completing cancer treatment are at increased risk of developing premature menopause, defined as cessation of menses before age 40 years. However, published data pertaining to the risk and frequency of premature menopause are limited.

METHODS

We assessed the incidence of and risk factors for premature menopause in 2819 survivors of childhood cancer who were older than 18 years and were participants in the multicenter Childhood Cancer Survivor Study (CCSS). The comparison group was 1065 female siblings of participants in the CCSS. A multiple Poisson regression model was constructed to determine risk factors for nonsurgical premature menopause. All statistical tests were two-sided.

RESULTS

A total of 126 childhood cancer survivors and 33 control siblings developed premature menopause. Of these women, 61 survivors (48%) and 31 siblings (94%) had surgically induced menopause (rate ratio [RR] = 0.8, 95% confidence interval [CI] = 0.52 to 1.23). However, the cumulative incidence of nonsurgical premature menopause was higher for survivors than for siblings (8% versus 0.8%; RR = 13.21, 95% CI = 3.26 to 53.51; P<.001). A multiple Poisson regression model showed that risk factors for nonsurgical premature menopause included attained age, exposure to increasing doses of radiation to the ovaries, increasing alkylating agent score (based on number of alkylating agents and cumulative dose), and a diagnosis of Hodgkin lymphoma. For survivors who were treated with alkylating agents plus abdominopelvic radiation, the cumulative incidence of nonsurgical premature menopause approached 30%.

CONCLUSIONS

The results of this study will facilitate counseling current survivors about their future risk of premature menopause and aid in designing new regimens that seek to diminish late ovarian toxicity.

Effects of acculturation and social exchange on the expectations of filial piety among Hispanic/Latino parents of adult children

This study explores the effects of acculturation and social exchange variables on the expectations of filial piety (values and beliefs about parents' care) among Hispanic/Latino parents of adult children. A convenience sample of 318 Hispanics/Latinos with adult children was assembled in Texas and North Carolina, USA, for face-to-face interviews in order to collect information about their families and to assess their expectations of filial piety by their adult children. The number of years in the USA, age, gender, the eldest child's age, and living with a person > or = 65 years of age had significant relationships to scores from a new Spanish version of the Expectations of Filial Piety Scale (EFPS). The significant variables explained 46.3% of the variance in the EFPS scores. A conceptual model that includes both acculturation and social exchange variables is a useful approach for understanding the expectations of filial piety by Hispanic/Latino parents of adult children.

Considerations in recruiting underscreened women to focus groups on screening for cervical cancer

This article describes recruitment activities and costs from two independently conducted studies that used similar, systematic approaches to recruiting two subgroups of underscreened women, Black women and Mexican women. The studies varied in number of recruiters, venues of recruitment, and region of the country. The ratio of women approached to women who were underscreened was 4:1 for Black women and 10:1 for Mexican women. Hysterectomy was a predominant reason for ineligibility among Black women but not Mexican women. In both studies, personal networks were the most productive method of identifying women. Flyers and organized community venues were least productive. The cost incurred for identifying a woman who was eligible for a focus group was 145 dollars for Black women and 59 dollars for Mexican women. Those planning research or program activities that include recruiting underscreened women either to focus groups or health services could benefit from this information.

Research opportunities for reducing the burden of menopause-related symptoms

The National Institutes of Health (NIH) State-of-the-Science (SoS) Conference on the Management of Menopause-Related Symptoms identified a number of important gaps in our understanding of the natural history of the menopausal transition and the etiology and course of menopause-related symptoms. Updated information is needed from prospective studies of reproductive aging in diverse populations of women, especially of younger women in their mid reproductive years, to better understand the underlying biology of ovarian aging as well as the etiology of conditions leading to premature spontaneous or surgical menopause. To facilitate this goal, a number of methodologic issues must be addressed, including the development of (1) consensus definitions of menopause-related terms and stages, and (2) standard measures and methods for assessing progression through the menopausal transition and related symptoms and outcomes. Estrogen therapy is highly efficacious in relieving menopausal symptoms and was the treatment of choice until 2002, when findings of unexpected harm from the Women's Health Initiative (WHI) were published. Consequently, there has been a burgeoning interest in a number of botanical products as well as other complementary and alternative medicine strategies, such as acupuncture, magnets, homeopathy, and behavioral regimens. However the benefits of most of these strategies are either very limited or equivocal, and related safety issues are poorly understood. Future research is needed to identify new efficacious strategies, to understand side effects and safety issues, and to provide new options to women who are burdened by bothersome menopause-related symptoms.

Hysterectomy prevalence and cardiovascular disease risk factors in American Indian women

OBJECTIVES

We investigated hysterectomy prevalence and associated demographic and reproductive factors among American Indian women. The association between hysterectomy and cardiovascular disease (CVD) risk factors was also examined.

METHODS

Data were from 2689 American Indian women who participated in the first examination of the Strong Heart Study from 1989 to 1992. Odds ratios were estimated for factors related to hysterectomy adjusting for other covariates. The association between hysterectomy and CVD risk factors was examined among 1726 eligible women using analysis of covariance.

RESULTS

Hysterectomy prevalence ranged from 24% to 34% across differing age groups and the percent with oophorectomy among those with a hysterectomy ranged from 43% to 63%. Geographic area, more prior pregnancy losses, more education, and less speaking of the native language were associated with increased hysterectomy prevalence. After adjustment for age, the women who had a hysterectomy with intact ovaries had higher total cholesterol and low-density lipoprotein cholesterol levels than those with a natural menopause.

CONCLUSIONS

American Indian women have comparable hysterectomy prevalence as non-Hispanic white women. Education and native language speaking related to hysterectomy in this population. Hysterectomy alone may relate to unfavorable changes of lipid profile.

A multicultural and multilingual outreach program for cervical and breast cancer screening

Partners in Health: The Breast and Cervical Health Cooperative is a New Orleans-based community health intervention program designed to increase the access of underserved multicultural, multiethnic, and multilingual women to cervical and breast cancer health education and screening. This article describes innovative approaches used over the past 4 years to successfully link the services of a university cancer center to women in the community through a culturally sensitive outreach program. In addition to cancer screening, health referrals were made for many other diverse medical/social complications such as hypertension, obesity, and violence. The program initially targeted African American women but during the past year has successfully integrated Latinas. Key to the program's success was the collaboration of community lay health educators, community churches, advanced practice nurses, and public health programs. This article provides an overview of program strategies and outcomes and discusses multicultural and multilingual issues.

Usefulness of prior hysterectomy as an independent predictor of Framingham risk score (The Women's Health Initiative)

The association of hysterectomy with increased coronary risk is controversial, and previous studies have reached differing conclusions as to whether the excess risk is confined to women who have also undergone bilateral oophorectomy. This analysis uses the Framingham algorithm to evaluate the hypothesis that hysterectomy with or without ovarian preservation is associated with increased coronary risk, using a cross-sectional analysis of baseline data from 1,501 participants of the Women's Health Initiative. Framingham risk scores, derived from the algorithm in the National Cholesterol Education Program Adult Treatment Panel III guidelines, which include age, smoking, systolic blood pressure, total and high-density lipoprotein cholesterol, were determined in a subgroup of Women's Health Initiative participants with measured plasma lipids and known ovariectomy status. Women with hysterectomy had fewer years of education than those without hysterectomy (30% with college degree vs 41%, p <0.0001) and higher body mass index (29 vs 28 kg/m(2), p <0.0001), consumed less alcohol, exercised less, and had a higher Framingham risk of myocardial infarction or coronary death (46% vs 41% with 10-year risk >/=4%, p = 0.04). In multivariate analysis, hysterectomy with bilateral oophorectomy was an independent predictor of Framingham risk (p = 0.04), whereas hysterectomy with ovarian preservation was not.