Hysterectomy: Effectiveness and Alternatives
June 2000; Volume 2; 45-47
Abstract & Commentary
Source: Kjerulff KH, et al. Effectiveness of hysterectomy. Obstet Gynecol 2000;95:319-326.
Synopsis: This report from the Maryland Women’s Health Study provides a prospective evaluation of the effectiveness of hysterectomy in the relief of eight target symptoms. In addition, measures reflecting quality of life, depression, and anxiety were recorded. Twenty-eight of the 32 Maryland hospitals with the highest volume of hysterectomies agreed to participate. Within these hospitals, 272 physicians provided subjects for the study. Women were enrolled based on a hysterectomy being scheduled and were interviewed shortly before surgery. They were reinterviewed 3, 6, 12, 18, and 24 months after surgery.
The target symptoms included vaginal bleeding, pelvic pain, fatigue, back pain, abdominal bloating, sleep disturbance, urinary incontinence, and limitation of activity. Quality of life was assessed with the Medical Outcome Study Short-Form General Health Survey, and depression and anxiety were assessed with the Profile of Mood States. No analysis was reported by indication for hysterectomy.
The study population consisted of 1,299 women. At the 24-month interview, 1,162 women still were involved. The percent reporting symptoms during the preoperative interview and at 24 months are shown in Table 1; for most of the symptoms, the percent reporting symptoms during the earlier postoperative interviews were similar to the 24-month percentages.
| Table 1-Percent of patients reporting symptoms | ||
| Symptom | Before surgery (n = 1,299) | 24 months after surgery (n = 1,162) |
| Vaginal bleeding | 59.2% | 0.3% |
| Pelvic pain | 63.1% | 7.8% |
| Back pain | 43.1% | 17.4% |
| Activity limitation | 57.5% | 2.4% |
| Sleep disturbance | 40.9% | 20.6% |
| Fatigue | 70.0% | 24.7% |
| Abdominal bloating | 47.8% | 12.1% |
| Urinary incontinence | 19.5% | 8.3% |
| Adapted from: Kjerulff KH, et al. Effectiveness of hysterectomy. Obstet Gynecol 2000;95:319-326. | ||
About 8% of women had the same number of problematic or severe symptoms at 24 months as they had prior to surgery, suggesting that 92% of women had symptom improvement with surgery. Of the 313 women who were evaluated as depressed prior to surgery, 75% had this problem relieved by 12 months after surgery. There were 768 women evaluated as anxious prior to surgery; 60% had the problem resolved by 12 months. Similar effects were seen at 24 months. Quality of life measures improved in 60-89% of subjects, depending on the parameter being considered. Acquisition of new problems after surgery occurred infrequently for most symptoms; the greatest increase was in sleep disturbance, which developed in 11% of women by 24 months.
Funding: Agency for Health Care Policy and Research.
Comment by Anthony R. Scialli, MD
This carefully performed and analyzed study provides high-quality data supporting the effectiveness of hysterectomy for a number of symptoms. In some cases, the effectiveness of hysterectomy is intuitive, for example, in the relief of vaginal bleeding. In other cases, the effectiveness of the operation is surprising. For example, the 24-month effectiveness of surgery for pelvic pain runs counter to traditional understanding of the causes and treatment of chronic pain.
There are possible explanations for these optimistic data. First, symptoms were evaluated as being problematic or severe if they were reported to be present all of the time, most of the time, some of the time, or not at all (for some symptoms) or to be a "big problem" or a "medium problem." A woman whose pain went from being present most of the time to being present some of the time would have been counted as having symptom relief. It is not known how often this kind of change occurred in the current study, and the possibility of habituation to pain resulting in a more favorable assessment of pain may have been responsible for some of the apparent improvement. Other interim treatments such as medications, acupuncture, exercise programs, or cognitive behavioral therapy may also have influenced symptom assessment over the two years of the study.
A second explanation is the pre-surgery symptom assessment, which was performed in most cases within a month of scheduling the hysterectomy. Imagine a woman with asymptomatic fibroids who is told by her gynecologist that she has uterine tumors and needs urgent hysterectomy. Might that woman develop somatic and mood symptoms prior to surgery? Is it possible that the surgeons may have caused some of the distress they were then able to relieve?
Even if these factors were responsible for some of the improvement associated with hysterectomy, it appears inescapable that the operation is effective for a substantial number of women. It would be unfortunate, however, if the demonstration of the success of hysterectomy led to policy or practice decisions favoring surgery. The main limitation of the Maryland Women’s Health Study recalls the Henny Youngman response to being asked how’s your wife: "Compared to what?"
The authors of the current study recognized that there was no comparison group in which hysterectomy was not used. They parry this potential criticism by referring to the 1994 report from the Maine Women’s Health Study. This report compared treatment satisfaction measures among women who had undergone hysterectomy and women who received nonsurgical treatment, with hysterectomy apparently producing better results. Many kinds of treatments might be included as nonsurgical therapy and the report of the Maine study did not give sufficient information to judge whether the nonsurgical therapy represented treatments that would now be considered state of the art. It is unlikely in 1994, for example, that uterine artery embolization would have been offered to women with abnormal uterine bleeding associated with uterine leiomyomata.
In the final analysis, it may well be that hysterectomy is effective for several gynecologic problems in the same way that tooth extraction is effective for several dental problems. The report of the Maryland Women’s Health Study can only be construed as demonstrating that hysterectomy works, not that it is optimal therapy for gynecologic complaints. Given the increasing number of nonhysterectomy alternatives for these disorders, it can be wondered why American gynecologists are not as committed to preserving female pelvic organs as American dentists are to preserving teeth.
Editor’s Note
The editor would like to thank the following people for their valuable input in preparing articles that appeared in previous issues of Alternative Therapies in Women’s Health: Rosemary Agostini, MD; Michael Balick, PhD; Ted Kaptchuk, OMD; and Ken Schulz, PhD.
June 2000; Volume 2; 45-47
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