By Alexandra Morell, MD
Synopsis: A matched retrospective cohort study including 77 participants younger than 30 years of age and 164 participants aged 31-49 years demonstrated that a younger participant cohort had significantly higher rates of surgical and loss-of-fertility regret compared with an older participant cohort (32.5% vs. 9.1%, P < 0.001 and 39.0% vs. 13.4%, P < 0.001, respectively).
Source: King NR, Zeccola AM, Wang L, et al. Effect of patient age on decisional regret after laparoscopic hysterectomy. Obstet Gynecol. 2024;144(6):757-764.
In the United States, hysterectomy is one of the most common surgical operations performed among patients assigned female at birth.1,2 A majority of these surgeries are performed for benign disease, including uterine fibroids, abnormal uterine bleeding, endometriosis, and pelvic organ prolapse.
Although no difference in patient satisfaction has been noted between laparoscopic compared with abdominal approaches to hysterectomy, the advent of minimally invasive techniques has allowed for faster patient recovery, shorter hospital stays, decreased risk of postoperative infection, and improved quality of life in the first few months following surgery.1 One potential factor that influences access to hysterectomy is patient age. There are limited data focused on the risk of regret following hysterectomy in younger patients.
This was a retrospective cohort study from 2009 to 2016 at a single academic institution with a main objective of comparing regret after hysterectomy in patients younger than 30 years of age to those patients between the ages of 31 and 49 years. Patients between 18 and 49 years of age undergoing laparoscopic hysterectomy for benign indications were included.
Exclusion criteria included gender-affirming surgeries, incomplete medical records, or patients who lived outside of the United States. All patients who met inclusion criteria were contacted by mail, followed by telephone, and email if there was no response by the initial method of contact. Patients who consented to participate completed the Decision Regret Scale (DRS), a validated measure of regret pertaining to healthcare choices. In addition, electronic medical records were reviewed for demographic and clinical data. The primary outcome was the rate of surgical and loss-of-fertility regret between younger patients (younger than 30 years of age) and older patients (31-49 years of age). Based on previous gynecologic surgery literature looking at regret, a DRS score of greater than 30 was defined as regret.
Power calculations determined a necessary sample size of 75 participants in the younger age group and 149 participants in the older age group at an alpha of 0.05 and a beta of 0.2. For statistical analyses, univariate analyses were performed using chi-square or Fisher exact tests and Wilcoxon rank sum tests for categorical and continuous variables, respectively. Multivariable logistic regression analyses also were performed.
A total of 287 patients initially were contacted for participation in the study and 241 completed the survey, representing an 84% response rate. The younger cohort had 77 (32%) total participants, and the older cohort had 164 (68%) participants. The cohorts were similar regarding race, parity, prior sterilization, intraoperative or postoperative complications, and history of depression or anxiety. There was an average of 7.2 years (range 3.7-12.1 years) from surgery to completion of the regret survey. Indication for hysterectomy more commonly was pelvic pain in the younger cohort (77.9% vs. 45.1%, P < 0.001) and more commonly was uterine leiomyomas in the older cohort (1.3% vs. 27.4%, P < 0.001). The younger cohort demonstrated significantly higher rates of surgical regret (32.5% vs. 9.1%, P < 0.001) and loss-of-fertility regret (39.0% vs. 13.4%, P < 0.001) compared with the older cohort.
Looking at the entire participant cohort, univariate analysis demonstrated higher rates of both surgical and loss-of-fertility regret in participants with self-reported pelvic pain (P = 0.003, P = 0.11), endometriosis diagnosis prior to surgery (P = 0.036, P = 0.046), and those with complications after surgery (P = 0.043, P < 0.001). On multivariate analysis, age remained a significant variable associated with surgical regret (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.3-6.5) and loss-of-fertility regret (OR, 2.8; 95% CI, 1.3-6.0).
Commentary
This retrospective cohort study demonstrated higher rates of surgical and loss-of-fertility regret among younger participants undergoing hysterectomy using a validated decisional regret questionnaire. There is a paucity of data specifically looking at decisional regret after hysterectomy. However, the current study does demonstrate higher rates of regret in younger patients compared to a previous study investigating a similar topic. Bougie et al demonstrated a 2.8% risk of regret among 71 Canadian patients younger than 35 years of age undergoing hysterectomy compared with a 32.5% rate of surgical regret and 39.0% rate of loss-of-fertility regret in a cohort younger than age 30 years in this study.3 The current study adds to the literature regarding risk of regret among young patients and demonstrates the need for continued investigation regarding this topic.
It is well-known that young age is associated with a risk of regret after permanent tubal surgical sterilization.4 The American College of Obstetricians and Gynecologists (ACOG) does not recommend age as a precluding factor for undergoing surgical tubal sterilization, but it does note the importance of counseling patients regarding the risk of regret based on age as part of the informed consent process. In addition, ACOG stresses the importance of shared decision-making with a focus on individualized patient goals and values when making surgical decisions.5
In the context of what is known about tubal sterilization, it appears that age should not be a barrier to undergoing hysterectomy when indicated for benign gynecologic conditions. However, the current study does provide evidence that should be discussed with patients during the informed consent process. Specifically, when discussing the risks associated with hysterectomy in this patient demographic, one component of the discussion should focus on a potentially higher risk of regret after surgery, but also address that overall information is limited and the choice to undergo hysterectomy should be individualized.
Alexandra Morell, MD, is Adjunct Instructor, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY.
References
1. [No authors listed]. Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017;129(6):e155-e159.
2. Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013;122(2 Pt 1):233-241.
3. Bougie O, Suen MW, Pudwell J, et al. Evaluating the prevalence of regret with the decision to proceed with a hysterectomy in women younger than age 35. J Obstet Gynaecol Can. 2020;42(3):262-268.e3.
4. [No authors listed]. ACOG Practice Bulletin No. 208 Summary: Benefits and risks of sterilization. Obstet Gynecol. 2019;133(3):592-594.
5. [No authors listed]. Informed consent and shared decision making in obstetrics and gynecology: ACOG Committee Opinion Summary, Number 819. Obstet Gynecol. 2021;137(2):
A matched retrospective cohort study including 77 participants younger than 30 years of age and 164 participants aged 31-49 years demonstrated that a younger participant cohort had significantly higher rates of surgical and loss-of-fertility regret compared with an older participant cohort (32.5% vs. 9.1%, P < 0.001 and 39.0% vs. 13.4%, P < 0.001, respectively).
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