BMJ  2005;330:1457-1458 (25 June), doi:10.1136/bmj.330.7506.1457

Editorial

Hysterectomy for benign conditions

Patients and doctors will benefit from evidence based guidelines

In contemporary clinical practice, patients should be given sufficient information about the reason for any treatment offered, the risks and benefits of the treatment, and the alternative options. For women undergoing hysterectomy, this ideal has scarcely been fulfilled. One reason for this has been the paucity of evidence on which to base counselling; the other is that gynaecologists, owing to limitations in their training, have not always been in a position to offer their patients a genuine choice of treatment options.

Hysterectomy has long been regarded as an operation performed by "hyster-happy,"¹ mostly male, surgeons. The medical historian Roy Porter counted the rising tide of hysterectomies among manifestations of the "abuse of gynaecological surgery to control women" in the 19th century.² Although campaigns against unnecessary hysterectomy have been vocal,³ this operation survived the feminist whirlwind of the mid to late 20th century and remains one of the most commonly performed operations in the world. In the United States, 600 000 hysterectomies are performed each year,⁴ or one hysterectomy every minute. In the United Kingdom, women have a one in five chance of having a hysterectomy by the age of 55.⁵

Nine of every 10 hysterectomies are performed for non-cancerous conditions. In many of these, no disease is present—and the term dysfunctional uterine bleeding is used to describe these cases. When there is disease it is commonly limited to the uterus and, in most parts of the world, is more likely than not to be a leiomyoma (uterine fibroid). Hysterectomy, usually with removal of the ovaries, may also be performed for pelvic pain. These indications are amenable to an expanding array of medical treatments—such as the levonorgestrel releasing intrauterine system—and to procedures that preserve the uterus—such as endometrial ablation and embolisation of fibroids. The uptake of these alternatives partly accounts for the fall in the number of hysterectomies performed in Europe in the past decade.⁶ Their availability also challenges the surgeon to provide more information about possible outcomes when he or she deems a hysterectomy to be necessary.

Hysterectomy rarely leads to perioperative death, but is it associated with a long term risk of death? Iversen et al tackle this question in a nested cohort study in this week's BMJ.⁷ One of the strengths of their study is the long duration of follow-up (mean length of more than 20 years). Women in this study who had a hysterectomy did not subsequently have, in the long term, a significantly increased risk of death—from cardiovascular disease, cancer, or all causes—compared with women who did not have the operation.

For several reasons, care must be taken when extrapolating these findings to all women who have had a hysterectomy. Firstly, the study participants had been recruited originally into a study of oral contraception, and women in that study were known to be healthier than the general population. Secondly, 98% of the participants in the original study were white—and there is some evidence⁸ that the incidence, indications, and outcome of hysterectomy could differ between white and black women.

Major long term complications other than death, as well as perioperative and short term complications, are studied in a systematic review by Johnson et al that also appears this week.^{9 10} Because the incidence of severe morbidity complicating hysterectomy is low,¹¹ randomised trials to compare surgical approaches require large numbers and are expensive to run. It is therefore not surprising that this systematic review and meta-analysis found that data for many important long term outcome measures, including pelvic pain, bowel dysfunction, and vaginal prolapse, were either absent or underpowered.

This deficiency is unfortunate because these outcomes are probably more important to patients than, say, duration of the operation or mean blood loss. The authors conclude, on the basis of their findings, that hysterectomy should be performed vaginally rather than abdominally where possible. Compared with abdominal hysterectomy, vaginal hysterectomy was associated with women's earlier discharge from hospital and a speedier return to normal activities. Laparoscopic hysterectomy also had these advantages over abdominal hysterectomy, but it carried a higher risk of injury to the urinary tract and was more expensive and the operations lasted longer than vaginal hysterectomy.

More robust evidence on the longer term outcomes of hysterectomy is required, especially for those outcomes that are important to patients¹²—quality of life, sexual function, pelvic pain, bowel and urinary function, and vaginal prolapse. For now, Johnson et al have provided the best available evidence,⁷ and gynaecologists should adapt their practice accordingly. This is not going to be easy, as only a handful of surgeons are equally competent in performing hysterectomy by all three routes, and most gynaecologists are much more comfortable with abdominal hysterectomy than vaginal or laparoscopic hysterectomy.

We must improve training in vaginal surgery for the younger generation of gynaecologists, and our colleges should now establish clinical guidelines for selecting the appropriate route of hysterectomy, based on the best available evidence. Such guidelines have been shown to enhance the uptake of vaginal hysterectomy.¹³

St Mary's Hospital, Manchester M13 0JH
(Leroy.Edozien{at}cmmc.nhs.uk)

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Papers p 1478 and Primary care p 1482

Competing interests: None declared.

References

1. Angier N. Woman, an intimate geography. New York, Virago: 1999: 113. (Chapter 6: Mass hysteria—losing the uterus.)
2. Porter R. The greatest benefit to mankind. A medical history of humanity from antiquity to the present. London, Fontana: 1999: 364.
3. Cloutier-Steele L. Misinformed consent. Women's stories about unnecessary hysterectomy. Chester, NJ: Next Decade, 2003.
4. Lepine LA, Hillis SD, Marchbanks PA, Koonin LM, Morrow B, Kieke BA, Wilcox LS. Hysterectomy surveillance—United States, 1980-1993. MMWR Morb Mortal Wkly Rep Surveill Summ 1997;46: 1-15.
5. Vessey MP, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynaecol 1992;99: 402-7.[ISI][Medline]
6. Reid PC, Mukri F. Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3. BMJ 2005;330: 938-9[Free Full Text]
7. Iversen L, Hannaford PC, Elliott AM, Lee AJ. Long term effects of hysterectomy on mortality: nested cohort study. BMJ 2005;330: 1482-5.[Abstract/Free Full Text]
8. Kjerulff KH, Guzinski GM, Langenberg PW, Stolley PD, Moye NE, Kazandjian VA. Hysterectomy and race. Obstet Gynecol 1993;82: 757-64.[Abstract/Free Full Text]
9. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330: 1478-81.[Abstract/Free Full Text]
10. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2005;(1): CD003677.
11. McPherson K, Metcalfe MA, Herbert A, Maresh M, Casbard A, Hargreaves J, et al. Severe complications of hysterectomy: the VALUE study. Br J Obstet Gynaecol 2004;111: 688-94.
12. Wade J, Pletsch PK, Morgan SW, Menting SA. Hysterectomy: what do women need and want to know? J Obstet Gynecol Neonatal Nurs 2000;29: 33-42.[CrossRef][Medline]
13. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85: 18-23.[Abstract]

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