Use of Other Treatments Before Hysterectomy for Benign Conditions in a Statewide Hospital Collaborative

Abstract

It is estimated that 1 in 3 women in the United States will have a hysterectomy by age 60 years. Complications of hysterectomy are well known. Alternatives to hysterectomy for benign indications include operative hysteroscopy, endometrial ablation, hormonal therapy, and the levonorgestrel intrauterine device (IUD). Despite increasing use of these alternatives, overutilization of this procedure is still high, with estimates ranging from 16% to 70%. The aim of this study was to examine medical records for documentation of alternative treatment prior to hysterectomy and to determine whether the specimen pathology supported the need for surgery. Data were obtained from the Michigan Surgical Quality Collaborative, a coalition of 52 academic and community hospitals that voluntarily participate in a statewide surgical quality improvement collaborative. From early January to early November 2013, hysterectomy data including demographics, preoperative alternative treatments, and pathology results were collected. The study population comprised women older than 18 years who underwent hysterectomy for benign indications including uterine fibroids, abnormal uterine bleeding (AUB), endometriosis, or chronic pelvic pain. Data were examined separately for those younger than 40, 40 to 50, and older than 50 years. Pathology findings supporting the need for hysterectomy were uterine fibroids, cervical dysplasia, endometrial hyperplasia with or without atypia, endometriosis, benign pelvic masses, or cancer of any type. Multivariable models were developed to identify predictors of alternative treatment use prior to hysterectomy and to predictors of unsupportive pathology. Data were available for 6042 hysterectomies. Of these, inclusion criteria were met by 3397 (56.2%), among which there was no documentation of alternative treatment prior to surgery in 37.7% (n = 1281). Women younger than 40 years were more likely to have documentation of alternative treatment than were women aged 40 to 50 years or older than 50 years (68% vs 62% vs 56%, respectively; P < 0.001). Women with larger uteri were more likely to consider alternative treatment (P < 0.001). The rate of unsupportive pathology was 18.3% (621/3397), decreased as age increased (<40 years, 37.8%; 40–50 years, 12.0%; >50 years, 7.5%; P < 0.001), and was higher among women with smaller uteri or with endometriosis/pain as the indication. Use of the levonorgestrel IUD, one of the most effective alternative treatments for AUB and pelvic pain, was considered by only 12% of the women, and only about 4% of these women failed or could not tolerate this IUD. These findings from Michigan show that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for AUB, uterine fibroids, endometriosis, or chronic pelvic pain. Pathology does not support the need for hysterectomy in 18% of women. The authors discuss opportunities to avoid utilization of hysterectomy.