Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

Abstract

ABSTRACT The prevalence of inpatient hysterectomy, a common surgical procedure in the United States, decreased by 36.4% between 2002 and 2010 in women with benign gynecologic conditions. One major factor contributing to the decline in inpatient hysterectomies was the growing number of uterine-preserving treatment options. Alternatives to hysterectomy include hormonal management, endometrial ablation, myomectomy, or uterine artery embolization. Additional reasons for desiring uterine preservation among women who do not desire future fertility may include the belief that the uterus provides improved sense of self, relationship, and femininity. There are ethnic and racial disparities in the number and route of hysterectomies performed. Rates are higher among Black women than among White women. Variations in hysterectomy rates are likely exacerbated in marginalized racial groups who have less access to uterine-sparing treatments or delayed care at earlier disease states. Although patient preferences may influence the choice of hysterectomy or uterine-preserving therapy, the contribution of race and socioeconomic status to one's preference for uterine preservation is unknown. The aim of this cross-sectional survey was to determine predictors for uterine preservation among patients who no longer desire fertility. A secondary aim was to identify reasons for placing high value on the uterus. The study was conducted at 3 hospital-based clinics in a large health care system in the United States. Participants were new patients 45 years or older seeking care for benign gynecologic conditions (including abnormal uterine bleeding, uterine fibroids, pelvic organ prolapse, endometriosis, or pelvic pain). The primary study outcome was the summative score of the VALUS ( Value of Uterus) instrument in predicting that a woman will undergo uterine preservation. The VALUS, a validated and reliable instrument, measures patient preferences and value placed on uterine preservation. Respondents placed either “low value” versus “high value” for the uterus in ovarian preservation. Secondary outcomes included individual questions within the VALUS instrument to determine drivers of uterine preservation. There were no prior data. Of the 230 surveys distributed, 206 (89.6%) were returned for analysis, and 163 of these (79.2%) met the criteria for completion. Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score <14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). Among women who wanted to be sexually active in the future, the likelihood of a high value for the uterus was substantially higher compared with those who did not; the adjusted odds ratio was 5.06, with a 95% confidence interval (CI) of 1.55 to 16.52, P = 0.01. Sexually active patients were substantially more likely to place a higher value on the uterus compared with those not sexually active or those who did not wish to be (adjusted odds ratio, 3.94; 95% CI, 1.36–11.43; P = 0.01). Non-White race, religion, and personal history of cancer were not statistically significant. These findings show that sexually active women and those who desire future sexual activity have 5- and 4-times higher odds of placing high value on the uterus compared with patients who are not sexually active. Patients who highly value the uterus believe that it is important for sexual function, sexual pleasure, sense of self, and staying complete as a woman. Future large-scale studies are needed to determine whether patient preferences contribute to the racial disparities in hysterectomy rates.