A hysterectomy is a surgical procedure to remove a woman’s uterus. It is one of the most common major surgeries performed on women in the United States. While hysterectomies are sometimes medically necessary, there has been concern that a significant number of hysterectomies are performed unnecessarily. This article will examine the prevalence of hysterectomy, reasons for the procedure, and estimates on the rate of unnecessary hysterectomies.
Background on Hysterectomy
A hysterectomy involves the surgical removal of a woman’s uterus. There are three main types of hysterectomy:
- Partial hysterectomy – the uterus is removed but the cervix is left in place
- Total hysterectomy – the entire uterus and cervix are removed
- Radical hysterectomy – the uterus, cervix, and surrounding tissue are removed
The most common reasons for a hysterectomy include:
- Fibroids – noncancerous growths in the uterus
- Endometriosis – tissue that normally lines the uterus grows outside of the uterus
- Uterine prolapse – when the uterus drops from its normal position
- Cancer – such as uterine, cervical, or ovarian cancers
- Chronic pelvic pain
- Abnormal uterine bleeding
For some conditions, there may be alternative treatment options to hysterectomy. However, hysterectomy is the only definitive treatment for uterine-related cancers and unmanageable uterine bleeding. The surgery is most often performed through an abdominal incision, vaginally, or laparoscopically using minimally invasive techniques. Typical recovery time is 4-6 weeks.
Prevalence of Hysterectomy
Hysterectomy is the second most common major surgical procedure performed on women in the United States. Approximately 600,000 hysterectomies are performed each year. According to the Centers for Disease Control and Prevention (CDC), by age 60, 1 in 3 women in the United States have had a hysterectomy.
The rate of hysterectomy increased dramatically from the 1965 to 1995. However, it has declined over the past 20 years. Here is a table showing hysterectomy rates over time:
| Time Period | Hysterectomy Rate (per 1,000 women) |
|---|---|
| 1965 | 5.1 |
| 1975 | 8.6 |
| 1985 | 9.9 |
| 1995 | 10.3 |
| 2005 | 7.6 |
| 2010 | 5.4 |
The decrease in hysterectomies over the past 20 years is likely due to several factors:
- Advancements in alternative treatments like uterine fibroid embolization
- Less invasive surgical techniques
- Increased use of hormone treatments
- Greater understanding of the importance of the uterus
Despite the decline, hysterectomy remains one of the most frequent surgeries for women in the U.S.
Reasons for Hysterectomy
The most common diagnosis associated with hysterectomy is uterine fibroids, accounting for 40% of hysterectomies. Fibroids are noncancerous growths that develop in the muscular wall of the uterus. While fibroids are extremely common, most women have no symptoms and do not require treatment.
When fibroids cause symptoms like heavy bleeding and pelvic pain, there are medications and less invasive procedures that can provide relief. However, hysterectomy remains a frequent treatment choice.
Other leading reasons for hysterectomy include:
- Endometriosis (15% of hysterectomies)
- Uterine prolapse (13%)
- Abnormal uterine bleeding (9%)
- Cancer (7%)
- Chronic pelvic pain (6%)
The remaining hysterectomies are performed for precancerous changes like endometrial hyperplasia and other less common conditions.
Fibroids
Uterine fibroids are the most common reason for hysterectomy, accounting for over 200,000 procedures annually in the U.S. Fibroids occur in up to 80% of women by age 50. However, the vast majority are asymptomatic and require no treatment. Even when fibroids cause symptoms, there are often alternatives to hysterectomy:
- Medications – Gonadotropin-releasing hormone (GnRH) agonists can help shrink fibroids and relieve symptoms.
- Myomectomy – Fibroids can be surgically removed while leaving the uterus intact.
- Uterine artery embolization – Blocking the blood supply to fibroids causes them to shrink.
- MRI-guided ultrasound surgery – Focused ultrasound beams destroy fibroids.
While hysterectomy is sometimes warranted for severe, refractory symptoms, many women can achieve symptom relief through less invasive options.
Endometriosis
Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, often on the ovaries and fallopian tubes. It affects over 11% of women aged 15-44. The condition can cause severe pelvic pain, painful periods, and infertility.
First-line treatments include pain medications and hormone treatments like birth control pills and gonadotropin-releasing hormone agonists. However, when medical treatments fail to provide adequate relief, surgery may be considered. This includes laparoscopic removal of endometrial lesions, often combined with hysterectomy.
While hysterectomy may provide definitive relief from pelvic pain for some women, preserving fertility should be considered for those still wishing to have children. Excision surgery without hysterectomy can improve symptoms and fertility in many cases.
Uterine Prolapse
Uterine prolapse is a condition where weakened pelvic muscles cause the uterus to drop down into the vagina. Symptoms include pelvic pressure, painful intercourse, urinary problems, and difficulty with bowel movements.
Nonsurgical treatments like Kegel exercises and pessaries can help manage prolapse in some women. When symptoms are severe, hysterectomy to remove the uterus may be recommended. However, uterus-sparing prolapse surgery is also very effective for appropriate candidates. This avoids the risks of hysterectomy while repairing the underlying tissue weakness.
Abnormal Uterine Bleeding
Heavy, abnormal periods affect up to 30% of women by age 50. After ruling out serious causes like endometrial hyperplasia and cancer, treatment options include hormone therapy, endometrial ablation, and hysteroscopic myomectomy. The least invasive options are typically tried first.
For abnormal bleeding that cannot be controlled by other treatments, hysterectomy is sometimes performed. In women who have completed childbearing, it may be the most definitive solution. However, hysterectomy should generally not be a first resort for management of heavy bleeding.
Rate of Unnecessary Hysterectomies
Given that many hysterectomies are performed for non-life-threatening conditions that have alternative treatments, there has been long-standing concern about unnecessary procedures. Unfortunately, there is no consensus on the actual rate of unwarranted hysterectomies. Estimates vary widely based on the criteria used.
Some key statistics on potentially unnecessary hysterectomies include:
- Up to 50% of hysterectomies for pelvic pain may be unwarranted (Annals of Internal Medicine)
- 50% of hysterectomies for endometriosis may be avoidable through conservative treatment (Fertility and Sterility)
- Over 75% of hysterectomies for fibroids may be unnecessary (American College of Obstetrics and Gynecology)
- 1/3 of hysterectomies for prolapse could be replaced with more specific repairs (International Urogynecology Journal)
Based on such estimates, a reasonable range is that 25-50% of the 600,000 hysterectomies performed annually in the U.S. may be unnecessary. However, calculating a precise statistic is challenging for several reasons:
Reasons Defining Unnecessary Hysterectomy is Difficult
- Subjectivity of symptoms – Pelvic pain and heavy bleeding have a large subjective component. Benefits of hysterectomy will depend on the woman’s experiences.
- Provider bias – Some gynecologists perform hysterectomy at much higher rates than others.
- Failure of conservative treatments – It’s unclear at what point alternative treatments should be deemed failures leading to hysterectomy.
- Risk tolerance – Women have different comfort levels for surgical risks versus possible recurrences with conservative management.
- Access – Not all women have access to alternatives like specialist excision surgery for endometriosis.
There are also financial incentives that can contribute to overuse of hysterectomy. Performance of surgery generates more revenue than triaging women to nonsurgical treatments.
Risks of Unnecessary Hysterectomy
While hysterectomy is a relatively safe surgery, it has risks both in the short and long term. Removing the uterus causes permanent effects on a woman’s health.
Surgical and Post-Surgical Risks
All surgeries carry a risk of bleeding and infection. Hysterectomy can also result in damage to other organs like the bowel, bladder, and ureters. Post-surgically, women may experience issues like:
- Pain
- Scar tissue
- Bowel obstruction
- Urinary incontinence
For vaginal and laparoscopic hysterectomy, risks are generally lower and recovery is faster versus abdominal hysterectomy. But each approach has downsides that warrant careful consideration for the right technique for an individual woman.
Long-Term Effects
The most concerning risks of unwarranted hysterectomy stem from long-term impacts on a woman’s health. These include:
- Loss of reproductive function – Permanent infertility.
- Hormonal changes – Increased risk of cardiovascular disease and osteoporosis.
- Added psychological stress – Some women have strong emotional connections to their uterus.
- Earlier menopause – Removal of the ovaries causes immediate menopause.
- Sexual dysfunction – Up to 40% of women report issues with desire or arousal after hysterectomy.
For women undergoing hysterectomy under age 35, the lifetime implications can be especially profound in terms of lost reproductive years.
Recommendations for Reducing Unnecessary Hysterectomies
To decrease overuse of hysterectomy, several changes are recommended:
- Improve provider knowledge about alternatives and their success rates.
- Increase availability and affordability of conservative treatments.
- Develop more definitive clinical guidelines on appropriate indications for hysterectomy.
- Change financial incentives that favor surgery over more conservative options.
- Ensure women understand the full range of treatment options and their tradeoffs.
Rather than rushing to hysterectomy, providers should start with the least invasive options whenever possible. The ideal rate is uncertain, but reducing hysterectomies by even 25% would have a large health impact.
Conclusion
Hysterectomy continues to be one of the most frequently performed surgeries among women in the U.S. Up to half of hysterectomies may be unwarranted as potential overuse. However, estimating the precise rate of unnecessary hysterectomies is difficult due to subjectivity in indications and lack of clear clinical guidelines.
While sometimes definitively needed, hysterectomy carries both surgical risks and lifelong impacts on a woman’s health. Efforts to optimize conservative management and clarify appropriate surgical thresholds are warranted to decrease overuse. This will require changes in clinical practice, financial incentives, and better patient education about treatment alternatives.