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Editorial
Hysterectomy is second only to cesarean section as the most frequently performed major operation in the United States. An estimated 633,000 hysterectomies are performed annually.1 Rates of hysterectomy vary significantly among regions, with a sixfold difference among Western countries.2 Thirty-seven percent of women in the United States and 20 percent of women in the United Kingdom have had a hysterectomy by the age of 60.3,4 Rates vary as much as fivefold even within the same geographic area and among physicians at the same hospital.5 Several important questions have been raised regarding the current use of hysterectomy. Why are so many performed? Why do the rates vary so much? What are the outcomes, and do outcomes differ among different types of hysterectomy? Hysterectomy came into widespread use in the early 20th century. Advances in anesthesia, aseptic technique, and antisepsis during the 19th and early 20th centuries allowed the development of safe surgical treatments for benign and malignant gynecologic disease. The rate of death due to abdominal hysterectomy decreased from 70 percent in 1880 to 3 percent in 1930.3 Currently, the mortality rate associated with hysterectomy is less than 0.1 percent.4,6 In general, hysterectomies are performed to improve quality of life rather than to cure life-threatening conditions. Hysterectomies performed for preinvasive and invasive gynecologic cancer, pelvic inflammatory disease, and obstetrical hemorrhage represent only 10 to 15 percent of cases. The most common indications are heavy or irregular uterine bleeding, pelvic pain, and pelvic pressure. These symptoms are often associated with uterine leiomyomas, endometriosis, adenomyosis, or pelvic-organ prolapse. However, the same symptoms also occur in the absence of identifiable disease; in the United Kingdom, specimens from 40 percent of hysterectomies performed for dysfunctional uterine bleeding have no pathological findings.4 Conversely, patients with uterine leiomyomas or endometriosis often have no symptoms and require no intervention. Hysterectomy rates vary for several reasons. One is that other options, including pharmacologic therapy and minimally invasive surgical techniques, are available to treat the conditions for which hysterectomy may be performed. Pharmacologic treatment is often first-line therapy for abnormal uterine bleeding and pelvic pain. Hormonal manipulation with estrogens, progestins, combination oral contraceptives, or gonadotropin-releasing hormone analogues may reduce abnormal uterine bleeding and pelvic pain due to endometriosis, leiomyomas, or anovulation. However, the success of this approach may be limited by side effects, variations in patient compliance, and the need for long-term therapy. Medications control but do not cure the problem. Minimally invasive surgical techniques that either resect or ablate the endometrial lining effectively reduce or stop uterine bleeding. However, randomized, controlled trials comparing hysterectomy with endometrial resection or ablation have consistently shown that hysterectomy is more effective in permanently curing abnormal uterine bleeding and results in higher patient-satisfaction scores than these minimally invasive procedures.7 Conversely, minimally invasive techniques provide considerable short-term benefits (including decreases in the duration of surgery, the length of the hospital stay, and the interval before returning to work, as well as decreased costs). Alternatives to hysterectomy are particularly useful near the time of menopause. The average age at hysterectomy is 40 to 45 years, and the average age at menopause in the United States is 51 years. Because symptoms such as abnormal bleeding and pelvic pain usually resolve when ovarian function ceases, pharmacologic therapy or minimally invasive surgical techniques that temporarily ameliorate symptoms can reduce the overall need for hysterectomy. Since multiple options for treating abnormal uterine bleeding and pelvic pain are available, physicians' preferences become an important factor in determining whether hysterectomy is performed. For example, chronic anemia due to heavy uterine bleeding might be a clear indication for hysterectomy according to one physician, whereas another would use pharmacologic treatment as first-line therapy, and a third would prefer endometrial ablation to induce amenorrhea. Patients' preferences also play a key part in decision making; some women strongly desire uterine preservation, whereas others adamantly request uterine removal. Simply put, there is no universal agreement with respect to strict criteria for hysterectomy, and treatment is currently tailored to individual patients. Hysterectomy is the only definitive cure for abnormal uterine bleeding. Aside from this obvious benefit, hysterectomy clearly improves quality of life in many women. Multiple studies have shown that symptoms such as pelvic pain, dyspareunia, and fatigue are abolished or significantly reduced after surgery.8,9 In a prospective study involving 1299 women, 88 percent of the women who had moderate to severe pelvic pain before surgery had significant improvement in this symptom at two years.10 Ninety-six percent reported that hysterectomy resulted in complete or almost complete resolution of the problems or symptoms that had been present before surgery. Nevertheless, controversy over the potential adverse effects of hysterectomy on lower urinary tract function and sexual function still exists. Hysterectomy may be performed by a vaginal, an abdominal, or a laparoscopic approach. The abdominal and laparoscopic operations may be total (i.e., involving removal of the uterus and cervix) or subtotal (i.e., involving removal of the uterine fundus and lower uterine segment, with preservation of the cervix) and may or may not include removal of the ovaries. In the United States, 65 percent of hysterectomies are total abdominal, 23 percent total vaginal, 10 percent total laparoscopic, and 2 percent subtotal abdominal or laparoscopic.11 It is not clear whether all types of hysterectomy result in similar outcomes. Subtotal abdominal hysterectomy has increased in popularity in recent years. It is thought that conservation of the cervix minimizes neurologic and anatomical disruption and that it therefore also helps to minimize potential adverse effects on bladder, bowel, and sexual function. In addition, it is theorized that subtotal abdominal hysterectomy decreases the incidence of posthysterectomy prolapse of the vaginal vault by preserving connective-tissue support of the upper vagina. This procedure is now widely used in Europe and in parts of the United States, although few data are available to support its efficacy. In this issue of the Journal, Thakar et al. report results of the largest and most comprehensive randomized trial to date comparing the effects of total and subtotal abdominal hysterectomy.12 One year after surgery, no significant differences were found between the two treatment groups with respect to bladder, bowel, or sexual function. These results, together with the 6.8 percent incidence of cyclical vaginal bleeding after subtotal hysterectomy, suggest that subtotal abdominal hysterectomy confers no advantage over total abdominal hysterectomy. This study, however, does not address the issue of posthysterectomy vaginal-vault prolapse. Since prolapse may occur years after hysterectomy, long-term follow-up is needed to assess whether cervical preservation results in better support of the vaginal vault. An important finding of the study by Thakar and colleagues is that urinary function improved in both groups after hysterectomy, in terms of the measured decreases in urinary stress incontinence, urgency, frequency, and nocturia. These results suggest that the conditions that may lead to hysterectomy adversely affect lower urinary tract function. The study also provides evidence that hysterectomy, whether total or subtotal, does not cause deterioration in sexual function. Hysterectomy has been a mainstay of gynecologic therapy for 100 years. It continues to be performed frequently because it is tremendously effective for the treatment of abnormal uterine bleeding and pelvic pain. The report by Thakar et al. provides solid evidence that hysterectomy performed with the use of either technique has a beneficial effect on lower urinary tract symptoms. Hysterectomy will probably continue to be common until other treatments are developed that provide similar results.
References
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