The Impact of Alternative Treatment for Abnormal Uterine Bleeding on Hysterectomy Rates in a Tertiary Referral Center

doi:10.1016/j.jmig.2008.09.608

Journal of Minimally Invasive Gynecology

Volume 16, Issue 1, January 2009, Pages 47-51

https://doi.org/10.1016/j.jmig.2008.09.608 Get rights and content

Abstract

Study Objective

The purpose of this study was to estimate the influence of alternatives to hysterectomy for abnormal uterine bleeding (AUB) on hysterectomy rates.

Design

Retrospective cohort study. Canadian Task Force II-2.

Setting

University hospital.

Patients

Premenopausal patients with AUB.

Interventions

Medical records of all premenopausal patients treated for AUB in our university clinic between January 1, 1995, and December 31, 2004, were reviewed. Patients were identified based on (specific) diagnostic and therapy codes used in the registry system of the hospital. The total number of placements of levonorgestrel-releasing intrauterine device (LNG-IUD), hysteroscopic surgery, and hysterectomies performed/year was estimated. In addition, the course of treatment of each patient was assessed.

Measurements and Main Results

A total of 640 patients received surgery and 246 LNG-IUDs were placed. The proportion of endometrial ablations decreased significantly over time (p <.001), whereas hysteroscopic polyp or myoma removal (p =.030) and insertion of LNG-IUD (p <.001) both increased. The proportion of patients receiving hysterectomy for AUB as their first therapy decreased significantly (p =.005) from 40.6% to 31.4%, although the total number of patients receiving hysterectomy remained similar (p =.449). The 5-year intervention-free percentage for LNG-IUD was 70.6% (SD = 3.3%), for hysteroscopic polyp or myoma removal 75.5% (SD = 3.3%), and for endometrial ablation 78.0% (SD = 4.3%; p =.067).

Conclusion

Despite the introduction of alternative therapies, the total hysterectomy rate in the management of AUB did not decrease in our clinic.

Section snippets

Material and Methods

Medical records of all premenopausal patients receiving surgery or LNG-IUD because of abnormal uterine bleeding between January 1, 1995, and December 31, 2004, were reviewed. Abnormal uterine bleeding was defined as menorrhagia, metrorrhagia, or intermenstrual bleeding. Patients were excluded in case of infertility, postmenopausal state, or (suggestion of) malignancy of the genital tract.

Eligible patients were identified based on (specific) diagnostic codes (e.g., for menorrhagia, metrorrhagia,

Results

In the investigated period, 2157 premenopausal patients with AUB attended our clinic. Of this group, 1271 (58.9%) patients received oral medical therapy or no treatment at all; the other 886 (41.1%) patients had either surgical therapy or received LNG-IUD. Within this time frame, staffing remained similar (staffing performing hysterectomy [n = 6] and endoscopic surgery [n = 3]).

Patient characteristics are detailed in Table 1. The mean age at which LNG-IUD (41.6 years) was placed and

Discussion

Even though several alternative treatment modalities were developed to date, the overall hysterectomy rate in the management of AUB did not decrease in our clinic during the years (1995–2004) reviewed in this study. The numbers of hysteroscopic surgeries and insertion of LNG-IUD as alternative treatment for this indication increased. On the contrary, the number of women receiving endometrial ablation declined. A probable explanation for this decline is the replacement by LNG-IUD, introduced in

Conclusion

In our clinic, the hysterectomy rate in the management of AUB did not decrease, despite the introduction of alternative therapies. An explanation to this phenomenon remains speculative, although to assure adequate implementation of alternative therapies it is of great importance to determine, at least nationwide and preferably internationally, its real impact on costs and satisfaction.

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Cited by (20)

Expulsion rates of the levonorgestrel 52 mg intrauterine system are similar among women with heavy menstrual bleeding and users for contraception
2022, Contraception
Citation Excerpt :
In 2015, this device was approved by the US Food and Drug Administration [5] and in more than 100 countries as a contraceptive method and as a medical treatment for heavy menstrual bleeding. Its use has been associated with a reduction in some medical and surgical treatments, such as use of tranexamic acid, oral progestins, endometrial ablation, and hysterectomy [6-9]. The LNG IUS is recommended as a first-line treatment in women with nonstructural heavy menstrual bleeding [10,11].
To compare the expulsion rates of the levonorgestrel (LNG) 52 mg intrauterine system (IUS) among women with heavy menstrual bleeding versus women using solely for contraception.
We conducted an audit study of 548 (8.8%) women with heavy menstrual bleeding and 5655 (91.2%) users for contraception (comparison group) for 4 years in Campinas, Brazil. We retrieved sociodemographic data, expulsion rates, and variables associated to device placement. Among women with heavy menstrual bleeding, we placed the devices after the cessation of bleeding or after the reduction of menstrual flow.
Thirty-one of 548 (5.6%) women with heavy menstrual bleeding and 315 of 5655 (5.6%) from the comparison group expelled the device. This constituted 7.8 expulsions/100 women-years in women with heavy menstrual bleeding and 10.3 expulsions/100 women-years from the comparison group (p = 0.94). Expulsion risk was associated with previous cesarean delivery in both groups (OR 1.93, 95% CI 1.36;2.74).
Expulsion rates of the LNG IUS among women with heavy menstrual bleeding whose IUS was placed after the cessation or reduction of bleeding were similar to expulsion rates among users for contraception. Previous cesarean delivery was a risk factor for expulsion.
We recommend the 52 mg LNG IUS placement after the cessation of bleeding or a reduction of menstrual flow among women with heavy menstrual bleeding because this strategy was associated with similar risk of expulsion when compared to users for contraception.
Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women
2018, American Journal of Obstetrics and Gynecology
Citation Excerpt :
This may be due to the increased use of endometrial ablation and progesterone eluting intrauterine devices to control bothersome abnormal bleeding and chronic pelvic pain. These therapies have enabled many premenopausal women to control symptoms without resorting to invasive, extirpative surgery.10 The number of hysterectomies for pelvic organ prolapse also decreased 19.4%.
Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown.
The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implications among women with commercially based insurance in the United States.
Hysterectomies between 2010 and 2013 were identified in the Health Care Cost Institute, a national data set with inpatient and outpatient private insurance claims for more than 25 million women. Surgical approach was categorized with procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 US dollars to account for change because of inflation.
Between 2010 and 2013, there were 386,226 women who underwent hysterectomy. The rate of utilization decreased 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were observed among women younger than 55 years and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with concomitant decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2 to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. There was also a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. By 2013, the rates were 15.4 and 19.6 per 10,000 women. In each year of analysis, the average reimbursement for outpatient procedures was 44-46% less than for similar inpatient procedures. Offsetting the lower utilization of hysterectomy and lower reimbursement for outpatient surgery were increases in average inpatient and outpatient hysterectomy reimbursement of 19.4% and 19.8%, respectively. Total payments for hysterectomy decreased 6.3%, from $823.4 million to $771.3 million.
Between 2010 and 2013, laparoscopy emerged as the most common surgical approach for hysterectomy, and outpatient hysterectomy became more common than inpatient among women with commercially based insurance. While average reimbursement per case increased, overall payments for hysterectomy are decreasing because of decreased utilization and dramatic differences in how hysterectomy is performed.
Temporal trend and nationwide utility for hysterectomies in Taiwan, 1997–2010
2016, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
Similar to most surgeries, hysterectomy causes a negative impact on the quality of life. Although a number of less invasive alternative therapies have been developed to replace hysterectomy [9], hysterectomy remains the second most common gynecological surgery in the United States [1]. In this study, we observed that the rate of hysterectomy varied from country to country [3].
This study investigates the nationwide utilization and temporal trend of hysterectomies in Taiwan.
The present study used the National Health Insurance Research Database that included claims of nearly the entire population in Taiwan since the inception of the National Health Insurance program in 1995. We analyzed age-adjusted rates of hysterectomies in Taiwan from 1997 through to 2010 and compared with the rates in 16 countries of the Organization for Economic Co-operation and Development. We also examined the utilization of various types of hysterectomies in Taiwan during this period.
There was a cross-country variation in the age-standardized rate of hysterectomy: 105 per 100,000 females in Spain, 156 per 100,000 females in Taiwan, 179 per 100,000 females in 16 Organization for Economic Co-operation and Development countries, and 325 per 100,000 females in the United States in 2008. The trend of the age-standardized rate of hysterectomy in Taiwan declined from 222.3 per 100,000 women in 1998 to 145.2 per 100,000 women in 2010. The most common type of hysterectomy during this period was total abdominal hysterectomy (51.2%). Subtotal hysterectomies increased by 117% (r² = 0.89; p < 0.01), from 672 in 1997 to 1458 in 2010; however, total hysterectomies decreased by 3.5% (r² = 0.43; p = 0.01), from 20,966 in 1997 to 20,230 in 2010. Laparoscopically assisted procedures (laparoscopic supracervical hysterectomy and laparoscopic hysterectomy) increased 4.98-fold (r² = 0.23; p = 0.09), from 1453 in 1997 to 8684 in 2010. By contrast, the proportion of conventional open hysterectomies (total abdominal hysterectomy, and subtotal or supracervical abdominal hysterectomy) decreased by 36.5% (r² = 0.59; p < 0.01), from 17,327 in 1997 to 10,994 in 2010. The proportion of vaginal hysterectomies decreased by 29.7% (r² = 0.72; p < 0.01), from 2858 in 1997 to 2010 in 2010.
As in most Western countries, hysterectomy rates in Taiwan declined by year. There was a marked shift in the types of hysterectomies from 1997 through to 2010 in Taiwan. Minimally invasive surgeries and supracervical hysterectomies were more commonly adopted.
Hysterectomy
2013, Women and Health
The trends of minimally invasive surgery for benign gynecologic lesions, 1997-2007 in Taiwan
2012, Gynecology and Minimally Invasive Therapy
Citation Excerpt :
Laparoscopy is indicated for benign uterine lesions including uterine myoma and adenomyosis, intractable pelvic pain, severe abnormal uterine bleeding, and poor response to medical treatment. The nonsurgical alternative treatments for benign uterine conditions have been developed to be first-line therapy, including levonorgestrel-releasing intrauterine device, hysteroscopic polyp or myoma removal, and endometrial ablation.13 However, the influence of these procedures on hysterectomy rates currently remains uncertain, due to the lack of long-term research studies that aim to identify the effectiveness of various treatment methods.12
The use of minimally invasive surgery (MIS) has grown over the past two decades in Taiwan and worldwide. Laparoscopic surgery has been applied to manage the adnexal mass, and ectopic pregnancy since 1989, followed by the first case series of laparoscopic-assisted vaginal hysterectomy (LAVH) in 1992 in Taiwan. These cases successfully advanced the development of the laparoscopic field. The most significant finding for hysterectomy is the significant increase of laparoscopic hysterectomy (LH) from 5.75% to 37.50%, which is accompanied by the decrease of total abdominal hysterectomies (TAH) from 77.93% to 48.12%, in 1997 and 2007, respectively. Laparoscopic surgery increased significantly from 35.78% to 71.66% for benign ovarian tumor; laparoscopic procedures significantly increased from 18.9% in 1997 to 73.95% in 2007 for ectopic pregnancy. Surgeon acceptance and a rapid evolution of instrumentation have enabled the use of laparoscopy to flourish in recent years. Based on nationwide population-based studies, the choices of surgical procedures are found to be dependent on patient factors, surgeon factors, and hospital factors. The academic activities launched by the MIS-related medical associations significantly lower the threshold for entering the field of endoscopy for gynecologists. This review demonstrates a considerable shift in the use of laparoscopic surgery as MIS in the approaches of benign gynecologic conditions, hysterectomy, ovarian tumor, and ectopic pregnancy, during the past 15 years in Taiwan. As a minimally invasive approach, laparoscopic surgery represents a profound change in patients, surgeons, and hospitals where the surgeries were performed.
Hysterectomy
2012, Women and Health, Second Edition

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Original ArticleThe Impact of Alternative Treatment for Abnormal Uterine Bleeding on Hysterectomy Rates in a Tertiary Referral Center

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Material and Methods

Results

Discussion

Conclusion

Obstet Gynecol

BJOG

Ann Epidemiol

Lancet

Best Pract Res Clin Obstet Gynaecol

Lancet

Hysterectomy and socioeconomic position in Rome

Italy. J Epidemiol Community Health

Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway

N Engl J Med

Original Article
The Impact of Alternative Treatment for Abnormal Uterine Bleeding on Hysterectomy Rates in a Tertiary Referral Center