Hysterectomy among Women of Reproductive Age, United States, Update for 1979-1980

Richard W. Sattin, M.D. George L. Rubin, M.B., F.R.A.C.P.

Epidemiologic Studies Branch Joyce M. Hughes

Research and Statistics Branch Division of Reproductive Health Center for Health Promotion and Education Introduction

Hysterectomy is one of the most frequently performed operations for women of reproductive age in the United States (1), making this procedure an important public health concern. In 1975, CDC began epidemiologic surveillance of hysterectomy; summary data have been published in three reports (2-4). This article provides a detailed analysis of the influence of age, race, and geographic region on hysterectomy rates and surgical approach in the period 1979-1980 and updates a previous analysis of hysterectomies for the period 1970-1978. Analysis showed that nationwide hysterectomy rates among women of reproductive age have declined to their lowest level since 1971, that major interregional differences in rates have persisted, and that the proportion of hysterectomies performed by the vaginal route has continued to decline since 1975. Materials and Methods

The methods of this study have been described in detail elsewhere (2-4). In brief, data used were collected by the National Center for Health Statistics (NCHS) as part of the ongoing National Hospital Discharge Survey (NHDS), which estimates the number and characteristics of patients admitted to United States non-Federal, short-stay hospitals for surgical procedures, disease, or injury. For this report, only simple hysterectomies were evaluated; radical hysterectomies and pelvic exenteration performed to treat patients with advanced pelvic cancer were excluded.

Population estimates used in computing rates for this report were based on data from current population surveys conducted by the United States Bureau of the Census. Data on race were grouped into the categories of white and black for analysis. The latter category includes all races other than white. We do not know the percentage of women in 1979 and 1980 in the latter category who were black; however, for the period 1970-1978, 93% were black.

This article focuses on the relationship of hysterectomy to the following variables: 1) age (15-44 years in 10-year age groups); 2) geographic region of the United States (Northeast, North Central, South, or West), as defined by the Bureau of the Census; 3) race (white or black); and 4) surgical approach (abdominal or vaginal). Since standardizing for age, race, and region did not appreciably alter the rates in this study, only unstandardized data are presented. Estimates in this report are rounded to the nearest thousand. Results

In the period 1970-1980, an estimated 4,342,000 women 15-44 years of age underwent hysterectomy in U.S. non-Federal, short-stay hospitals (Figure 1). The number of hysterectomies increased from a low of 306,000 in 1970 to a high of 442,000 in 1977 and then declined to 405,000 in 1979 and 401,000 in 1980.

The hysterectomy rate in 1979 was 8.0/1,000 women ages 15-44 years and in 1980 was 7.6, the lowest level since 1971 (Figure 2). Although nearly three-quarters of all hysterectomies in 1979-1980 were performed on white women, the average rate of hysterectomy for black women (8.7/1,000 women ages 15-44) was higher than that for white women (7.7/1,000 women ages 15-44). However, this racial difference in hysterectomy rates narrowed in 1980. In the period 1975-1980, the hysterectomy rate declined 16% for whites and 22% for blacks. In 1979-1980, the average age at the time of hysterectomy was 34.8 years for black women and 35.0 years for white women.

For 1979-1980 as in previous years, the highest hysterectomy rate for women of reproductive age was for the 35- to 44-year age group, and the lowest was for the 15- to 24-year age group (Figure 3). Just as the nationwide hysterectomy rate has been decreasing steadily since 1977, so have the hysterectomy rates for the 25- to 34- and 35- to 44-year age groups for the same reporting period. For the 15- to 24-year age group, the hysterectomy rate increased from 0.8/1,000 women ages 15-24 years in 1979 to 1.0 in 1980, but the rate in 1980 was lower than that in 1977. In 1979 and 1980, the average age for women who had hysterectomy varied by region as follows: Northeast--36.5 years; North Central--35.4; South--34.2; and West--35.0. In 1980, approximately one of every 60 women in the age group 35-44 years had a hysterectomy. This is a conservative estimate because women who had had hysterectomies in previous years were not removed from the denominator.

Hysterectomy rates varied by region in 1979 and 1980 (Figure 4). As in previous years, women in the Northeast had the lowest hysterectomy rates of the four regions. Women in the South had the highest hysterectomy rates. The hysterectomy rate for women in the South was nearly two and one-half times that for women in the Northeast.

In 1979 and 1980, 25% and 22%, respectively, of all hysterectomies were performed by the vaginal route (Figure 5). The absolute proportion of all hysterectomies performed by the vaginal route declined by 4% between 1970 and 1980. The proportion of vaginal hysterectomies performed on white women was almost the same as that for black women in 1970 and 1971. However, the proportion of vaginal hysterectomies performed during 1970-1980 on black women decreased by 46%, while decreasing 12% for white women. The decrease in the percentage of hysterectomies performed vaginally was evident in all geographic areas. In the period 1972-1980, women in the West had the highest proportion of vaginal hysterectomies, and women in the Northeast had the lowest proportion throughout the reporting period. Women ages 25-34 years had consistently higher proportions of vaginal hysterectomies than women in other age groups in the period 1970-1980. Discussion

Analysis of NHDS data on hysterectomy shows that the nationwide rate at which hysterectomies are performed on women of reproductive age has continued to decline since 1977 and that the rate in 1980 was the lowest since 1971. Since 1977, rates for both race groupings, all age groups, and all geographic regions have declined. Throughout the study period, interregional differences in rates and in mean ages of women undergoing hysterectomy have continued. Interracial differences in rates, however, declined noticeably in 1980. The percentage of women undergoing hysterectomy via the vaginal approach has declined steadily since 1975 regardless of age, race, or geographic region.

These results probably underestimate the true rates of hysterectomy because women undergoing hysterectomy in Federally operated hospitals are not included in the NHDS data and women ages 15-44 years who had already had a hysterectomy were not excluded from the denominator. The level to which these rates are underestimated is probably greater in those areas and for those ages that have had relatively higher rates of hysterectomy. However, a recent study that adjusted hysterectomy rates for the number of U.S. women ages 15-44 years who had already had a hysterectomy showed temporal variations in rates similar to those reported in previous CDC surgical sterilization surveillance reports (5).

The NHDS data for 1970-1980 show an initial increase in nationwide hysterectomy rates followed by a leveling off and then a decline. Several factors may account for the increase in hysterectomy rates in the early 1970s: an increase in uterine or pelvic pathology; advances in medical technology (e.g., laparoscopy) that make possible the early and accurate diagnosis of uterine pathology; an increased awareness on the part of women concerning their reproductive health and their risk of gynecologic neoplasms; changes in gynecologic practice regarding indications for hysterectomy; and a desire on the part of more women to undergo sterilization (2). The leveling off in the mid-1970s followed by the decline in the late 1970s may reflect a reversal of some of these patterns. For example, tubal sterilization was used much more frequently in 1980 than in 1970--i.e., an increase of 164% (4).

The proportion of vaginal hysterectomies varies by region and has declined continuously since 1975. In fact, the proportion in 1980 was the lowest since CDC began its hysterectomy surveillance reports. Several factors may be contributory. First, parity among U.S. women has declined since 1960 (6). This decline--together with changes in gynecologic practice in the 1970s--may have led to fewer procedures being performed for conditions related to symptomatic pelvic relaxation. Second, the training obstetrics/gynecology residents in regard to vaginal hysterectomy may have been modified. Third, the incidence of pelvic inflammatory disease among U.S. women has increased (7). The abdominal approach may be preferred to the vaginal approach when performing hysterectomies on women with a history of pelvic inflammatory disease. Finally, colposcopy and cryosurgery have made conservative management of cervical intra-epithelial neoplasia more feasible as an alternative to hysterectomy performed via either route (8).

Although hysterectomy rates in all geographic areas have decreased since 1977, variations by region have persisted since 1970 (2,3,4,9). Both patient- and physician-related factors may contribute to these regional differences. Patient-related factors may include regional differences in incidence of uterine pathological conditions and general attitudes toward surgery or sterilization during the reproductive years (10). Among physician-related factors, regional differences in trends in training and practice may be contributory (11,12). However, lower rates of surgical procedures do not necessarily mean higher standards of practice (13,14).

In conclusion, in 1980 national and regional hysterectomy rates declined to their lowest levels since 1971, but interregional differences continued to be present. These trends should be considered when assessing national and regional patterns of related conditions, such as endometrial carcinoma. Further surveillance and estimates of the numbers and rates of hysterectomies among women of reproductive age in U.S. non-Federal, short-stay hospitals will be necessary to determine whether this downward trend in hysterectomy rates is continuing.References 1.National Center for Health Statistics. Detailed diagnoses and surgical procedures for patients discharged from short-stay hospitals, United States, 1979. Hyattsville, Md.: National Center for Health Statistics, 1982 (DHHS publication no. ŐPHSĺ 82-1274-1). 2.CDC. Surgical sterilization surveillance; hysterectomy in women aged 15-44, 1970-1975. Atlanta, Ga.: Centers for Disease Control, 1980. 3.CDC. Surgical sterilization surveillance; hysterectomy in women aged 15-44, 1976-1978. Atlanta, Ga.: Centers for Disease Control, 1981. 4.CDC. Surgical sterilization surveillance in women aged 15-44, 1979-1980. Atlanta, Ga.: Centers for Disease Control (in press). 5.Nolan TF, Ory HW, Layde PM, Hughes JM, Greenspan JR. Cumulative prevalence rates and corrected incidence rates of surgical sterilization among women in the United States, 1971-1978. Am J Epi 1982;116:776-81. 6.National Center for Health Statistics. Vital statistics of the United States, 1978, Vol. 1. Washington, D.C.: United States Government Printing Office, 1982 (DHHS publication no. ŐPHSĺ 82-1100). 7.Curran JW. Economic consequences of pelvic inflammatory disease in the United States. Am J Obstet Gynecol 1980;138:848-51. 8.Wilbanks GD. Cervical intraepithelial neoplasia. In: Buchsbaum HJ, Sciaria JT, eds. Gynecology in obstetrics. Philadelphia: Harper & Row, 1982. 9.Dicker RC, Scally MJ, Greenspan JR, et al. Hysterectomy among women of reproductive age: trends in the United States, 1970-1978. JAMA 1982;248:323-7. 10.Rochat RW. Regional variation of sterility, United States, 1970. Advances in Planned Parenthood 1976;9:1-11. 11.Wennberg JE, Gittlesohn A. Variations in medical care among small areas. Scientific America 1982;246:120-34. 12.Wennberg JE. Factors governing utilization of hospital services. Hospital Practice 1979;14:115-27. 13.Dyck F, Murphy FA, Murphy JK, et al. Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. N Engl J Med 1977;296:1326-8. 14.Roos NP, Roos LL, Henteleff PD. Elective surgical rates--do high rates mean lower standards? Tonsillectomy and adenoidectomy in Manitoba. N Engl J Med 1977;295:360-5.

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