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Uterine Symptoms and Failed Therapies Predict Hysterectomy


SAN FRANCISCO -- Just as gynecologists have long suspected, most women with multiple uterine symptoms eventually turn to hysterectomy when less invasive therapies fail.

SAN FRANCISCO, April 12 -- Just as gynecologists have long suspected, most women with multiple uterine symptoms eventually turn to hysterectomy when less invasive therapies fail.

The validation of this widely held but previously untested belief may allow high-risk women to skip years of pain and disappointing alternative treatments and head directly to hysterectomy, said Lee A Learman, M.D., of the University of California San Francisco, and colleagues.

The presence of more than one uterine condition, previous use of a gonadotropin-releasing hormone agonist to induce "medical menopause," or lack of symptom relief from other therapies each doubled the likelihood of hysterectomy, they reported in the April issue of the Journal of the American College of Surgeons.

As part of the ongoing SOPHIA (Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives) study, the researchers followed the hysterectomy status of 762 premenopausal women (ages 33 or older) who were seeking care for uterine conditions at private, HMO, or university-affiliated clinics and practices in 1998 and 1999.

Two-thirds of the women were seeking care for heavy or irregular uterine bleeding alone or in combination with chronic pelvic pain or symptomatic uterine fibroids with abnormal bleeding or pressure. Forty-five percent had had symptoms for at least five years.

Previous treatments included myomectomy (11%), endometrial ablation (7%), and GnRH agonist treatment (10%). Whereas 58% of the women reported at least some symptom resolution at baseline, 42% said their symptoms were "not at all" resolved.

Over the four years of follow-up, there were 99 hysterectomies for a 13.5% cumulative hysterectomy rate (0.044 per person-year of observation).

On the basis of biennial self-reports, the independent predictors of hysterectomy were:

  • Multiple pelvic symptoms or symptomatic fibroids (hazard ratio 1.97, 95% confidence interval 1.18 to 3.28).
  • Previous use of a GnRH agonist (HR 2.54, 95% CI 1.53 to 4.24).
  • Absence of any symptom resolution (HR 2.24, 95% CI 1.46 to 3.44).

With each additional risk factor, survival curves indicated escalating hysterectomy risk, the researchers said.

Predicted hysterectomy rates ranged from 20% for a 55-year-old woman with no risk factors to 95% for one with all three predictors. For a woman with one risk factor (44.3% of the cohort) the likelihood was 40% to 55% whereas it was 70% to 85% for one with two risk factors (33.4% of the cohort).

On multivariate analysis, the risk of hysterectomy was:

  • 1.97 times higher for those with more than one uterine condition--both abnormal uterine bleeding and chronic pelvic pain or symptomatic uterine fibroids-versus only one (95% CI 1.18 to 3.28, P=0.009).
  • 2.24 times higher for those who had no symptom resolution versus subjects with full resolution of symptoms (95% CI 1.46 to 3.45, P<0.001).
  • 2.54 times higher for those with prior GnRH agonist treatment versus without (95% CI 1.53 to 4.24, P<0.001).
  • Not influenced by sociodemographic characteristics, symptom duration, frequency or severity, or prior myomectomy or endometrial ablation.

GnRH agonist use may represent the failure of other medical treatments and not merely a precursor to hysterectomy, the researchers said, because the study did not include women who were scheduled for hysterectomy at baseline and sensitivity analyses showed it did not act as a proxy for such symptomatic fibroids or chronic pelvic pain from endometriosis.

The overall cumulative hysterectomy rate of 13.5% was substantially lower than the 23% rate found among Maine women during a single year of follow-up, according to a 1994 report. So, the researchers said they expected the findings might be less generalizeable to other regions.

Further study will be needed to replicate the findings in other cohorts and other regions of the country.

"It is also possible that our study participants, nearly half of whom were symptomatic for at least five years, might over-represent women who are predisposed not to want definitive surgical management," they wrote.

Nonetheless, the study adds to the scant prospective data on the natural history of uterine conditions "and the probability that treatment alternatives can actually prevent, and not merely delay, hysterectomy," they wrote.

The findings may also help physicians prospectively identify women most likely to undergo hysterectomy to assist in counseling them on treatment alternatives, they added.

"Women presenting for care with multiple risk factors can be counseled about the high likelihood of hysterectomy within several years and can potentially make an earlier decision to have the procedure," they wrote, "and women without risk factors can be reassured that hysterectomy will be unlikely."

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