Hysterectomy is one of the most common surgical procedures performed. After cesarean delivery, it is the second most frequently performed major surgical procedure in the United States (1). According to the National Hospital Discharge survey, the rate of hysterectomy during the 5-year study period was 5.4 per 1,000 women per year in 2000 and declined to 5.1 per 1,000 per year in 2004. These data do not represent hysterectomies performed in ambulatory settings.
The highest rate of hysterectomy is between the ages of 40 and 49 years with an average age of 46.1 years (1). The highest rates of hysterectomy are for women living in the southern United States and they occur at a younger age. The lowest rates are consistently in the northeastern portion of the United States. Lower socioeconomic status is associated with increased hysterectomy rates (2). Hysterectomy rates are higher for black women (3). Reports on the effect of physician gender conﬂict with data that shows no overall impact (4). Bilateral salpingo-oophorectomy decreased between 2000 and 2004 from 53.8% to 49.5% (1). The frequency was the highest with abdominal hysterectomy and the lowest with vaginal hysterectomy.
The indications for hysterectomy are listed in Table 24.1. Uterine leiomyomas are consistently the leading indication for hysterectomy. As expected, the indications differ with the patient’s age (1). Hospitalization rates for hysterectomy in women between the ages of 15 and 54 years decreased from 1998 to 2005 for all indications except for menstrual disorders (5).
Leiomyomas The proportion of hysterectomies performed for leiomyomas decreased over time (1) (see Chapter 15). Fertility-preserving surgical management (myomectomy) is possible in most patients with leiomyomas. The decision to perform a hysterectomy for leiomyomas is usually based on the need to treat symptoms—abnormal uterine bleeding, pelvic pain, or pelvic pressure. Other indications for intervention have included “rapid” uterine enlargement, ureteral compression, or uterine growth after menopause. There is no clearly reproducible definition of rapid growth. The concept of rapid growth was challenged because these patients did not demonstrate clearly malignant conditions (6). Refuted reasons for hysterectomy in patients with leiomyomas are size greater than 12 weeks of gestation without symptoms, inability to palpate the ovaries on bimanual examination, and increased morbidity at hysterectomy with increased uterine size. If the procedures are performed abdominally, there is no difference in surgical morbidity between patients with a 12-week-sized uterus and those with a 20-weeksized uterus (7). Therefore, hysterectomy for leiomyomas should be considered only in symptomatic patients who do not desire future fertility (7).