Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased In recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.

Annual hospital costs associated with hysterectomy, the second most common major surgery performed in the United States, surpass $5 billion.[1] After peaking in 1975 at 725,000 per year, the number of hysterectomies performed each year has declined and is currently estimated to be 576,000 per year.[2]

The majority of hysterectomies are elective, and more than 90 percent of all procedures are performed in women with nonmalignant conditions.[3] Currently, appropriate indications for hysterectomy remain controversial among health care professionals. Besides the medical indications for hysterectomy, both patient and health care provider characteristics may influence hysterectomy rates.

This article reviews the current recommendations concerning common nonmalignant indications for hysterectomy, suggests alternative treatments and discusses nonmedical predictors of hysterectomy.

Medical Indications for Hysterectomy

UTERINE LEIOMYOMAS

Uterine leiomyomas are the most common indication for hysterectomy and are the reason given for 25 to 30 percent of hysterectomies.[3,4] Leiomyomas, or benign tumors composed of smooth muscle cells and fibrous connective tissue, arise most often in women 30 to 49 years of age and are typically slow-growing, multiple and variable in size. Although the precise etiology of leiomyomas is unknown, sex steroid hormones, specific enzymes and epidermal growth factor are believed to play a role in their development.[5]

Women with leiomyomas are usually asymptomatic. They may, however, have abnormal uterine bleeding, pelvic pain and pressure, lower urinary tract symptoms, infertility, spontaneous abortion and preterm labor.

Medical management of symptomatic uterine leiomyomas may involve hormonal therapy or nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve menorrhagia, dysmenorrhea or pelvic discomfort. Gonadotropin-releasing hormone (GnRH) agonists may induce a state of hypoestrogenemia, causing a reduction in tumor size.[6] However, use of GnRH agonist therapy is limited by the rapid regrowth of tumors following cessation of therapy, decreases in bone density and vasomotor symptoms.[7,8]

Myomectomy is a conservative surgical management option for uterine leiomyoma, is often performed laparoscopically on an outpatient basis, and appears to have good long-term effectiveness.[7] The advantages of hysteroscopic resection of leiomyomas include preservation of fertility, reduced postoperative discomfort and a relatively short recovery period.[9] Unfortunately, leiomyomas recur in an estimated 15 to 30 percent of patients following myomectomy, and operative risks increase with multiple myomectomies.[10]

Hysterectomy is the appropriate and definitive treatment for a woman who has finished childbearing and who has large, symptomatic uterine leiomyomas.[7] Table 1 summarizes the recommendations of the American College of Obstetricians and Gynecologists (ACOG) regarding hysterectomy for leiomyoma.[11] Experts, however, disagree on whether hysterectomy is justified for a woman with asymptomatic or minimally symptomatic fibroids.[12] Traditionally, indications for hysterectomy in a woman with asymptomatic leiomyomas include the following: (1) nonpalpable adnexa that interferes with the diagnosis of ovarian cancer; (2) prophylaxis against future symptoms; (3) avoidance of increased surgical morbidity from continued uterine enlargement, and (4) avoidance of the rare disorder leiomyosarcoma.[12,13] Available evidence challenges these traditional arguments, and current guidelines do not recommend hysterectomy for an enlarged uterus caused by asymptomatic leiomyomas.[12,13]

TABLE 1

Criteria for Hysterectomy for Leiomyomas

Confirmation of leiomyomas (presence of 1 or 2 or 3)
1. Asymptomatic leiomyomas of such size that they are palpable
abdominally and are a concern to the patient
2. Excessive uterine bleeding evidenced by either of the following:
a. Profuse bleeding with flooding or clots or repetitive periods
lasting more than eight days
b. Anemia due to acute or chronic blood loss
3. Pelvic discomfort caused by myomas (presence of a or b or c)
a. Acute and severe
b. Chronic lower abdominal or low back pressure
c. bladder pressure with urinary frequency not due to urinary
tract infection

Actions prior to procedure
1. Confirm the absence of cervical malignancy
2. Eliminate anovulation and other causes of abnormal bleeding
3. When abnormal bleeding is present, confirm the absence of
endometrial malignancy
4. Assess surgical risk from anemia and need for treatment
5. Consider patient’s medical and psychologic risks concerning
hysterectomy

Contraindications
1. Desire to maintain fertility, in which case myomectomy should
be considered
2. Asymptomatic leiomyomas of size less than 12 weeks of gestation
determined by physical examination or ultrasound examination

From Quality assessment and improvement in obstetrics and
gynecology. Washington, D.C.: American College of Obstetricians
and Gynecologists, 1994. Used with permission.