Hysterectomy - Women's Health Highlights: Recent Findings (continued)

Hysterectomy
Hysterectomy is second only to cesarean delivery as the most frequently performed major surgical procedures for women of reporductive age in the United States. Approximtely 600,000 hysterectomies are performed each year, and an estimated 20 million U.S. women have had a hysterectomy. Hysterectomy is performed most often in women aged 40-44 years, and the three conditions most often assosicated with hysterectomy are fibroid tumors, endometriosis, and uterine prolapse.

•Three clinical characteristics increase the likelihood of hysterectomy for women with certain noncancerous conditions.
In this study of 734 women at several California clinics and offices, three clinical characteristics—abnormal uterine bleeding, chronic pelvic pain, and symptomatic uterine fibroids—predicted the likelihood of subsequent hysterectomy. Nearly half of the women had suffered from symptoms for more than 5 years, and some of the women had already had surgery to remove fibroids, undergone removal of uterine lining, or had hormone treatment. A total of 99 of the women (13.5 percent) underwent hysterectomies during the 4-year study period. Women with multiple pelvic symptoms or symptomatic fibroids were nearly twice as likely to have a hysterectomy as other women. Learman, Kuppermann, Gates, et al., J Am Coll Surg 204:633-641, 2007 (AHRQ grants HS07373, HS09478, HS11657).

•Many young women who underwent hysterectomy during their childbearing years had lingering depression.
Researchers interviewed 1,140 women before they underwent hysterectomies in 1992 and 1993 and followed up with them for 2 years after surgery. Although 86 percent of the women said they were fine with their childbearing days being over, 14 percent were either ambiguous or said they would have liked to have children. The women who wanted children tended to put off their surgeries for 4.5 years, despite severe pelvic pain. Women who wanted children were twice as likely as those who did not to have sought mental health counseling prior to surgery and to still be depressed 2 years after surgery. Leppert, Legro, and Kjerulff, J Psychosom Res 63(3):269-274, 2007 (AHRQ grant HS06865).

•Removal of the ovaries in premenopausal women does not negatively affect quality of life.
This study found that women who underwent bilateral salpingo-oophorectomy had an initial decline in quality of life in the first 6 months after surgery, but they had no apparent differences in quality of life 2 years later, compared with women who had hysterectomies but kept their ovaries. At 6 months after surgery, there were no differences between the two groups in sexual functioning, hot flushes, urinary incontinence, or pelvic pain. And at the 2-year followup, scores were similar for both groups on all measures of health-related quality of life and sexual functioning, irrespective of estrogen use. Teplin, Vittinghoff, Lin, et al., Obstet Gynecol 109(2):347-354, 2007 (AHRQ grant HS09478).

Other
•Breastfeeding benefits both mothers and infants.
According to a 2007 AHRQ evidence report, breastfeeding is beneficial for both mother and infant. In this question-and-answer article, the authors discuss the report and the role of clinicians in promoting breastfeeding, the particular advantages of breastfeeding for premature infants, lifestyle factors that affect nursing mothers, and ways to overcome societal barriers to breastfeeding. J. Godfrey, D. Meyers, J Womens Health, September 2009; 18(9):1307-1310 (AHRQ Publication No. 10-R034).* See also D. Meyers, Breastfeed Med, 2009; 4(Suppl 1):S-13-S-15 (AHRQ Publication No. 10-R024)* (Intramural) and Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153 (AHRQ Publication No. 07-E007)* (AHRQ contract 290-02-0022).

•Treatment without exams and lab texts appears effective for some women with vaginal symptoms.
Offering women treatment for uncomfortable symptoms of bacterial vaginosis, trichomoniasis, or vaginal candidiasis based on their symptoms—while skipping speculum examination and lab tests—may be appropriate in some cases, according to this study of 44 women. The 23 women who received treatment for their vaginal symptoms without examination had outcomes and satisfaction ratings similar to those of the 21 women who underwent a traditional exam and lab tests. Anderson, Cohrssen, Klink, and Brahver, J Am Board Fam Med 22(6):617-624, 2009 (AHRQ grant HS16050).

•Researchers examine associations among various pathogens and bacterial vaginosis.
Bacterial vaginosis (BV) is a common lower genital tract infection that may lead to pelvic inflammatory disease (PID) and other conditions. Researchers analyzed stored specimens from 50 randomly selected women with confirmed endometritis to determine the associations among various pathogens and BV. They found several types of bacteria known to be associated with BV among women with confirmed PID. Haggerty, Totten, Ferris, et al., Sex Transm Infect 85:242-248, 2009 (AHRQ grant HS08358)

•Despite CDC-recommended treatment, the pathogen that causes PID may persist.
Pelvic inflammatory disease (PID) is associated with the pathogen Mycoplasma genitalium, and it appears to be very resistant to commonly used treatments. The PID Evaluation and Clinical Health Study (PEACH) examined stored cervical and endometrial specimens from 682 women treated with ceftoxin and doxycycline and found that the pathogen persisted among nearly half of the women after 30 days of treatment. The researchers conclude that M. genitalium is associated with endometritis and short-term PID treatment failure as evidenced by persistent endometritis and continued pelvic pain. Haggerty, Totten, Astete, et al., Sex Transmit Dis 84(5):338-342, 2008. See also Short, Totten, Ness, et al., Clin Infect Dis 48(1):41-47, 2009 (AHRQ grant HS08358).

•Symptoms of menopause may persist for as long as 4 years.
Researchers reviewed 410 studies to determine the duration of vasomotor symptoms (hot flashes and night sweats) in menopausal women. They found that these symptoms tend to peak 1 year after a woman's last menstrual period, but 50 percent of women continue to experience vasomotor symptoms for up to 4 years. The researchers note that clinical guidelines may need to be modified so that women's quality of life is balanced against the risks of hormone therapy. Politi, Schleinitz, and Col, J Gen Intern Med 23(9):1507-1513, 2008 (AHRQ grant HS13329).

•Abnormally heavy uterine bleeding has both quality of life and financial effects.
This study of 237 women who had surgery for dysfunctional uterine bleeding (DUB) between 1997 and 2001 found that women with the condition experience both decreased quality of life (cramps, pain, fatigue, and limited physical activity) and financial burdens, including out-of-pocket costs for drugs and sanitary products (average of $333/year) and lost productivity due to missed work and/or the inability to function at home (average of $2,625/year). Frick, Clark, Steinwachs, et al., Womens Health Issues 19(1):70-78, 2009 (AHRQ grant HS09506).

•Noncancerous pelvic problems are linked to poor quality of life for premenopausal women.
Researchers examined the treatment and outcomes of 1,493 women who sought care for noncancerous pelvic problems and had not undergone a hysterectomy. Such problems typically include heavy bleeding and pelvic pain and pressure. The women were asked about their symptoms, attitudes, quality of life, sexual functioning, and treatment satisfaction. The majority of women reported no or only partial symptom resolution from treatment, and nearly half said their pelvic problems interfered with their ability to have and enjoy sex. The women's physical and mental health scores were substantially lower than population norms for women aged 40 to 49 years, and overall, less than half of the women were satisfied with their treatment. Kuppermann, Learman, Schembri, et al., Obstet Gynecol 110(3):633-642, 2007 (AHRQ grants HS09478, HS11657, HS07373).

•Researchers find that evidence is lacking on the effectiveness of most interventions for symptomatic fibroids.
This review was intended to update a previous AHRQ report published in 2001 on the management of symptomatic fibroids. The first evidence review found that the overall quality of the literature on the management of fibroids was poor, and that there was almost no evidence to support the effectiveness of commonly recommended treatments. The authors of this review found essentially the same thing. They found the lack of well-conducted trials in U.S. populations that directly compared treatment options to be particularly notable. Management of Uterine Fibroids: An Update of the Evidence, Evidence Report/Technology Assessment No. 154 (AHRQ Publication No. 07-E011)* (AHRQ contract 290-02-0016).

•Both behavioral and drug therapies can help women with urinary incontinence.
Researchers analyzed existing evidence on nonsurgical treatment for urinary incontinence (UI) in women and found that pelvic floor muscle training (Kegel exercises) and bladder training resolved women's UI compared with usual care. Certain medications also resolved UI compared with placebo, while the effects of electrostimulation, medical devices, injectable bulking agents, and vaginal estrogen therapy were inconsistent. UI affects nearly one in five women age 44 or younger and as many as one in three elderly women. Shamliyan, Kane, Wyman, and Wilt, Ann Intern Med 148(6):459-473, 2008 (AHRQ contract 290-02-0009).

•Uterine artery embolization found to be a low-risk procedure.
Researchers examined the outcomes of more than 3,000 women who underwent uterine artery embolization for fibroids. The women were treated at 72 sites across the United States. Overall, less than 1 percent of women suffered from major inpatient complications; 4.8 percent suffered from major events (mostly inadequate pain relief ) within the first 30 days following hospital discharge. There were no deaths related to the procedure, but 31 women required additional surgical intervention with 30 days of the procedure. Worthington-Kirsch, Spies, Myers, et al., Obstet Gynecol 106(1):52-59, 2005; see also pp. 44-51 by the same authors in the same journal (AHRQ grant HS09760).

•Task Force recommends screening at-risk women for certain sexually transmitted infections.
The U.S. Preventive Services Task Force recommends that women at increased risk of infection be screened for Chlamydia, gonorrhea, HIV, and syphilis. The Task Force also recommends that pregnant women be screened for hepatitis B, HIV, and syphilis. Those pregnant women at high risk for STIs should be additionally screened for Chlamydia and gonorrhea, and sexually active women younger than age 25 should be considered at increased risk for Chlamydia and gonorrhea. The Task Force identifies women as being at high risk for STIs if they have multiple current partners, have unprotected sex, or have sex in exchange for money or drugs. Meyers, Wolff, Gregory, et al., Am Fam Physician 77(6):819-824, 2008 (AHRQ Publication No. 08-R056)* (Intramural).

•Two simple steps can improve rates of screening for Chlamydia in young women.
Use of exam room screening reminders and clinic-level intervention strategies (physician opinion leaders and physician feedback) can improve Chlamydia testing rates in young women making preventive care visits, according to this study. Researchers randomized 23 primary care clinics in one managed care plan to either standard care or intervention care. They found that a combination of clinic-level change and patient activation may improve testing, particularly among asymptomatic women. Scholes, Grothaus, McClure, et al., Prev Med 43:343-350, 2006 (AHRQ grant HS10514).

•Certain factors predict chronic pelvic pain after PID.
One-third of women with pelvic inflammatory disease (PID) subsequently suffer from chronic pelvic pain. A study of 780 urban women with PID found that women who smoked, those who had previous episodes of PID, women who were married, and those who had low mental health scores were more likely than other women to experience chronic pelvic pain. The researchers also note that recurrent PID can cause adhesions to form and may represent persistent, chronic infection or inflammation, all of which can result in chronic pelvic pain. Haggerty, Peipert, Weitzen, et al., Sex Trans Dis 32(5):293-299, 2005 (AHRQ grant HS08358).

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Women's Health Highlights: Recent Findings (continued)