Effect of Patient Age on Decisional Regret After Laparoscopic Hysterectomy

This is a matched retrospective cohort study intended to evaluate regret after hysterectomy between patients aged 30 years or less compared to patients 31–49 years of age. Eligible patients were identified from a database of patients who underwent hysterectomy by minimally invasive gynecologic surgeons as a single academic institution between 2009–2016 and were 18 years of age older. Consistent with the World Health Organization’s definition of reproductive age, participants who were post-menopausal or older than 49 years were excluded. Patients were also excluded if they were diagnosed with a malignancy, had surgery for gender affirmation, lived outside of the United States, or had incomplete medical records. The study was approved by the University of Pittsburgh’s IRB (STUDY19010290). Eligible participants were first contacted by mail. Those who did not respond to the request were subsequently contacted by telephone. Participants who were unable to be contacted by telephone after three attempts were then emailed. Contacted participants were informed of the study’s processes and goals. Those who consented to participate were asked to complete a validated decision regret scale (DRS) as well as a supplementary questionnaire investigating patients’ current state of health, relevant gynecologic care, and fertility treatments. The DRS is a validated tool which measures regret after a health care decision. 13 It has been used in the gynecologic literature to evaluate both surgical regret for hysterectomies and endometriosis surgery as well as fertility regret in gender-affirming and oncologic care. 14 – 18 The DRS contains 5 questions graded on a Likert scale (1–5) and two questions that are reverse coded. Regret scores were calculated for each participant using the predefined scoring algorithm with higher scores indicating more regret ( https://decisionaid.ohri.ca/docs/develop/Tools/Regret_Scale.pdf ). 19 To eliminate interviewer bias, questionnaires were either completed by hand and mailed back to research staff or online through a personalized link generated by a secure database (REDCap). A detailed chart review was carried out to obtain relevant demographic and clinical data on all participating patients. Patient race was included to control for any potential racial influences on feelings of regret as well as determine the generalizability of the results. Data collection and storage was performed using secure web-based (REDCap) software. Recruitment continued until the specified sample sizes were met. The primary outcome was the difference in rates of both surgical and loss of fertility regret between two age groups. The age of participants was dichotomized between ≤30 and 31–49 years old at the time of preoperative visit, as this reflects the age when decision for hysterectomy is made. The age of 30 was used as a cut-off to align with the prior regret data reported for sterilization. 7 Regret was defined as a score of ≥30 on the DRS. While the DRS does not have a defined cut-off, a previous systematic review of its use suggested a cut-off of 30 which has been adopted by other studies investigating regret in gynecologic surgery. 13 , 15 Power analysis was first performed to estimate the necessary sample size. The only previous study measuring regret after hysterectomy for all patients reported a 21–43% regret rate. 11 Given no prior studies compared regret after hysterectomy by age, anticipated difference in regret rate by age was extrapolated from the CREST data (20.3% in patients aged 30 or younger vs. 5.9% is patient older than 30). 7 Consequently, if 21% of patients older than 30 experienced regret after hysterectomy, than an expected 63% of patients age 30 or younger would report regret, for an effect size of 0.42. The study was planned to have two age groups matched for year the surgery was performed (≤30, 31–49). Using a cut-off of aged 30 or younger, 33% of the patients fall into the exposed group while the remainder fall into the unexposed group. Alpha was set to 0.05 and beta was set to 0.2. The calculated sample size necessary was 75 in the younger cohort and 149 in the older cohort. Univariate analysis was performed using Chi-square or Fisher’s exact test for categorical variables, and Wilcoxon Rank Sum test for continuous variables between age and regret groups. Multivariable analysis was performed using logistic regression to evaluate the association between demographic or clinical characteristics and presence of regret. A p-value <.05 was considered statistically significant. All analyses were performed using SPSS version 28.

287 participants were successfully contacted and asked to participate in the study of which 241 completed the survey (84.0% response rate) and were included ( Figure 1 ). There was no difference in age between participants based on ability to contact, willingness to participate, or completion of survey (p=0.327). Of included participants, 77 (32.0%) were ≤30 and 164 (68.0%) were >30 years old at the time of preoperative visit, satisfying the pre-defined sample sizes based on power analysis. All patients underwent a planned laparoscopic hysterectomy, with only one conversion to an abdominal procedure (0.004%). Age of participants was dichotomized between ≤30 and 31–49 years old at the time of their preoperative visit. Of participants ≤30 years old, 21 (27.3%) were aged between 20–25 years old and the remaining 56 (72.7%) were aged between 26–30 years old. Of participants 31–49 years old, 38 (23.1%) were aged 31–35 years old, 51 (31.1%) were aged 36–40 years old, 39 (23.8%) were aged 41–45 years old, and 36 (22.0%) were aged 46–49 years old. Table 1 compares the demographic and clinical data between age groups. The groups did not differ by race (p=0.633), parity (p=0.267), prior sterilization (41.6% vs 36.6%, p=0.459), intraoperative (13% vs. 0.6%, p=0.538) or postoperative (11.7% vs. 9.8%, p=0.646) complications, or rates of depression and anxiety (37.7% vs. 34.8%, p=0.661). Participants in the younger age group were more likely to undergo hysterectomy for pelvic pain (77.9% vs. 45.1%, p<0.001) while participants in the older group were more likely to undergo hysterectomy for uterine fibroids (1.3% vs. 27.4%, p<0.001). There was no difference between groups for all other surgical indications. Younger participants more commonly attempted medical therapy prior to undergoing hysterectomy (94.8% vs. 80.5%, p=0.004), but both groups had similar rates of previous surgical treatment for their symptoms (37.7% vs. 37.8%, p=0.983). Participants ≤30 years old had higher rates of additional pelvic pain (42.9% vs. 22.6%, p<0.001) and additional gynecologic surgery (19.5% vs. 3.7%, p30 years old. At the time of survey completion, the average time since surgery was 7.2 (± 2.2; range 3.7–12.1) years across all participants and did not differ between groups. Table 2 compares the rates of surgical regret and loss of fertility regret between age groups. Participants aged 30 years or younger had significantly higher rates of both surgical regret (32.5% vs. 9.1%, p<0.001; OR 4.8; 95%CI 2.3–9.8) and loss of fertility regret 39.0% vs. 13.4%, p<0.001; OR 4.1, 95% CI 2.2–7.8) than patients older than 30. When participants who had already undergone prior sterilization were excluded from the loss of fertility regret analysis, the loss of fertility regret rates were 37.8% for those <30 years of age compared to 15.4% for those 31–49 years of age (OR 3.3, 95% CI 1.5–7.5). When comparing only participants who had undergone prior sterilization, the loss of fertility regret rates were 40.6% for those <30 years of age compared to 10.0% for those 31–49 years of age (OR 6.2, 95% CI 2.0–18.5) Responses to the DRS addressing both surgical regret and loss of fertility regret were compared between groups as displayed in Figure 2a and 2b , respectively. When considering the surgery itself, 83.1% of younger participants either strongly agreed or agreed that hysterectomy was the right choice for them compared to 97.0% of the older participants (p<0.001). Moreover, 92.0% of the older participants either strongly agreed or agreed that they would choose to undergo hysterectomy again, while 77.6% of the younger participants would make the same choice (p=0.002). When asked about losing their fertility, both groups had slightly higher rates of regret, with similar differences between age groups. 75.3% of participants aged 30 years or younger either strongly agreed or agreed that losing fertility was the right choice compared to 89.6% of older participants (p=0.004). Univariate analysis of all participants was carried out to assess whether any demographic and clinical characteristics were associated with regret ( Table 3 ). Higher rates of surgical regret and loss of fertility regret were seen in participants with self-reported pelvic pain (p=0.003, p=0.011), a pre-operative diagnosis of endometriosis (p=0.037, p=0.046), and post-operative complications (p=0.043, p<0.001). Rates of surgical regret and loss of fertility regret did not vary based on parity (p=0.386, p=0.190), previous sterilization (p=0.795, p=0.784), concomitant bilateral oophorectomy (p=0.407, p=0.264), or previous medical (p=0.619, p=0.919) or surgical treatment (p=0.268, p=0.838). While time since hysterectomy was not associated with the rate of surgical regret (p=0.155), participants further from their hysterectomy had a lower rate of regret related to loss of fertility (p=0.004). Multivariate analysis was then performed to control for several potential confounders including parity, prior sterilization, self-reported pelvic pain, operative complications, feeling of having completed childbearing at time of hysterectomy, and need for additional surgeries for pelvic pain after hysterectomy ( Table. 4 ). When controlling for these potential confounders, patient age remained significantly associated with both surgical regret (adjusted OR 2.9 [95% CI 1.3–6.5]) and loss of fertility regret (adjusted OR 2.8 [95% CI 1.3–6.0]).

In our study, participants aged 30 years or less were more than 4 times as likely to regret both undergoing surgery and loss of fertility than patients older than 30 years. 83.1% of younger patients reported that undergoing surgery was the right choice for them compared to 97.0% of older patients. When asked about the loss of fertility after hysterectomy, both younger and older patients reported slightly lower rates of satisfaction compared to undergoing surgery, but the stark difference between age groups persisted. These results resemble the stark age-based difference in regret rates after tubal sterilization (20.3% vs. 5.9%) from the U.S. Collaborative Review of Sterilization Working Group. 7 Our results are also consistent with studies that found high fertility-related regret rates after hysterectomy ranging from 30.0%% at 1 year to 25.2% at 3 years. 11 Conversely, our results differ from those of Bougie, et al. which showed a low risk (2.8%) of regret in patients under 35 who underwent hysterectomy, but this study was limited by a small sample size and no comparative cohort. Furthermore, that same study found that 23.9% of patients ultimately desired more children. 12 Surprisingly, this study suggests that the rates of regret were not affected by prior sterilization or parity, which highlights that regret is a risk for all patients regardless of family size or prior sterilization. Furthermore, while regret was more strongly tied to patients with pelvic pain or endometriosis, significant differences in regret rates between age groups persisted when the analysis controlled for these variables. Consistent with prior studies, patients who experienced complications were more likely to regret their decision, but complication rates remained low in our study and did not differ between groups. 5 Overall, these data suggest that young age is an independent factor that portends regret after hysterectomy. Our study has several strengths that support the quality of its results, including a large sample size and high response rate. We used the DRS which is a validated tool to evaluate decisional regret which decreases response bias. None of the researchers provided clinical care to the participants, decreasing the risk of bias from a prior doctor-patient relationship. Additionally, all participants underwent minimally invasive hysterectomy by one of four physicians at a single institution with a very low conversion and complication rates. This minimized potential confounders related to route of surgery or differences in peri-operative care and counseling. On average, patients were surveyed 7 years after their surgery, capturing substantial feelings of regret that have persisted for years after surgery. Limitations include those stemming from our study design and population. Survey data is susceptible to non-response bias; however, this is decreased by the high response rate of contacted patients in our study. Additionally, the dichotomization of patients by age further negates this bias, as patients in both groups may be influenced to either participate or not based on similar factors. Recall bias can exist, but most survey questions addressed current feelings of regret, while historical data was gathered from medical records. Retrospective chart review is subject to errors in the patient record or data gathering process, but reviewer bias was reduced as the investigator performing the chart review was blinded to the regret data. It is important to note that our study may not reflect surgical regret after hysterectomy by abdominal or vaginal routes. It should also be noted that while race did not differ between age cohorts, most patients in this study were Caucasian (88.8%); and of non-white patients, the majority were Black (10.4%). This limits the generalizability of results and does not account for possible racial, ethnic, or cultural difference that may influence both the decision to undergo hysterectomy and possible regret after it. There may be other reasons a patient may regret their surgery that were not investigated in our study. Overall, our study suggests that younger patients have a higher risk of regret after hysterectomy – and our data did not identify any potential protective factors. However, it must be emphasized that this data should not preclude the option of hysterectomy when deemed appropriate as a strong majority of patients in both age groups were satisfied with their decision. Instead, focus should be placed on shared-decision making and respect for patient autonomy when counseling individuals about procedures that result in permanent sterilization, as ACOG advised in 2024. 20 Accordingly, our data should be used to counsel patients, especially those aged 30 and younger, about the risk of regret during informed consent for hysterectomy.

Hysterectomy is one of the most commonly performed surgeries, and the majority are performed electively for benign indications to alleviate symptoms and improve quality of life. 1 Prior studies report high rates of symptom relief and patient satisfaction after hysterectomy; however, these studies include mostly older patients undergoing abdominal hysterectomy with concurrent bilateral salpingo-oophorectomy. 2 – 5 Advances in minimally invasive techniques have decreased risks and recovery times after the procedure which can affect satisfaction. 6 Despite this high satisfaction, surgeons continue to use young age as a barrier to access hysterectomy due to concerns about regret. Compared to the sterilization literature, which consistently demonstrates younger age (≤30 years) as a direct risk factor for regret after sterilization, the incidence of regret in young patients after hysterectomy is under-investigated. 7 – 10 Farquhar et al. reported a 21–43% incidence of fertility related regret after hysterectomy however this study included very few patients aged ≤30 and did not evaluate if age was a predictive factor. 11 Bougie et al. reported a 2.8% rate of fertility related regret after hysterectomy in patients under age 35, however the study is limited by a small sample size, short term follow-up, and lack of a comparative group of older patients. 12 Given this paucity of data it is difficult to counsel young patients using shared decision making while respecting an individual’s reproductive autotomy. The aim of our study is to compare long term decision regret between younger (≤30) and older (31–49) patients who underwent minimally invasive hysterectomy for benign disease.