The indication for hysterectomy as a risk factor for subsequent pelvic organ prolapse repair

Rune Lykke, Jan Blaakær, Bent Ottesen, Helga Gimbel
International urogynecology journal · 2015 · doi:10.1007/s00192-015-2757-y · PMID:26049977
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This study found that indications for hysterectomy other than fibroids/polyps, such as abnormal uterine bleeding and pain, significantly increased the risk of subsequent pelvic organ prolapse surgery.

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This Danish cohort study investigated whether the indication for hysterectomy for benign conditions predicts subsequent pelvic organ prolapse (POP) surgery, using data from 154,882 women in the Danish National Patient Register followed from hysterectomy (1977–2009) to POP surgery, death/emigration, or study end. Using Cox proportional hazards models with fibroids/polyps as the reference (adjusted for calendar period, age at hysterectomy, and hysterectomy route), the authors found a significantly higher risk of first POP surgery for indications including abnormal uterine bleeding, pain, endometriosis, and “other indications,” compared with fibroids/polyps, and also reported that the cumulative incidence of POP surgery was highest for those whose POP was the hysterectomy indication. POP surgery was predominantly in the posterior compartment for nearly all indications except benign ovarian tumors. The main caveats are reliance on registry-coded indications and surgeries, and limited ability to account for unmeasured factors affecting later POP surgery; it was a large population-based analysis but observational in design. Relevance to endometriosis: endometriosis is one of the hysterectomy indications analyzed as being associated with a higher subsequent risk of POP surgery, though the paper’s primary focus is the effect of hysterectomy indication on later POP repair rather than endometriosis-specific mechanisms.

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Abstract

INTRODUCTION AND HYPOTHESIS: The aim of this study was to investigate whether the indication for hysterectomy was itself a risk factor for subsequent pelvic organ prolapse (POP) in Danish women who underwent hysterectomy from 1977 to 2009. METHODS: Data from 154,882 women who underwent hysterectomy for benign conditions during the period 1977 - 2009 were extracted from the Danish National Patient Register. Patients were followed up from hysterectomy to POP surgery, death/emigration, or end of study period. Hazard ratios (HR) for the first POP surgery in each woman were calculated using the Cox proportional hazards model. Survival analysis for each indication for hysterectomy was performed using the Kaplan-Meier product limit method. RESULTS: Fibroids/polyps as the indication was used as the reference when calculating HRs. After adjustment for calendar period, patient age, and hysterectomy route, the HR for POP was 6.57 (95% confidence interval 5.91 - 7.30). The HR for abnormal uterine bleeding (AUB), pain, endometriosis, and "other indications" was significantly higher than the reference. POP surgery was performed predominantly in the posterior compartment for all indications except benign ovarian tumors. CONCLUSIONS: POP as the indication for hysterectomy was associated with the highest cumulative incidence of subsequent POP surgery 32 years after hysterectomy. But the indications AUB, pain, endometriosis, and "other indications" were associated with a higher risk of subsequent POP surgery after hysterectomy than the indication fibroids/polyps. The predominant compartment for POP surgery was the posterior compartment for almost all indications. The indication for hysterectomy and the compartment in which POP surgery was performed subsequent to hysterectomy were associated.
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Abstract

Introduction and hypothesis The aim of this study was to investigate whether the indication for hysterectomy was itself a risk factor for subsequent pelvic organ prolapse (POP) in Danish women who underwent hysterectomy from 1977 to 2009.

Methods

Data from 154,882 women who underwent hysterectomy for benign conditions during the period 1977 – 2009 were extracted from the Danish National Patient Register. Patients were followed up from hysterectomy to POP surgery, death/emigration, or end of study period. Hazard ratios (HR) for the first POP surgery in each woman were calculated using the Cox proportional hazards model. Survival analysis for each indication for hysterectomy was performed using the Kaplan-Meier product limit method.

Results

Fibroids/polyps as the indication was used as the reference when calculating HRs. After adjustment for calendar period, patient age, and hysterectomy route, the HR for POP was 6.57 (95 % confidence interval 5.91 – 7.30). The HR for abnormal uterine bleeding (AUB), pain, endometriosis, and “other indications” was significantly higher than the reference. POP surgery was performed predominantly in the posterior compartment for all indications except benign ovarian tumors.

Conclusions

POP as the indication for hysterectomy was associated with the highest cumulative incidence of subsequent POP surgery 32 years after hysterectomy. But the indications AUB, pain, endometriosis, and “other indications” were associated with a higher risk of subsequent POP surgery after hysterectomy than the indication fibroids/polyps. The predominant compartment for POP surgery was the posterior compartment for almost all indications. The indication for hysterectomy and the compartment in which POP surgery was performed subsequent to hysterectomy were associated. Similar content being viewed by others

References

Lykke R, Blaakaer J, Ottesen B, Gimbel H (2013) Hysterectomy in Denmark 1977-2011: changes in rate, indications, and hospitalization. Eur J Obstet Gynecol Reprod Biol 171:333–338. doi:10.1016/j.ejogrb.2013.09.011 Lykke R, Blaakaer J, Ottesen B, Gimbel H (2015) Pelvic organ prolapse (POP) surgery among Danish women hysterectomized for benign conditions: age at hysterectomy, age at subsequent POP operation, and risk of POP after hysterectomy. Int Urogynecol J 26:527–532. doi:10.1007/s00192-014-2490-y Altman D, Falconer C, Cnattingius S, Granath F (2008) Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 198:572.e1–572.e6 Chow D, Rodriguez LV (2013) Epidemiology and prevalence of pelvic organ prolapse. Curr Opin Urol 23:293–298. doi:10.1097/MOU.0b013e3283619ed0 Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104:579–585 Blandon RE, Bharucha AE, Melton LJ 3rd, Schleck CD, Babalola EO, Zinsmeister AR et al (2007) Incidence of pelvic floor repair after hysterectomy: a population-based cohort study. Am J Obstet Gynecol 197:664.e1–664.e7 Dallenbach P, Kaelin-Gambirasio I, Dubuisson JB, Boulvain M (2007) Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol 110:625–632 Dallenbach P, Kaelin-Gambirasio I, Jacob S, Dubuisson JB, Boulvain M (2008) Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 19:1623–1629. doi:10.1007/s00192-008-0718-4 Lukanovic A, Drazic K (2010) Risk factors for vaginal prolapse after hysterectomy. Int J Gynaecol Obstet 110:27–30. doi:10.1016/j.ijgo.2010.01.025 Forsgren C, Lundholm C, Johansson AL, Cnattingius S, Zetterstrom J, Altman D (2012) Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence surgery. Int Urogynecol J 23:43–48. doi:10.1007/s00192-011-1523-z Lidegaard O, Hammerum MS (2002) The National Patient Registry as a tool for continuous production and quality control. Ugeskr Laeger 164:4420–4423 Ottesen M (2009) Validity of the registration and reporting of vaginal prolapse surgery. Ugeskr Laeger 171:404–408 Baird DD, Dunson DB (2003) Why is parity protective for uterine fibroids? Epidemiology 14:247–250. doi:10.1097/01.EDE.0000054360.61254.27 Cruikshank SH, Kovac SR (1999) Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 180:859–865 Financial support None. Conflicts of interest None. Author information Authors and Affiliations Corresponding author Rights and permissions About this article Cite this article Lykke, R., Blaakær, J., Ottesen, B. et al. The indication for hysterectomy as a risk factor for subsequent pelvic organ prolapse repair. Int Urogynecol J 26, 1661–1665 (2015). https://doi.org/10.1007/s00192-015-2757-y Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00192-015-2757-y

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endometriosis

MeSH descriptors

Hysterectomy Pelvic Organ Prolapse Cohort Studies Denmark Denmark Female Humans Hysterectomy Pelvic Organ Prolapse Risk Factors

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