The relation of heavy or prolonged bleeding during the menopause transition to risk of hysterectomy

Sioḃán D. Harlow, Michelle M. Hood, Alain Mukwege, John F. Randolph, Ellen B. Gold, Michael R. Elliott, Amina White, Gail A. Greendale
In: Women's Health · 2025 · vol. 21 , pp. 17455057251351418 · doi:10.1177/17455057251351418 · PMID:40637738 · W4412160505
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This study examined whether heavy or prolonged bleeding during the menopause transition was associated with risk of hysterectomy, using data on bleeding patterns and related factors in a study population analyzed with hazard ratios in unadjusted and multivariable models. Heavy/prolonged bleeding measures included prolonged bleeding (PMB: bleeding >8 days at least three times within 6 months) and heavy bleeding (HMB: ≥3 days at least three times within 6 months), and the models adjusted for pelvic pain, hormone therapy use, and “life interference” variables, with key limitations related to statistical adjustment and attenuation of associations after accounting for competing factors. The results showed PMB was associated with hysterectomy risk in unadjusted and partially adjusted models (e.g., HR 2.75 unadjusted), but this association was weakened and no longer significant after additional adjustment with life interference (HR 1.72; 95% CI 0.87–3.43). HMB showed no significant association in adjusted models (e.g., HR 0.88; 95% CI 0.27–2.86), while pelvic pain and hormone therapy use remained strongly associated. Relevance to endometriosis: adenomyosis/endometriosis are not discussed in the provided text, so this paper is included in the corpus via keyword match rather than explicit endometriosis/adenomyosis content.

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Abstract

BACKGROUND: During the menopause transition, one in three women experiences abnormal uterine bleeding. Few studies have evaluated the probability of hysterectomy associated with abnormal uterine bleeding during the menopause transition. OBJECTIVES: To estimate the risk of hysterectomy associated with abnormal uterine bleeding, specifically prolonged or heavy menstrual bleeding, during the menopause transition. DESIGN: Prospective cohort studyMethods:We used data collected in the Study of Women's Health Across the Nation, a community-based, longitudinal cohort that followed women from pre- to post-menopause. It includes 1200 White (45.4%), Black (15.4%), Japanese (20.8%), and Chinese (18.4%) women, from three study sites that participated in a sub-study and provided at least 1 year of prospectively recorded menstrual calendars. Calendars ascertained bleeding days, menstrual interference with life in four domains (work, daily life, sexual life, and relationships), menopausal hormone therapy, and smoking. At baseline and 12 annual follow-up visits, information on surgeries, body mass index, pelvic pain, and socio-demographic characteristics was obtained. Multivariable Cox proportional hazard models were used to assess the relationships of hysterectomy with prolonged menstrual bleeding, heavy menstrual bleeding, and covariates. RESULTS: Women who reported prolonged menstrual bleeding had an elevated hazard of hysterectomy (hazard ratio = 2.35, 95% confidence interval = 1.20-4.61), adjusting for pelvic pain, hormone use, and race/ethnicity; hazard ratios were attenuated after adjusting for life interference. The association of heavy menstrual bleeding with hysterectomy was not statistically significant (hazard ratio = 1.34, 95% confidence interval = 0.42-4.30). The adjusted hazard ratio for hysterectomy increased 1.5-fold for each domain in which bleeding interfered with a woman's life. Pelvic pain, hormone therapy, and Black race were also significant predictors of hysterectomy risk. CONCLUSION: Prolonged menstrual bleeding during the menopause transition, particularly when accompanied by interference in one or more domains of a woman's life, increased the risk of hysterectomy. Counseling women about non-surgical therapeutic options, and estimating the proximity of menopause, may mitigate against this increased risk.
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Abstract

Background:

Objectives

Design:

Methods

Results:

Conclusion

Plain language summary

Introduction

Methods Abnormal uterine bleeding Menopause Covariates Statistical analysis

Results

| Variables | N (%) | Hysterectomy | p valuea | | |---|---|---|---|---| | No (N = 1125), N (%) | Yes (N = 75), N (%) | ||| | Bleeding >8 days at least three times within 6 months (PMB) | 358 (29.83) | 325 (28.89) | 33 (44.00) | 0.006 | | Heavy bleeding ⩾3 days at least three times within 6 months (HMB) | 208 (17.33) | 186 (16.53) | 22 (29.33) | 0.005 | | Pelvic pain | 359 (29.92) | 319 (28.36) | 40 (53.33) | <0.001 | | Hormone therapy use | 380 (31.67) | 335 (29.78) | 45 (60.00) | <0.001 | | Any type of bleeding interference | 786 (65.50) | 730 (64.89) | 56 (74.67) | 0.085 | | Total types of interference reported due to bleeding | <0.001 | ||| | 0 | 414 (34.50) | 395 (35.11) | 19 (25.33) | | | 1 | 254 (21.17) | 239 (21.24) | 15 (20.00) | | | 2 | 179 (14.92) | 172 (15.29) | 7 (9.33) | | | 3 | 151 (12.58) | 144 (12.80) | 7 (9.33) | | | 4 | 202 (16.83) | 175 (15.56) | 27 (36.00) | | | Race/ethnicity | 0.062 | ||| | Black | 185 (15.42) | 166 (14.76) | 19 (25.33) | | | White | 545 (45.42) | 511 (45.42) | 34 (45.33) | | | Chinese | 221 (18.42) | 212 (18.84) | 9 (12.00) | | | Japanese | 249 (20.75) | 236 (20.98) | 13 (17.33) | | | Education | 0.939 | ||| | Less than high school | 55 (4.58) | 51 (4.53) | 4 (5.33) | | | High school | 186 (15.50) | 174 (15.47) | 12 (16.00) | | | Greater than high school | 959 (79.92) | 900 (80.00) | 59 (78.67) | | | How hard to pay for basics | 0.513 | ||| | Very | 77 (6.42) | 73 (6.49) | 4 (5.33) | | | Somewhat | 302 (25.17) | 279 (24.80) | 23 (30.67) | | | Not at all | 821 (68.42) | 773 (68.71) | 48 (64.00) | | | Current smoker | 292 (24.33) | 272 (24.18) | 20 (26.67) | 0.728 | | Obeseb | 390 (32.50) | 363 (32.27) | 27 (36.00) | 0.589 | | Variables | Unadjusted models | Adjusteda model without life interference | Adjusted model with life interference | ||| |---|---|---|---|---|---|---| | HR (95% CI) | p value | HR (95% CI) | p value | HR (95% CI) | p value | | | PMB models | |||||| | PMB | 2.75 (1.41–5.37) | 0.003 | 2.35 (1.20–4.61) | 0.013 | 1.72 (0.87–3.43) | 0.121 | | Pelvic pain | 2.63 (1.55–4.48) | <0.001 | 1.98 (1.15–3.42) | 0.014 | 1.80 (1.04–3.10) | 0.034 | | Hormone use | 3.16 (1.92–5.19) | <0.001 | 2.97 (1.79–4.92) | <0.001 | 2.49 (1.50–4.16) | <0.001 | | Black womenb | 2.17 (1.29–3.66) | 0.004 | 2.28 (1.34–3.88) | 0.003 | 1.82 (1.06–3.12) | 0.030 | | Number of types of interference | 1.73 (1.48–2.02) | <0.001 | - | - | 1.52 (1.29–1.79) | <0.001 | | Educationc | |||||| | Less than high school | 1.45 (0.53–4.01) | 0.470 | – | – | – | – | | High school | 1.13 (0.61–2.10) | 0.704 | – | – | – | – | | How hard to pay for very basicsd | |||||| | Very | 0.93 (0.33–2.58) | 0.886 | – | – | – | – | | Somewhat | 1.36 (0.83–2.24) | 0.222 | – | – | – | – | | Current smokere | 1.26 (0.74–2.14) | 0.402 | – | – | – | – | | Obesef | 1.18 (0.72–1.94) | 0.500 | – | – | – | – | | HMB models | |||||| | HMB | 1.72 (0.54–5.51) | 0.358 | 1.34 (0.42–4.30) | 0.623 | 0.88 (0.27–2.86) | 0.834 | | Pelvic pain | – | 2.03 (1.18–3.50) | 0.011 | 1.81 (1.05–3.12) | 0.032 | | | Hormone use | – | 3.09 (1.87–5.10) | <0.001 | 2.57 (1.54–4.27) | <0.001 | | | Black women | – | 2.19 (1.29–3.73) | 0.004 | 1.76 (1.03–3.02) | 0.039 | | | Number of types of interference | – | – | – | 1.56 (1.32–1.83) | <0.001 |

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