Toward ‘net zero’ hysterectomy for Australia; New Zealand is already heading there…

Globally, hysterectomy remains a common gynaecological procedure; however, marked geographical variations exist. In Australia, hysterectomy rates have remained stable over the last two decades with 32 000 procedures annually, a rate of 255/100 000 women.1, 2 Over the same timeframe, the rates of hysterectomy worldwide have consistently declined.3 In New Zealand, the hysterectomy rate is 48% lower at 134/100 00 and in Denmark with the lowest rate in the Organisation for Economic Co-operation and Development (OECD) community – 93% lower at 19/100 000 women. We must ask why Australia is not following these reductions in hysterectomy rate? The reasons for this remain unclear although competing interests such as reimbursement in the private sector may play a role. Patient request in an era of immediate gratification and access to resources – particularly in a country as vast as Australia – may also influence the decisions to undertake this procedure. Hysterectomy is often recommended for gynaecological symptomatology because menstruation inevitably ceases, and the mortality rate associated with this operation is low3. However, there are potential physical, psychological, and social complications following this operation that must be considered (Fig. 1).4 If we exclude malignancy and severe prolapse, the two most common interventions for benign hysterectomy are abnormal uterine bleeding (AUB) and pain. The PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic and not yet classified) is a system to describe disorders that cause AUB.5 This group of disorders can lead to AUB, iron deficiency and anaemia, which, in turn, may impair work capacity, sexual health and quality of life, the most common treatment option being combined oral contraceptives, and progesterone administration where bleeding flow may be halved. Despite high levels of control with oral medications, an American College of Obstetricians and Gynecologists practice bulletin states that within a period of ten years 46% of those using medicines for AUB ultimately underwent surgery, and hysterectomy is the most effective method to end abnormal uterine bleeding.6 Studies have shown that the levonorgestrel-releasing intrauterine system (LNG-IUS) is more effective than cyclical norethisterone – and with better compliance.7, 8 In the only randomised study with five-year follow-up, there were no differences in quality of life or psychological scores comparing LNG-IUS vs hysterectomy, despite 42% of patients treated with LNG-IUS subsequently undergoing this procedure.9 Timely management of the underlying pathology of AUB may negate the necessity for hysterectomy. Disappointingly in Australia, hysterectomy was over-represented in regional, compared to metropolitan areas,10 where limited access to primary health services due to geographical barriers, and socioeconomic factors reduced access to conservative treatments such as myomectomy and endometrial ablation. There are no randomised controlled trials comparing fibroid enucleation techniques with hysterectomy. Intracavitary fibroids can be treated with hysteroscopic myomectomy, with proven efficacy. Findings from cohort studies support hysteroscopic myomectomy as an effective treatment for AUB symptoms in up to 90% of cases, but recurrence of pathology remains a challenge. Uterine artery embolisation and endometrial ablation do not achieve the same definitive reduction in bleeding as hysterectomy.11, 12 But complications with these techniques are rare compared to those following hysterectomy, particularly in the rural setting where admission rates for this surgery were three-fold those observed in the major cities.10 The Clinical Care Standards from the Australian Commission On Safety And Quality In Health Care present an evidence-based assessment on the choices available to treat AUB and arose as a direct result of the variations identified. All clinicians should have knowledge of and follow these standards which provide choice and clarity regarding interventions for these clinical presentations.13 So, what about hysterectomy and pelvic pain? Endometriosis affects 11.4% of women by the age of 44 years and is diagnosed in 20–68% of women with infertility.12 Hysterectomy often is recommended by gynaecologists as ‘definitive therapy’ for endometriosis, but there are few data to support that claim. There are data that have shown a decreasing durability for sustained symptomatic improvement following surgery for pain, with conservative laparoscopic excisional surgery leading to reoperation in 1/3 women up to five years after initial surgery.13 This has been compared to a lower rate of reintervention when hysterectomy is performed in association with removal of endometriosis.14 Despite improvement in symptoms, with significantly fewer post-surgical operations occurring in the hysterectomy groups irrespective at stage of disease, pain may continue or recur, and we do need to abandon the term ‘definitive’ – since it certainly isn’t. Ovarian removal at the time of hysterectomy looked favourable when assessing pelvic pain, since data from 1995 suggested a relative risk (RR) for repeat surgery of 8.8,15 in 2008; this RR was revised to 2.4416 and current data from 2020 in a large-scale epidemiological study suggest that this is only 1.18.14 But oophorectomy removal comes at a hefty price. A Mayo Clinic cohort study with 38 years follow-up, of 2000 women with age-match subjects showed increased mortality rates with oophorectomy at less than 45 years;17 the causes of death included cardiovascular disease, and osteoporotic fractures. Findings also included an increase in cognitive impairment, dementia, parkinsonism symptoms, decreased sexual function, and psychological wellbeing when comparing total abdominal hysterectomy bilateral salpingo-oophorectomy with total abdominal hysterectomy patients. So, cherish the ovaries, remove disease from them, but keep them should a hysterectomy be considered. The old data suggesting a substantive benefit has been well and truly superseded. So why persist with hysterectomy in such high numbers? Comparisons can be made in other specialities, where ‘overdiagnosis’ and overservicing is now widely recognised to occur when people are labelled with or treated for a disease that would never cause them harm. The drivers for this include culture, the health system, industry, professionals, and patients and the public.10, 18 Parallels can also be made in other surgical specialties, with an over-representation of spinal fusion, appendicectomy for a normal appendix, cholecystectomy for incidental gallstones, and hernia repairs in the private sector which may also be driven by the ‘worried well’, overservicing, and the financial incentive of private sector medicine, with billing via item number as a fee for service.10, 19, 20 The gynaecologist’s particular practice style is likely to be influenced by their experience and training, the views of their peers and by the constraints of the healthcare system in which they work. With more than half of the Australian population having private health insurance, access to operating theatre time, and availability of surgical resources makes hysterectomy possible in a timely manner. This is in stark contrast to the British National Health Service, where approximately 11% of the population hold private health insurance, and health service resources are rationed. With many OECD countries moving toward a ‘net zero’ hysterectomy rate for benign disease, perhaps Australia should look at why we are lagging behind. Otherwise, we may pick up yet another ‘colossal fossil’ award ….