Hysterectomy at a Young Age

Olga Bougie, MPH, FRCSCHysterectomy is a common surgical procedure that is an effective and safe treatment option for a number of gynecologic conditions. Although there are an increasing breadth of options available to treat the most common benign indications for surgery, such as uterine leiomyomas, endometriosis, and pelvic pain, some patients may experience side effects, adverse outcomes, or insufficient symptom relief from these.1 Some patients ultimately may desire to undergo hysterectomy to hopefully achieve definitive symptom resolution. Considerations when counseling patients on treatment options include nonmaleficence, beneficence, justice, and patient autonomy.2 However, as a clinician, it can be difficult to balance patient autonomy and risk of future regret when offering patients irreversible treatment options such as tubal sterilization, endometrial ablation, or hysterectomy. This delicate balance becomes even more precarious when patients are younger in age, nulliparous, or both. This concern is supported by research demonstrating higher prevalence of regret in patients who had tubal ligations at younger ages.3 Although there are similarities in the irreversible nature of tubal ligation and hysterectomy, the evidence for higher rates of regret among a younger population after hysterectomy is unclear. The demographics of patients wishing to undergo hysterectomy likely vary compared with those desiring permanent contraception. There is limited literature on the prevalence of regret among younger patients undergoing hysterectomy, although one previous retrospective study (performed at two sites and including patients younger than age 35 years who underwent hysterectomy) found that the prevalence of regret was generally low.4 Overall, 2.8% of the patients surveyed in that study expressed regret with their decision to undergo hysterectomy, and 14% said that, “this caused them harm.” Of note, the majority of patients in that study had trialed other medical options previously. Patients generally expressed that the decision was a wise one and well supported by their health care team. Reddington et al5 recently published a single-center study from Melbourne Australia that did not find an association between age or parity with expression of regret after hysterectomy; however, only 29 of the 268 participants in the study were younger than age 36 years. In this month's issue of Obstetrics & Gynecology (see page 757), King et al6 add to the literature with a matched retrospective cohort of patients who underwent laparoscopic hysterectomy for benign indications at a single institution between 2009 and 2016. They explored regret with respect to undergoing surgery as well as loss of fertility using two validated decision regret questionnaires. Furthermore, they compared the responses from 77 patients who were younger than age 30 years and 164 who were aged 31–49 years. King et al identified that, compared with patients aged 31–40 years, those aged younger than 30 years were more likely to express regret at undergoing surgery (32.5% vs. 9.1%, P<.001; odds ratio [OR] 4.8; 95% CI, 2.3–9.8), as well as regret due to loss of fertility (39.0% vs. 13.4%, P<.001; OR 4.1, 95% CI, 2.2–7.8). Overall, 83.1% of younger participants agreed that hysterectomy was the right choice compared with 97% of older participants (P<.001). Higher rates of surgical regret and loss-of-fertility regret were seen in participants with self-reported pelvic pain (P=.003, P=.011), preoperative diagnosis of endometriosis (P=.037, P=.046), and postoperative complications (P=.043, P<.001). Although time since hysterectomy did not affect rate of surgical regret (P=.138), participants further from their hysterectomies had lower rates of loss-of-fertility regret (P=.003). 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) on multivariable logistic regression. Given that hysterectomy at a young age is uncommon, it is difficult to recruit a large study population and follow them prospectively, which would provide a stronger answer to the question at hand. A randomized controlled trial is most certainly out of the question. The decision to proceed with hysterectomy at a young age is complex, difficult, and nuanced, where unique considerations are involved for each patient. The nature of indication for surgery, previous therapies, childbearing, and future fertility wishes all contribute to the decision and interplay with one's social and cultural identity. Although King et al did explore whether the risk of regret was influenced by race and did not identify this factor to influence outcomes, there may be additional associations with culture and ethnicity not captured in the analysis. Previous work has demonstrated significant differences in the desire to preserve fertility among patients of different ethnicities, even when they expressed completion of childbearing.7 Additionally, a patient's relationship with their health care professionals and surgeon may influence their decision to proceed with the surgery, as well as subsequent satisfaction or regret. Both of the studies exploring this question4,6 included approximately 70 patients who underwent hysterectomy at a young age (younger than 30–35 years). King et al surveyed patients in their study after a long period of follow-up (mean greater than 7 years) and explored regret from two different perspectives. The finding of higher rates of regret among younger patients undergoing hysterectomy would be better interpreted if the context of prior attempted interventions was presented as well. It is likely that patients who felt that they had a chance to explore different options would express less regret in their decision. The choice to dichotomize patient age as 30 years or younger and 31–49 years is interesting, because regret is likely associated with age in a continuous and not a dichotomous fashion. Age 31 to 49 years encompasses a broad age category in which patients at the upper and lower bounds likely cannot be appropriately compared. Overall, these studies both highlight the complexity of decision making when patients select hysterectomy as the management option for their benign gynecologic conditions. The high rate of regret observed in the population studied by King et al raises significant concern in offering younger patients this definitive surgical option. Given the different findings stemming from each study cohort, it is evident that further research is needed in this field to guide both health care professionals and patients to help ensure an informed shared decision-making process. Future work should include a comprehensive evaluation of the decision pathway of patients considering hysterectomy, including their experience with prior treatment options. It is worthwhile to consider qualitative research in this area to characterize patient decision pathways and postintervention satisfaction associated with hysterectomy.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.