Clinical opinion
Global epidemiology of hysterectomy: possible impact on gynecological cancer rates

https://doi.org/10.1016/j.ajog.2015.02.019Get rights and content

Despite the fact that hysterectomy is the most common surgical procedure worldwide in gynecology, national reporting of the incidence rate of gynecological cancers rarely removes the proportion no longer at risk of the disease from the population-at-risk-denominator (ie, women who have had a hysterectomy). The incidence rate of gynecological cancers is thus likely underestimated. Because hysterectomy, as well as oophorectomy, incidence varies across countries, age, and over time, meaningful comparison of gynecological cancer incidence rates may be compromised. Without accurate estimates of gynecological cancer incidence rates, performed via removing the proportion of hysterectomized or oophorectomized women from the population-at-risk-denominator, the impact of prevention strategies may be masked or misinterpreted. Furthermore, because national cervical cancer screening guidelines are at least in part based on the national reporting of cervical cancer incidence, it is important that the incidence rate reflects the true population at risk.

Section snippets

Hysterectomy by indication

Hysterectomy is most commonly performed because of benign disease, such as fibroids, bleeding disorders, endometriosis, and uterine prolapse. In 2000–2004, hysterectomy caused by benign disease accounted for 90% of all hysterectomies in the United States; malignant disease, such as uterine cancer, cervical cancer, and ovarian cancer, accounted for the remaining 10%.1 Hysterectomy may also include the removal of both ovaries (bilateral oophorectomy). In 2000–2004, approximately 54% of women

Surgical procedure

Hysterectomy can be performed vaginally or abdominally or by a laparoscopic approach. Most commonly, hysterectomy includes removal of the uterine cervix, but subtotal or supracervical hysterectomy, in which the cervix is left intact, is also an option. The latter approach is not a common procedure in the United States (7.5%),6 in the United Kingdom (4%),7 and in Germany (4.8%),8 whereas it has been more common in the Scandinavian countries such as Sweden and Denmark during the past 20 years.9,

Hysterectomy incidence across countries

In the past years, several papers have been published on hysterectomy incidence rates in developed countries (Table 1). The incidence rate is very high in countries such as the United States (510 per 100,000 in 2004),1 ranging from 430 of 100,000 for women living in the Northeast to 630 per 100,000 for those living in the South, whereas lower hysterectomy incidence rates have been reported in several European countries, including Denmark (173 per 100,000 in 2011).2

The hysterectomy incidence

The impact of hysterectomy and oophorectomy on gynecological cancer rates

The incidence rate of cervical cancer has declined significantly in developed countries after implementation of cervical cancer screening programs,20 but the same phenomenon has not been seen in uterine and ovarian cancer, presumably because of the lack of an efficient screening tool.13, 21, 22 Table 1 summarizes the incidence rate of cervical, uterine, and ovarian cancer in the United States, in Australia, and in 3 European countries. As shown, the cervical cancer incidence is higher in

Age-specific cancer rates after correction for hysterectomy

A few studies have reported that the difference in hysterectomy corrected vs uncorrected incidence rates of cervical cancer is highest in older women because hysterectomy incidence is cumulative with age.13, 14, 26, 29 These studies all found that older women were at highest risk of cervical cancer (Figure) after adjusting for hysterectomy. In Finland, women older than 70 years had the highest cervical cancer incidence regardless of hysterectomy status,13 whereas a German study found a 67%

Conclusion

Despite the growing evidence from previous studies, national reporting of gynecological cancer incidence rarely removes the proportion of women who have undergone hysterectomy or oophorectomy from the population-at-risk denominator. This is important when calculating incidence rates on all gynecological cancers; however, for cervical cancer it is especially important that the incidence rate reflects the true population at risk because national screening guidelines are based, in part, on

References (50)

  • E.L. Hill et al.

    Hysterectomy trends in Australia—between 2000–2001 and 2004–2005

    Aust N Z J Obstet Gynaecol

    (2010)
  • A. Stang et al.

    Hysterectomy in Germany: a DRG-based nationwide analysis, 2005–2006

    Dtsch Arztebl Int

    (2011)
  • A. Loft et al.

    Incidence of ovarian cancer after hysterectomy: a nationwide controlled follow up

    Br J Obstet Gynaecol

    (1997)
  • R.M. Merrill

    Hysterectomy surveillance in the United States, 1997 through 2005

    Med Sci Monit

    (2008)
  • I.Z. MacKenzie et al.

    1170 consecutive hysterectomies: indications and pathology

    J Br Menopause Soc

    (2004)
  • A. Stang et al.

    Prevalence-corrected hysterectomy rates by age and indication in Germany 2005–2006

    Arch Gynecol Obstet

    (2012)
  • H. Gimbel et al.

    Hysterectomy on benign indication in Denmark 1988–1998. A register based trend analysis

    Acta Obstet Gynecol Scand

    (2001)
  • C. Lundholm et al.

    Hysterectomy on benign indications in Sweden 1987–2003: a nationwide trend analysis

    Acta Obstet Gynecol Scand

    (2009)
  • S.L. Nielsen et al.

    Use of vaginal hysterectomy in Denmark: rates, indications and patient characteristics

    Acta Obstet Gynecol Scand

    (2011)
  • Settnes A; Steering Committee. Danish hysterectomy and hysteroscopy database. National annual report 2012. Dansk...
  • R. Luoto et al.

    Effect of hysterectomy on incidence trends of endometrial and cervical cancer in Finland 1953–2010

    Br J Cancer

    (2004)
  • A.F. Rositch et al.

    Increased age and race-specific incidence of cervical cancer after correction for hysterectomy prevalence in the United States from 2000 to 2009

    Cancer

    (2014)
  • L.A. Lepine et al.

    Hysterectomy surveillance—United States, 1980-1993

    MMWR CDC Surveill Summ

    (1997)
  • T.H. Brummer et al.

    FINHYST 2006—national prospective 1-year survey of 5,279 hysterectomies

    Hum Reprod

    (2009)
  • L. Gustafsson et al.

    International incidence rates of invasive cervical cancer before cytological screening

    Int J Cancer

    (1997)
  • Cited by (86)

    • Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort

      2022, Gynecologic Oncology
      Citation Excerpt :

      In another study by Vicus et al., authors found that in women over the age of 30, having had a cervical cancer screening 3–36 months prior to diagnosis of cervical cancer was protective of mortality with an OR of 0.28–0.60 [36]. Therefore, lack of guideline-adherent screening is a concern, especially as more women age with their uterus in place due to improved medical treatments for abnormal bleeding and other conditions that previously led to hysterectomy [37]. In addition, the COVID-19 pandemic has further decreased screening rates, which may further impact future cancer incidence and mortality [38].

    View all citing articles on Scopus

    A.H. has received a nonrestricted grant (no. DKK 50,000) from Sanofi Pasteur MSD (Denmark). The other authors report no conflicts of interest.

    View full text