Hysterectomy and socioeconomic position in Rome, Italy. (Research Report).(Statistical Data Included)

Study objective: There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons.

Design: An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend.

Main results: The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more.

Conclusions: The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.

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Hysterectomy is one of the most common surgical interventions for women in Western countries, and about 90% of hysterectomies are performed for treating uterine leiomyomas, dysfunctional bleeding, pelvic organ prolapse, and other non-malignant diseases of the uterus. (1 2) None the less, for many of these conditions, this intervention is very controversial, and professional uncertainty is reflected in the considerable small area variations in hysterectomy rates. (3) National level rates also vary greatly, ranging from 10 per 10 000 women in Norway and Sweden (4) to about 60 per 10 000 women in North America, with the rates for Britain and other European countries falling within this range. (4) The extent to which these variations are attributable to psychosocial and cultural factors is so great that understanding the differences in rates entails examining societies more than histological specimens. (6)

In recent times, hysterectomy rates have been decreasing in the USA (7) because of the availability of less invasive techniques for removing leiomyomas or modifying bleeding, including endoscopy, (8) embolisation, (9) hormonal therapy, (10) and percutaneous laser thermoablation. (11) Although it has been reported that hysterectomy may increase cardiovascular risk factors such as hypertension and body mass index (12) and it may predispose to ovarian failure and, indirectly, to loss of libido, (6) these issues are still controversial. (13) Prevention of uterine and cervical cancer, (1) undiagnosed pelvic pain, (1) and sterilisation (14) were at one time common reasons for the procedure, yet with the availability of ultrasonography, even large leiomyomas are no longer an unequivocal indication for hysterectomy in the absence of bleeding or pain. (15) Furthermore, the great quantity of internet sites created by lay women associations and discussion groups on alternatives to hysterectomy indicates that the pattern of demand is also changing.

Socioeconomic factors are also related to variations in hysterectomy rates. Specifically, in the United Kingdom, (16 17) Denmark, (18 19) the United States, (20-22) and Australia, (23 24) this intervention has been observed to be more common among women of lower educational and income level. In the United States, the rate of hysterectomy was reported to be higher for black than for white women. (5) By contrast, hysterectomy has been shown to be positively associated with income in studies performed in Los Angeles (USA) (25) and Finland. (26 27)

The aim of this study was to evaluate whether socioeconomic level is related to hysterectomy undertaken for different medical reasons and in different age groups.

METHODS

The study population consisted of 3498 women, aged 35 years or more and residing in Rome, who in 1997 underwent a hysterectomy, excluding pelvic evisceration (ICD-9-CM 68.3-68.7,68.9). The data analysed were those reported on hospital discharge records, retrieved through the hospital information system run by the health authority of the Lazio Region. This system collects and manages data from all discharges from both public and private hospitals in the region as well as discharges of Lazio residents hospitalised elsewhere in Italy. In 1997 the region had …