OB/GYNs' Attitudes Toward Hysterectomy

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.

Dr. Ling reports no financial relationship to this field of study.

Synopsis: When presented with a case involving symptomatic leiomyomas, gynecologists' sex did not significantly affect their opinion for or against hysterectomy. Only age and practice type were independently significant in this decision making.

Source: Brummitt K, et al. Gynecologists' Attitudes Toward Hysterectomy. J Reprod Med. 2006;51:21-25.

A survey was mailed to 500 members of the American College of Obstetricians and Gynecologists presenting a case of symptomatic fibroids. The respondents were asked to choose hysterectomy or a uterus-sparing procedure, 49% responded. Univariate logistic regression analysis of the demographics of those who answered showed that gender did not affect the therapeutic choice. (77.6% vs 87.1%; OR, 0.51; 95% CI, 0.26-1.01). Hysterectomy was recommended more if the physician were either in an academic setting or of a younger age. In the multivariate model, both age and academic practice remained independently significant.

Commentary

My take on this study is more of a philosophical nature than practical, ie, what we as individual readers should do is get beyond the results, and look inside our own decision-making. The authors were focusing on the attitudes toward hysterectomy using a case-driven survey, trying to decipher what demographic factors influenced how the individual physicians would treat the patient. As a result, one has to wonder whether this is more of a study on attitudes toward leiomyomata rather than hysterectomy. Had the authors scripted the case differently, with an older patient, or different symptoms, etc, would the results have been the same?

More importantly, the study shows that there are real differences out there. Not much of a surprise, though, right? We all know that each of us is most strongly influenced by the residency program in which we are trained; and that there is always a little voice in the back of our head that is telling us to recommend surgery (or not) depending on the case. That voice often sounds a lot like our departmental chair, the head of gynecology, or one of our mentors on the gynecologic service.

It's nice to know that gender is not an independent factor in decision-making, although there is certainly the perception among some that female gynecologists will be more user-friendly or empathetic than their male counterparts. Indeed, how you were trained and by whom remain critical in each decision you make everyday, whether it be related to hysterectomy or any other clinical decision. It should be noted that this study shows that age is a factor. One could interpret this as saying that the more experienced you are, the less patient you are about uterus-sparing procedures. Another interpretation could give your years in the trenches more credit by saying that you have learned that uterus-sparing procedures are more likely to fail and that the patient will, in the long run, be more satisfied with surgery right away. By the same token, why were those in academics less likely to recommend hysterectomy? Were they smarter and, therefore, knew more about the options than their community-based colleagues? Were they less motivated to do the procedure because they were on a salary rather than on a productivity-based compensation plan? You can't draw broad-stroke conclusions about individuals who are lumped together in a survey like this one, but you can look at your own decision-making process.

The survey presented a 36-year-old multiparous patient who had undergone a tubal ligation but who now had menorrhagia and central pelvic pain. She bled heavily from the 14-week-size uterus despite 3 months of progestin therapy. So what would you do in your practice? I am less interested in the final decision of what you would do (hysterectomy, myomectomy, hormones, expectant management, or uterine artery embolization) than I am in how you get there. How important is reimbursement? I hope not much. How important are the patients' attitudes? I hope a lot. Do you catch where I'm coming from? This study shows that gender is not a factor. I'm glad for that. Hopefully that is the case with you as an individual. What are the important driving factors in what you recommend for the next woman who comes in with symptomatic fibroids? I would be interested to know what the little voice in the back of your mind is telling you.