Annette Settnes

Hysterectomy on benign indication in Denmark 1988–1998

Background. The aims of the study were to describe the trends in Danish hysterectomy rates from 1988 to 1998 for operations done on benign indication.

Hysterectomy in a Danish cohort. Prevalence, incidence and socio‐demographic characteristics

Background The aim has been to assess the frequency of hysterectomy in relation to sociode‐mographic characteristics.

Hysterectomy in Danish women: Weight-related factors, psychologic factors, and life-style variables**

Objective To assess weight-related risk factors, psychologic factors, and life-styles of importance for hysterectomy performed for benign conditions. Methods In a prevalence study, 2301 Danish women aged 30, 40, 50, or 60 years were selected at random in 1982, and self-report questionnaires were collected from 77%. Information about weight and dieting history, life-style, psychologic factors, gynecologic history, and social background were recorded. Weight, height, and plasma lipids were measured. In an incidence study, the cohort was followed during 1982–1990 via central registers to assess the incidence of hysterectomy. Logistic and Cox regression were used to analyze the data. Results In the prevalence study, weight cycling (recurrent weight loss and weight gain of more than 5 kg) was associated with hysterectomy for benign disease (odds ratio 1.77, 95% confidence interval [CI] 1.05–2.99) by multivariate analysis independent of overweight, smoking, psychologic factors, social factors, and gynecologic characteristics. In the incidence study, all the weight-related factors except slimming diets were significant risk factors for hysterectomy performed recently for benign disease in women under age 50. In the multivariate analysis, weight cycling was the only significant weight-related factor (relative risk 2.49, 95% CI 1.10–5.60), explaining the relation between hysterectomy and psychologic factors. Coffee, tea, alcohol, smoking, and plasma lipids were not related to hysterectomy in either study. Conclusion Weight cycling might be an important risk factor for premenopausal hysterectomy performed for benign conditions. Whether weight cycling causes menstrual irregularities and leiomyomas, these results give us a better understanding of the pathways to hysterectomy.

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

Objective. To describe the use of vaginal, abdominal and laparoscopic hysterectomy in Denmark from 1999 to 2008, the influence of national guidelines and the patient and procedure‐related characteristics associated with the choice of vaginal hysterectomy. Design. Nationwide register‐based cohort study. Setting. Danish Hysterectomy Database and Danish National Patient Registry. Population. All women with a hysterectomy for benign indications in Denmark from 1999 to 2008. Methods. The incidence rate/100 000 women was used to describe the route of surgery in hysterectomies of 50 755 women. A multiple logistic regression analysis was done to examine the association between patient‐ and procedure‐related characteristics and choice of surgical procedure including 20 486 women. Main outcome measures. Trends in surgical approach from 1999 to 2008. Patient‐ and surgery‐related characteristics associated with vaginal hysterectomy from 2004 to 2008. Results. There was an overall increase in the use of vaginal hysterectomies from 12 to 34%, a decrease in the use of abdominal hysterectomies and a consistent number of laparoscopic hysterectomies. The number of vaginal hysterectomies varied between regions, ranging from 2 to 86%. The use of vaginal hysterectomy was not dependent on the total number of hysterectomies performed at the hospital. The characteristics associated with vaginal hysterectomy were higher age, smaller uterus size, indications for surgery (genital prolapse and severe uterine bleeding), less smoking and moderate alcohol intake. Conclusions: Vaginal hysterectomy has replaced abdominal hysterectomy increasingly but cannot be directly correlated to the implementation of national guidelines as there was large national variation. Several characteristics are significantly associated with vaginal hysterectomy.

Hypertension and hysterectomy in danish women

Objective To assess whether hypertension is a risk factor for hysterectomy performed for benign diseases. Methods Self-report questionnaires were collected from 77% of 2301 Danish women aged 30, 40, 50, or 60 years selected at random in 1982 for a prevalence study. Information about cardiovascular diseases, hypertension, use of medicine, weight and dieting history, life-styles, psychologic factors, gynecologic history (including history of hysterectomy), and social background were recorded. Weight, height, and blood pressure were measured. In an incidence study, the cohort was followed during 1982-1990 via central registers to assess the incidence of hysterectomy. Logistic and Cox regressions were used to analyze data. Results In the prevalence study, history of hypertension partly explained the relation between hysterectomy and cardiovascular diseases. In the incidence study, history of hypertension and use of diuretics were significant risk factors for hysterectomy. After confounder control, use of diuretics was explained by weight-related variables, and hypertension was a risk factor for hysterectomy in educated women (adjusted relative risk [RR] 2.88, 95% confidence interval [CI] 1.07, 7.76) and in women with weight fluctuations (adjusted RR 3.31, 95% CI 1.35, 8.14). Weight cycling and lack of education remained significant risk factors for hysterectomy in women with and without hypertension, respectively. Conclusion History of hypertension, weight cycling, and lack of education are closely related risk factors for premenopausal hysterectomy. These three risk factors contribute to women undergoing hysterectomy having an increased risk for cardiovascular diseases. We proposed that hypertension might be a plausible biological cause of menorrhagia and an indication for hysterectomy.

The Danish Hysterectomy and Hysteroscopy Database.

Aim of the database The steering committee of the Danish Hysterectomy and Hysteroscopy Database (DHHD) has defined the objective of the database: the aim is firstly to reduce complications, readmissions, reoperations; secondly to specify the need for hospitalization after hysterectomy; thirdly to secure quality assessment of hysterectomy and hysteroscopy by setting standards and national guidelines; and finally to intensify the monitoring of laparoscopic surgery and explore long-term side effects after hysterectomy. Study population We include all women in Denmark who have had elective benign uterine surgery since 2003. The surgery includes hysterectomy and operative hysteroscopy. In the latter, we include resection of the endometrium and submucosal leiomyomas and ablations of the endometrium. Main variables Detailed information about the hysterectomy and hysteroscopy operation techniques, cooperations, and indications is registered directly in the National Patient Register (NPR), as well as relevant lifestyle factors and confounders. It is mandatory to register information about complications and readmissions in the NPR. Data included in DHHD are directly extracted from the NPR. Descriptive data Annually approximately 4,300 hysterectomies and 3,200 operative hysteroscopies are performed in Denmark. Since the establishment of the database in 2003, 50,000 hysterectomies have been registered. DHHD’s nationwide cooperation and research have led to national guidelines and regimes. Annual national meetings and nationwide workshops have been organized. Conclusion The use of vaginal and laparoscopic hysterectomy methods has increased during the past decade and the overall complication rate and hospital stay have declined. The regional variation in operation methods has also decreased.

A systematic review and meta-analysis of the effect of prophylactic tranexamic acid treatment in major benign uterine surgery

The value of tranexamic acid (TA) treatment as bleeding prophylaxis in major uterine surgery is unclear.

Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority

Hysterectomy for benign gynecological conditions is a common operation that has developed extensively through the last 20 years. Methods and surgical techniques vary throughout the regions in Denmark as well as internationally. Consequently, the Danish Health Authority initiated a national clinical guideline on the subject based on a systematic review of the literature. A guideline panel of seven gynecologists formulated the clinical questions for the guideline. A search specialist performed the comprehensive literature search. The guideline panel reviewed the literature and rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Finally, the panel weighted the evidence and formulated the clinical recommendations. Based on the limited available literature and the corresponding quality of evidence according to GRADE, the guideline panel gave the following recommendations: ↓ Subtotal hysterectomy should only be preferred over total hysterectomy after careful consideration because there are documented disadvantages such as persistent cyclic vaginal bleeding (⊕ΟΟΟ). ↑ Consider vaginal hysterectomy rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible (⊕ΟΟΟ). ↓ Robot-assisted laparoscopic hysterectomy should only be preferred over conventional laparoscopic hysterectomy after careful consideration because the beneficial effect is uncertain and because of the longer operating time (⊕⊕ΟΟ). ↑ Consider concomitant bilateral salpingectomy at the time of hysterectomy if the procedure is not considered to increase the risk of complications significantly (⊕ΟΟΟ). ↑ Consider vaginal vault suspension to the cardinal and the uterosacral ligaments when performing hysterectomy for non-prolapsed uteri (⊕ΟΟΟ). Though supporting evidence is missing, the guideline panel emphasizes that it is good practice not to morcellate uteri with presumed fibroids inside the peritoneal cavity (√). The recommendations serve as professional advice in specific clinical situations. The implementation of the guideline in Denmark will be monitored through the national Danish Hysterectomy and Hysteroscopy Database.