Kristen A. Matteson

Minimally Invasive Hysterectomies—A Survey on Attitudes and Barriers among Practicing Gynecologists

STUDY OBJECTIVE To explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies. DESIGN Mixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists. SETTING Nationwide survey in the United States. PARTICIPANTS Nonretired obstetrician-gynecologists identified through a physician list from the American Medical Association. INTERVENTIONS Postal and online survey. MEASUREMENTS & MAIN RESULTS: We received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent. CONCLUSIONS While a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access.

Vaginal cuff dehiscence: risk factors and management.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.

Tailored Intervention to Increase Dual Contraceptive Method Use: A Randomized Trial to Reduce Unintended Pregnancies and Sexually Transmitted Infections

OBJECTIVE The objective of the study was to determine whether a transtheoretical model-tailored expert system intervention increases dual-method contraceptive use, compared with a nontailored educational intervention. STUDY DESIGN We performed a randomized clinical trial of 542 women at high risk for sexually transmitted infections (STIs) and unintended pregnancy. The intervention group received computer-based tailored feedback using a multimedia program. The control group received general contraceptive information and nontailored advice. RESULTS Participants in the intervention group were more likely to report use of dual contraceptive methods during follow-up (adjusted hazard rate ratio 1.70, 95% confidence interval 1.09, 2.66), compared with controls. However, there were no differences in the rates of incident STI or unintended pregnancy between the 2 groups. CONCLUSIONS The computer-based transtheoretical model-tailored intervention resulted in a 70% increase in reported dual-method contraceptive use in a group of women at high risk for STIs and unintended pregnancy. Inconsistent use of dual methods may explain the lack of effect on unintended pregnancy rates and incident STIs.

Nonsurgical management of heavy menstrual bleeding: a systematic review.

OBJECTIVE: To compare the effectiveness of nonsurgical abnormal uterine bleeding treatments for bleeding control, quality of life (QOL), pain, sexual health, patient satisfaction, additional treatments needed, and adverse events. DATA SOURCES: MEDLINE, Cochrane databases, and Clinicaltrials.gov were searched from inception to May 2012. We included randomized controlled trials of nonsurgical treatments for abnormal uterine bleeding presumed secondary to endometrial dysfunction and abnormal uterine bleeding presumed secondary to ovulatory dysfunction. Interventions included the levonorgestrel intrauterine system, combined oral contraceptive pills (OCPs), progestins, nonsteroidal anti-inflammatory drugs (NSAIDs), and antifibrinolytics. Gonadotropin-releasing hormone agonists, danazol, and placebo were allowed as comparators. METHODS OF STUDY SELECTION: Two reviewers independently screened 5,848 citations and extracted eligible trials. Studies were assessed for quality and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Twenty-six articles met inclusion criteria. For reduction of menstrual bleeding in women with abnormal uterine bleeding presumed secondary to endometrial dysfunction, the levonorgestrel intrauterine system (71–95% reduction), combined OCPs (35–69% reduction), extended cycle oral progestins (87% reduction), tranexamic acid (26–54% reduction), and NSAIDs (10–52% reduction) were all effective treatments. The levonorgestrel intrauterine system, combined OCPs, and antifibrinolytics were all superior to luteal-phase progestins (20% increase in bleeding to 67% reduction). The levonorgestrel intrauterine system was superior to combined OCPs and NSAIDs. Antifibrinolytics were superior to NSAIDs for menstrual bleeding reduction. Data were limited on other important outcomes such as QOL for women with abnormal uterine bleeding presumed secondary to endometrial dysfunction and for all outcomes for women with abnormal uterine bleeding presumed secondary to ovulatory dysfunction. CONCLUSION: For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, we recommend the use of the levonorgestrel intrauterine system over OCPs, luteal-phase progestins, and NSAIDs. For other outcomes (QOL, pain, sexual health, patient satisfaction, additional treatments needed, and adverse events) and for treatment of abnormal uterine bleeding presumed secondary to ovulatory dysfunction, we were unable to make recommendations based on the limited available data.

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding

STUDY OBJECTIVE To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains. DESIGN Systematic review. SETTING Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options. PATIENTS Women with AUB, predominantly from ovulatory disorders and endometrial causes. INTERVENTIONS Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system. MEASUREMENTS AND MAIN RESULTS Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found. CONCLUSION Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Questioning our Questions: Do frequently asked questions adequately cover the aspects of women's lives most affected by abnormal uterine bleeding? Opinions of women with abnormal uterine bleeding participating in focus group discussions

Objectives of this article are: (1) to explore the effects on womens lives by heavy or irregular menstrual bleeding; and (2) to examine whether aspects of womens lives most affected by heavy or irregular menstrual bleeding were adequately addressed by questions that are frequently used in clinical encounters and available questionnaires. We conducted four focus group sessions with a total of 25 English-speaking women who had reported abnormal uterine bleeding. Discussions included open-ended questions that pertained to bleeding, aspects of life affected by bleeding, and questions frequently used in clinical settings about bleeding and quality of life. We identified five themes that reflected how womens lives were affected by heavy or irregular menstrual bleeding: irritation/inconvenience, bleeding-associated pain, self-consciousness about odor, social embarrassment, and ritual-like behavior. Although women responded that the frequently used questions about bleeding and quality of life were important, they felt that the questions failed to go into enough depth to adequately characterize their experiences. Based on the themes identified in our focus group sessions, clinicians and researchers may need to change the questions used to capture “patient experience” with abnormal uterine bleeding more accurately.

Unplanned pregnancy: does past experience influence the use of a contraceptive method?

OBJECTIVE: To investigate whether women between the ages of 14 and 25 years with a past unplanned pregnancy were more likely to use a contraceptive method compared with women without a history of unplanned pregnancy. METHODS: We analyzed baseline data of 424 nonpregnant women between the ages of 14 and 25 years enrolled in a randomized trial to prevent sexually transmitted diseases and unplanned pregnancy (Project PROTECT). Women at high risk for sexually transmitted diseases or unplanned pregnancy were included. Participants completed a demographic, substance use, and reproductive health questionnaire. We compared women with and without a history of unplanned pregnancy using bivariate analysis and log binomial regression. RESULTS: The prevalence of past unplanned pregnancy in this sample was 43%. Women reporting an unplanned pregnancy were older, and had less education, and were more likely to be nonwhite race or ethnicity. History of an unplanned pregnancy was not associated with usage of a contraceptive method (relative risk 1.01, 95% confidence interval 0.87–1.16) in bivariate analysis or when potential confounders were accounted for in the analysis (adjusted relative risk 1.10, 95% confidence interval 0.95–1.28). CONCLUSION: Several factors were associated with both unplanned pregnancy and overall contraceptive method use in this population. However, a past unplanned pregnancy was not associated with overall contraceptive method usage. Future studies are necessary to investigate the complex relationship between unplanned pregnancy and contraceptive method use. LEVEL OF EVIDENCE: II-2

Intrapartum group B streptococci prophylaxis in patients reporting a penicillin allergy.

OBJECTIVE: To examine adherence to the 2002 Centers for Disease Control and Prevention (CDC) guidelines for group B streptococci (GBS) prophylaxis in patients who reported a penicillin allergy. METHODS: This is a retrospective cohort study of GBS-positive, penicillin-allergic obstetric patients who delivered at our institution from 2004 through 2005 (N=233). Medical records were analyzed for type of delivery, gestational age at delivery, antimicrobial sensitivity testing, and antibiotics administered. Antimicrobial sensitivity testing and appropriate prophylactic antibiotic choice were analyzed. “Appropriate antibiotic choice” was defined using the 2002 CDC guidelines for GBS prophylaxis. Women with either a scheduled cesarean delivery or a preterm delivery were excluded from analyses. Data were analyzed using Stata 9.0. RESULTS: Overall, 95% (95% confidence interval [CI] 91–97%) of GBS-positive, penicillin-allergic women received antibiotic prophylaxis and only 16% (95% CI 11–21%) of patients received an appropriate antibiotic. The majority of women who were given antibiotics received clindamycin (83%, 95% CI 77–87%); however, antimicrobial sensitivity testing was performed in only 11% (95% CI 9–17%) of patients. More women received an appropriate antibiotic in 2005 than in 2004 (20% compared with 11%, P=0.11). Although the study was underpowered to evaluate the magnitude of increase, the overall prevalence of appropriate antibiotic administration in 2005 was still only 20% (95% CI 13–28%). CONCLUSION: Adherence to the 2002 CDC guidelines for GBS prophylaxis in penicillin-allergic women is far from optimal. Improvements are necessary in obtaining antimicrobial sensitivity testing and choosing an appropriate antibiotic for GBS-positive women with a reported penicillin allergy. LEVEL OF EVIDENCE: II

Surveying ourselves: examining the use of a web-based approach for a physician survey.

A survey was distributed, using a sequential mixed-mode approach, to a national sample of obstetrician–gynecologists. Differences between responses to the web-based mode and the on-paper mode were compared to determine if there were systematic differences between respondents. Only two differences in respondents between the two modes were identified. University-based physicians were more likely to complete the web-based mode than private practice physicians. Mail respondents reported a greater volume of endometrial ablations compared to online respondents. The web-based mode had better data quality than the paper-based mailed mode in terms of less missing and inappropriate responses. Together, these findings suggest that, although a few differences were identified, the web-based survey mode attained adequate representativeness and improved data quality. Given the metrics examined for this study, exclusive use of web-based data collection may be appropriate for physician surveys with a minimal reduction in sample coverage and without a reduction in data quality.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review.

OBJECTIVE: To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy. DATA SOURCES: MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries. METHODS OF STUDY SELECTION: Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14–0.7% compared with 0.02–0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04–1.92). Coronary heart disease (HR 1.26, 95% CI 1.04–1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27–2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results. CONCLUSION: Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.