CDC Study Reveals--South's Hysterectomy Rate Highest

By AET

Vol. 8, No. 3, 1986, pp. 13-14

Nearly five million American women underwent hysterectomies in the last decade, making this procedure one of the most frequently performed operations for women of reproductive age and an important public health concern. Since 1970, the Centers for Disease Control (CDC) in Atlanta have provided epidemiologic surveillance of hysterectomies performed on women from fifteen to forty-four years of age. This summer the CDC released a report which examined, among other factors, the influence of race and geographic section of the US on hysterectomy rates for 1981-1982, and which updated the analysis of hysterectomy rates for 1970-1980. The results of the survey contain striking findings for women of reproductive age in the Southern states.

The data that was used for this surveillance effort was gathered from 1970 to 1982 as part of the ongoing National Hospital Discharge Survey. This survey samples hospitals throughout the US in order to estimate the number of patients, their diagnoses and the surgical procedures they undergo. The sample of hospitals is designed to reflect an overall distribution of short-stay hospitals in the United States. In most cases women will have a hysterectomy done in a short-stay hospital. The CDC survey is a sample, not the actual number of hysterectomies done in the US, and as such may contain unknown biases.

A 1983 analysis showed that the nationwide hysterectomy rate declined from 1975 to 1980 among women of reproductive age. The current study however, indicates that the noted decline may have begun to plateau, although rates in 1982 were the lowest since 1970. The average age at time of hysterectomy for women in the fifteen to forty-four age group was similar in all geographic areas, ranging from 34.2 years in the South to 36.6 years in the Northeast.

As in previous years, major differences in hysterectomy rates by section of the country have persisted (see Figure 1). The South continues to show the highest rates. The most striking differences exist between the South and the Northeast. The hysterectomy rate for women of reproductive age in the South was two and a half times that for women in the Northeast.

During 1979-1980, differences in hysterectomy rates between blacks and whites declined noticeably. In 1981, however, the rates of blacks and whites diverged, only to converge again in 1982. In 1982 (the most recent year for which data is available), for the first time since surveillance began in 1970, blacks had a lower hysterectomy rate than whites.

Variations in hysterectomy rates by section of the country have persisted since 1970. Lacking more than the limited data from the sample study, CDC researchers are quite cautious about speculating on the regional differences. "As epidemiologists in the federal government," comments Dr. Kathleen Irwin, researcher on the CDC study, "we feel that our job is to present the numbers and let other people speculate on them."

The CDC study suggests only that "patient-related factors may include regional differences in the incidence of gynecologic conditions and in general attitudes toward surgery or sterilization during the reproductive years. Physician-related factors may include regional differences in trends in training and practice."

"If there were true differences in the South compared to other regions," asks Dr. Irwin, "what could these be? There could be a whole range of differences. Our study looked at only one factor at a time: race, region, age group for the United States. We didn't look at race and region at the same time. It could be an age-related phenomenon: that the age distribution in the South is different than in other parts of the country among women who are likely to get hysterectomies. It may be that there is a higher prevalence in the South of certain diseases of the uterus which are treated with hysterectomies. It could be that physicians in the South are more liable to treat a given condition with a hysterectomy.

"Because of the nature of our analysis," says Dr. Irwin, "we're not in a position to say which one of those things or which combination it could be."

"It's disturbing to me," commented clinic administrator Lynn Thogersen, of the Atlanta Feminist Women's Health Center, "as a women's health care


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provider, and as a woman, to see the rate of hysterectomies for women in general being so high, and especially to see the difference for women in the South when compared with other areas of the country. Certainly we wonder if all these hysterectomies were necessary.

"One thing that might have a bearing on the numbers in the South," continues Thogersen, "is the fact that in all of the Southern states, unlike states such as New York and California, Medicaid no longer pays for abortions, and hasn't since about 1981. We wonder if in fact women are choosing hysterectomy as a way of controlling their fertility because other options aren't available to them.

"And I wonder if one reason that rates of hysterectomies have dropped in other sections of the country is due to the availability of tubal ligations as a method of sterilization. Sterilization, including both male and female, is now the most used method of contraception in the United States, but it's mostly women who are choosing sterilization.

"Statistics like these," concludes Thogersen, "make you want to ask many other questions for which we have no answers. What, for instance, is the difference in hysterectomy rates between black and white women in the South? Between poor and middle-class women? What, if any, significance can be read in this study about the traditional timidity and acceptance of professional authority shown by women in the South toward the largely white male ranks of physicians? Simply put, we need to know much more about what lies behind these disturbing rates."

The CDC study, "Hysterectomy Among Women of Reproductive Age, Unites States, Update for 1981- 1982," was published in the CDC Surveillance Summary, Vol. 35, No. ISS (June 1986). The study was conducted by Kathleen L Irwin, M.D. and Herbert B. Peterson, M.D. (both of the Epidemiologic Studies Branch) and Joyce M. Hughes and Sara W. Gill (of the Research and Statistics Branch), Division of Reproductive Health, Center for Health Promotion and Education.