Int Urogynecol J DOI 10.1007/s00192-014-2422-x
ORIGINAL ARTICLE
Hysterectomy and urinary incontinence in postmenopausal women Bela I. Kudish & David Shveiky & Robert E. Gutman & Vanessa Jacoby & Andrew I. Sokol & Rebecca Rodabough & Barabara V. Howard & Patricia Blanchette & Cheryl B. Iglesia
Received: 10 February 2014 / Accepted: 27 April 2014 # The International Urogynecological Association 2014
Abstract Introduction and hypothesis To evaluate an association between hysterectomy and urinary incontinence (UI) in postmenopausal women. Methods Women (aged 50–79) with uteri (N=53,569) and without uteri (N=38,524) who enrolled in the Women’s Health Initiative (WHI) Observational Study between 1993 and 1996 were included in this secondary analysis. Baseline
This paper was selected for a full oral presentation and presented at the 39th Annual Society of Gynecologic Surgeons Scientific Meeting in Charleston, SC, USA B. I. Kudish Division of Urogynecology, Obstetrics and Gynecology, Winnie Palmer Hospital, Orlando, FL, USA D. Shveiky Obstetrics and Gynecology, Hadassah, Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel R. E. Gutman : A. I. Sokol : C. B. Iglesia Obstetrics and Gynecology and Urology, Washington Hospital Center/Georgetown University, Washington, DC, USA V. Jacoby Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA R. Rodabough Fred Hutchinson Cancer Research Center, Seattle, WA, USA B. V. Howard MedStar, Bethesda, MD, USA P. Blanchette John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA B. I. Kudish (*) 2014 Water Key Drive, Windermere, FL 34786, USA e-mail: [email protected]
(BL) and 3-year demographic, health/physical forms and personal habit questionnaires were used. Statistical analyses included univariate and logistic regression methods. Results The baseline UI rate was 66.5 %, with 27.3 % of participants having stress urinary incontinence (SUI), 23 % having urge UI (UUI), and 12.4 % having mixed UI (MUI). 41.8 % of women had undergone hysterectomy, with 88.1 % having had the procedure before age 54. Controlling for health/physical variables, hysterectomy was associated with UI at BL (OR 1.25, 95 % CI 1.19, 1.32) and over the 3-year study period (OR 1.23, 95 % CI 1.11, 1.36). Excluding women with UI at BL, a higher incidence of UUI and SUI episodes was found in hysterectomy at year 3. Among women who had undergone hysterectomy, those with bilateral oophorectomy (BSO) did not have increased odds of developing UI at BL or over the 3-year study period. Hormone use was not associated with a change in UI incidence (estrogen + progesterone, p=0.17; unopposed estrogen, p=0.41). Conclusions Risk of UI is increased in postmenopausal women who had undergone hysterectomy compared with women with uteri. Keywords Hysterectomy . Urinary incontinence
Introduction Over 600,000 hysterectomy procedures are performed annually in the United States [1], with hysterectomy being the second most common major surgery after cesarean section. It is estimated that by age 60 about 40 % of US women have had a hysterectomy [2]. Nearly 90 % of hysterectomies are performed for benign indications, including fibroids, abnormal uterine bleeding, pelvic pain, and pelvic organ prolapse. Hysterectomy has been implicated as a risk factor for the development of urinary incontinence (UI), which is found in
Int Urogynecol J
up to 46 % of women over 60, with a population-based prevalence of 45 % in the USA [3, 4]. UI after hysterectomy can be the result of a lasting injury to the pelvic plexus at the time of uterosacral/cardinal ligament complex transection, bladder flap formation, and possibly disruption of the anatomical support to the bladder neck and urethra. Since 1950, multiple studies have attempted to evaluate the impact of hysterectomy on UI. They have looked at the impact of the hysterectomy route on UI, as well as the impact of hysterectomy on UI sub-types. Most prospective studies have a small sample size [5–7]. Both prospective and retrospective studies have shown increases, decreases, and no effect of hysterectomy on UI [5, 7–13]. The debate regarding the role of hysterectomy as a risk factor for UI continues. In this study, we use data from the observational study (OS) of the Women’s Health Initiative (WHI) to evaluate the association between hysterectomy and UI in a large cohort of postmenopausal women.
Materials and methods The Publications and Presentations committee of the Women’s Health Initiative (WHI) approved this secondary analysis. A total of 93,676 postmenopausal women aged 50 to 79 were enrolled in the WHI observational study (OS) at one of 40 clinical centers nationwide. The goal of the WHI OS was to evaluate to what extent known risk factors predict heart disease, cancers, and fractures, and to identify "new" risk factors for these and other diseases in women. WHI OS participants were not required to take any medication or change their behaviors/habits and their health was tracked over an average of 8 years. Women who joined this study completed baseline screening and enrollment questionnaires by interview and selfreport, a physical examination, and blood specimen collection. Baseline information included age, age at last delivery, race/ethnicity, education, occupation, overall quality of life (rated 1–10), chronic medical morbidities, time since menopause, parity, duration of prior hormone use, hysterectomy status, constipation, current and past smoking, and physical activity (episodes per week). Additionally, weight (kg), height (cm), and waist and hip circumferences (cm) were recorded. Route of childbirth (vaginal or cesarean) and history of POP and SUI surgery were not recorded. Routine follow-up for OS participants consisted of mailed self-administered questionnaires including questions on health habits, medical history, as well as psychosocial questionnaires. Three years after enrollment into the study, all OS participants were invited to a follow-up clinic visit. At the clinic visit, blood was drawn, medication and supplement use was recorded, and height, weight, blood pressure, waist, and hip circumference was measured.
Hysterectomy status was determined by the subject’s answer to the question “Did you ever have a hysterectomy?” Oophorectomy status was determined by the answer to the question “Did you ever have an operation to have one or both of your ovaries taken out?” Only women who answered “yes” with regard to both ovaries were considered as having had a bilateral oophorectomy (BSO) [14]. Age at both hysterectomy and oophorectomy was self-reported as ranges of less than 30, 30–34, 35–39, etc. Questions on UI were given at baseline and at 3 years only. They were based on similar items used and validated in previous epidemiological studies and included on a selfadministered quality of life form (available online at WHI. org). Participants who answered “yes” to the question “Have you ever leaked even a very small amount of urine involuntarily and you couldn’t control it?” were categorized as having UI. Those who answered the question “When do you usually leak urine?” with only “When I cough, laugh, sneeze, lift, stand up or exercise” were considered to have stress UI (SUI). Those who answered that they leak only “When I feel the need to urinate and can’t get to the toilet fast enough” were considered to have urge UI (UUI). Those who responded positively to both questions were considered to have mixed UI (MUI). Women who responded “Not once during the past year” or “no longer leak urine” were classified as continent. Descriptive characteristics at baseline were compared across hysterectomy status using Chi-squared tests of association. Bothersomeness of UI at baseline and year 3 was categorized as worse versus the same or better and related to the frequency of UI episodes to examine if the UI episode frequency adequately represented UI symptom severity. Multinomial logistic regression was used to examine the association between hysterectomy status and frequency of UI (overall and by sub-type—SUI, UUI, and MUI) at baseline. To find possibly stronger evidence for an association between hysterectomy and UI, the data on a prospective cohort (BL to 3 years) of women without UI at baseline were analyzed. Women with UI at baseline were excluded from multinomial logistic regression models examining the association between hysterectomy status and frequency of new UI episodes (overall and by sub-type) over the 3-year study period. All models were adjusted for age, ethnicity, income, smoking, alcohol use, BMI, waist circumference, physical activity, parity, years since menopause, age at BSO, years since hysterectomy, E-alone use status and duration, estrogen+ progesterone use status and duration, history of asthma, emphysema, and constipation. Information on the history of prolapse and incontinence surgeries before and during the study period was not available and was not used in the analyses. Women with missing values for any of these variables (n=1,583, 1.7 % at BL and n=11,290, 12.1 % at 3 years) and those who had undergone hysterectomy (n=1,250, 2.3 %)
Int Urogynecol J
during the 3 years were excluded from the models (Fig. 1). All statistical analyses were performed using SAS software version 9.2 (SAS Institute, Cary, NC, USA).
Results At baseline 93,676 postmenopausal women were included in the WHI OS study. Figure 1 shows the number of participants used for analyses at baseline (N=92,093) and at 3 years (N= 79,553). The cohort characteristics according to hysterectomy status are presented in Tables 1 and 2. Of the participants who had undergone hysterectomy, 88.1 % had had the procedure before age 54. BSO had been performed in 49.5 % of women who had undergone hysterectomy (HW) with 50.8 % having had BSO before the age of 40. The baseline UI rate was 66.5 %, with 27.3 % of participants having SUI, 23 % having UUI, and 12.4 % having MUI. Figure 1 reflects the change in the UI rate over the 3-year study period.
Table 1 contains baseline demographic, health, and personal habits characteristics. Use of a multinomial logistic regression, adjusting for the differences between the demographic categories, enabled evaluation of possible risk factors for UI. Black women were less likely to have SUI than white women (OR range 0.27–0.47, p
ORIGINAL ARTICLE
Hysterectomy and urinary incontinence in postmenopausal women Bela I. Kudish & David Shveiky & Robert E. Gutman & Vanessa Jacoby & Andrew I. Sokol & Rebecca Rodabough & Barabara V. Howard & Patricia Blanchette & Cheryl B. Iglesia
Received: 10 February 2014 / Accepted: 27 April 2014 # The International Urogynecological Association 2014
Abstract Introduction and hypothesis To evaluate an association between hysterectomy and urinary incontinence (UI) in postmenopausal women. Methods Women (aged 50–79) with uteri (N=53,569) and without uteri (N=38,524) who enrolled in the Women’s Health Initiative (WHI) Observational Study between 1993 and 1996 were included in this secondary analysis. Baseline
This paper was selected for a full oral presentation and presented at the 39th Annual Society of Gynecologic Surgeons Scientific Meeting in Charleston, SC, USA B. I. Kudish Division of Urogynecology, Obstetrics and Gynecology, Winnie Palmer Hospital, Orlando, FL, USA D. Shveiky Obstetrics and Gynecology, Hadassah, Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel R. E. Gutman : A. I. Sokol : C. B. Iglesia Obstetrics and Gynecology and Urology, Washington Hospital Center/Georgetown University, Washington, DC, USA V. Jacoby Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA R. Rodabough Fred Hutchinson Cancer Research Center, Seattle, WA, USA B. V. Howard MedStar, Bethesda, MD, USA P. Blanchette John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA B. I. Kudish (*) 2014 Water Key Drive, Windermere, FL 34786, USA e-mail: [email protected]
(BL) and 3-year demographic, health/physical forms and personal habit questionnaires were used. Statistical analyses included univariate and logistic regression methods. Results The baseline UI rate was 66.5 %, with 27.3 % of participants having stress urinary incontinence (SUI), 23 % having urge UI (UUI), and 12.4 % having mixed UI (MUI). 41.8 % of women had undergone hysterectomy, with 88.1 % having had the procedure before age 54. Controlling for health/physical variables, hysterectomy was associated with UI at BL (OR 1.25, 95 % CI 1.19, 1.32) and over the 3-year study period (OR 1.23, 95 % CI 1.11, 1.36). Excluding women with UI at BL, a higher incidence of UUI and SUI episodes was found in hysterectomy at year 3. Among women who had undergone hysterectomy, those with bilateral oophorectomy (BSO) did not have increased odds of developing UI at BL or over the 3-year study period. Hormone use was not associated with a change in UI incidence (estrogen + progesterone, p=0.17; unopposed estrogen, p=0.41). Conclusions Risk of UI is increased in postmenopausal women who had undergone hysterectomy compared with women with uteri. Keywords Hysterectomy . Urinary incontinence
Introduction Over 600,000 hysterectomy procedures are performed annually in the United States [1], with hysterectomy being the second most common major surgery after cesarean section. It is estimated that by age 60 about 40 % of US women have had a hysterectomy [2]. Nearly 90 % of hysterectomies are performed for benign indications, including fibroids, abnormal uterine bleeding, pelvic pain, and pelvic organ prolapse. Hysterectomy has been implicated as a risk factor for the development of urinary incontinence (UI), which is found in
Int Urogynecol J
up to 46 % of women over 60, with a population-based prevalence of 45 % in the USA [3, 4]. UI after hysterectomy can be the result of a lasting injury to the pelvic plexus at the time of uterosacral/cardinal ligament complex transection, bladder flap formation, and possibly disruption of the anatomical support to the bladder neck and urethra. Since 1950, multiple studies have attempted to evaluate the impact of hysterectomy on UI. They have looked at the impact of the hysterectomy route on UI, as well as the impact of hysterectomy on UI sub-types. Most prospective studies have a small sample size [5–7]. Both prospective and retrospective studies have shown increases, decreases, and no effect of hysterectomy on UI [5, 7–13]. The debate regarding the role of hysterectomy as a risk factor for UI continues. In this study, we use data from the observational study (OS) of the Women’s Health Initiative (WHI) to evaluate the association between hysterectomy and UI in a large cohort of postmenopausal women.
Materials and methods The Publications and Presentations committee of the Women’s Health Initiative (WHI) approved this secondary analysis. A total of 93,676 postmenopausal women aged 50 to 79 were enrolled in the WHI observational study (OS) at one of 40 clinical centers nationwide. The goal of the WHI OS was to evaluate to what extent known risk factors predict heart disease, cancers, and fractures, and to identify "new" risk factors for these and other diseases in women. WHI OS participants were not required to take any medication or change their behaviors/habits and their health was tracked over an average of 8 years. Women who joined this study completed baseline screening and enrollment questionnaires by interview and selfreport, a physical examination, and blood specimen collection. Baseline information included age, age at last delivery, race/ethnicity, education, occupation, overall quality of life (rated 1–10), chronic medical morbidities, time since menopause, parity, duration of prior hormone use, hysterectomy status, constipation, current and past smoking, and physical activity (episodes per week). Additionally, weight (kg), height (cm), and waist and hip circumferences (cm) were recorded. Route of childbirth (vaginal or cesarean) and history of POP and SUI surgery were not recorded. Routine follow-up for OS participants consisted of mailed self-administered questionnaires including questions on health habits, medical history, as well as psychosocial questionnaires. Three years after enrollment into the study, all OS participants were invited to a follow-up clinic visit. At the clinic visit, blood was drawn, medication and supplement use was recorded, and height, weight, blood pressure, waist, and hip circumference was measured.
Hysterectomy status was determined by the subject’s answer to the question “Did you ever have a hysterectomy?” Oophorectomy status was determined by the answer to the question “Did you ever have an operation to have one or both of your ovaries taken out?” Only women who answered “yes” with regard to both ovaries were considered as having had a bilateral oophorectomy (BSO) [14]. Age at both hysterectomy and oophorectomy was self-reported as ranges of less than 30, 30–34, 35–39, etc. Questions on UI were given at baseline and at 3 years only. They were based on similar items used and validated in previous epidemiological studies and included on a selfadministered quality of life form (available online at WHI. org). Participants who answered “yes” to the question “Have you ever leaked even a very small amount of urine involuntarily and you couldn’t control it?” were categorized as having UI. Those who answered the question “When do you usually leak urine?” with only “When I cough, laugh, sneeze, lift, stand up or exercise” were considered to have stress UI (SUI). Those who answered that they leak only “When I feel the need to urinate and can’t get to the toilet fast enough” were considered to have urge UI (UUI). Those who responded positively to both questions were considered to have mixed UI (MUI). Women who responded “Not once during the past year” or “no longer leak urine” were classified as continent. Descriptive characteristics at baseline were compared across hysterectomy status using Chi-squared tests of association. Bothersomeness of UI at baseline and year 3 was categorized as worse versus the same or better and related to the frequency of UI episodes to examine if the UI episode frequency adequately represented UI symptom severity. Multinomial logistic regression was used to examine the association between hysterectomy status and frequency of UI (overall and by sub-type—SUI, UUI, and MUI) at baseline. To find possibly stronger evidence for an association between hysterectomy and UI, the data on a prospective cohort (BL to 3 years) of women without UI at baseline were analyzed. Women with UI at baseline were excluded from multinomial logistic regression models examining the association between hysterectomy status and frequency of new UI episodes (overall and by sub-type) over the 3-year study period. All models were adjusted for age, ethnicity, income, smoking, alcohol use, BMI, waist circumference, physical activity, parity, years since menopause, age at BSO, years since hysterectomy, E-alone use status and duration, estrogen+ progesterone use status and duration, history of asthma, emphysema, and constipation. Information on the history of prolapse and incontinence surgeries before and during the study period was not available and was not used in the analyses. Women with missing values for any of these variables (n=1,583, 1.7 % at BL and n=11,290, 12.1 % at 3 years) and those who had undergone hysterectomy (n=1,250, 2.3 %)
Int Urogynecol J
during the 3 years were excluded from the models (Fig. 1). All statistical analyses were performed using SAS software version 9.2 (SAS Institute, Cary, NC, USA).
Results At baseline 93,676 postmenopausal women were included in the WHI OS study. Figure 1 shows the number of participants used for analyses at baseline (N=92,093) and at 3 years (N= 79,553). The cohort characteristics according to hysterectomy status are presented in Tables 1 and 2. Of the participants who had undergone hysterectomy, 88.1 % had had the procedure before age 54. BSO had been performed in 49.5 % of women who had undergone hysterectomy (HW) with 50.8 % having had BSO before the age of 40. The baseline UI rate was 66.5 %, with 27.3 % of participants having SUI, 23 % having UUI, and 12.4 % having MUI. Figure 1 reflects the change in the UI rate over the 3-year study period.
Table 1 contains baseline demographic, health, and personal habits characteristics. Use of a multinomial logistic regression, adjusting for the differences between the demographic categories, enabled evaluation of possible risk factors for UI. Black women were less likely to have SUI than white women (OR range 0.27–0.47, p
