Inl J Gynaecol Obsiet 17: 263-264, 1979
Hysterectomy Following Sterilization C. O'Herlihy and C. Chandler Department of Obstetrics and Gynaecology, University of Leeds, Leeds, England
ABSTRACT O'Herlihy C, Chandler C (Dept of Obstetrics and Gynaecology, University of Leeds, Leeds, England). Hysterectomy following sterilization. Inl J Gynaecol Obstet 17: 263-264, 1979 In a review of ¿08 cases of consecutively selected women undergoing hysterectomy for nonmalignant disease, it was found that one third of the patients or their husbands had previously been sterilized. In many instances, the gynecologic problem necessitating hysterectomy antedated the sterilizing procedure. It is postulated that, when couples request sterilization, two operations might be avoided if routine consideration were given to any condition that might lead to hysterectomy.
women; in 36 cases (33.3%) either the patient or her husband had previously been sterilized. RESULTS Indication for hysterectomy T h e chief indications for hysterectomy are listed in Table I. T h e frequency of dysfunctional uterine bleeding, cervical dysplasia and dysmenorrhea was higher in the previously sterilized group. Among these women, 20 (55.5%) had undergone tubal occlusion, while the husbands of the remaining 16 patients had undergone vasectomy. Time of indication
INTRODUCTION Surgical sterilization for social rather than medical indications has recently become more acceptable to relatively young women. Concurrently, the traditional indications for hysterectomy have expanded to include functional uterine disorders or simply sterilization (1, 3). Not surprisingly, therefore, many patients who now must undergo hysterectomy have already been sterilized. This report analyzes such a group, including women whose partners had been vasectomized. The authors have attempted to identify circumstances where two operations could have been avoided by consideration of any possible indication for hysterectomy at the time when sterilization was requested.
PATIENTS A N D M E T H O D S All patients under 45 years of age, undergoing hysterectomy for nonmalignant disease in the Professorial Unit of the Hospital for Women at Leeds, England, were prospectively studied over an eightmonth period from March to November, 1977. This consecutively selected group was comprised of 108
In a majority of cases (52.7%), it could be deduced that the ultimate indication for hysterectomy h a d been present at the time of sterilization (Table II). This was more often the case after the husband had been sterilized. When the problem developed following sterilization, in almost one third of the cases symptoms commenced immediately on cessation of oral contraception or after puerperal sterilization. Patient characteristics T h e mean age at hysterectomy was 36.5 years (range from 23 to 44 years) in previously sterilized patients compared with 39.7 years in the nonsterilized group (range from 26 to 44). T h e women in the former group were of higher parity, and for 80.5% of them hysterectomy was performed vaginally; only 58.3% of the nonsterilized women had a vaginal operation. Where the male partner had undergone vasectomy, the mean interval to hysterectomy was 3.4 years, compared with 6.9 years following tubal occlusion.
DISCUSSION This study confirms that omission of gynecologic assessment, including cervical cytology, prior to ster-
InlJ Gynaecol Obstet 17
264
O'Herlihy and Chandler
Table I. Chief indication for hysterectomy in 108 patients. Previously Sterilized (N = 36) Indication Dysfunctional uterine bleeding Abnormal cervical cytology Uterine myomata Dysmenorrhea Prolapse Endometriosis Termination of pregnancy
Nonsterilized (N = 72)
No.
%
No.
%
21
58.5
36
50.0
6 3 3 3 -
16.6 8.3 8.3 8.3 -
9 11 1 6 5
12.5 15.4 1.4 8.3 6.9
-
-
4
5.5
sterilizing procedure include avoidance of future risks of uterine malignancy and menstrual symptoms (6). Because of its absolute irreversibility, it is certainly not the method of choice for relatively young women or those with an unstable marriage or in the puerperium (8). With increasing appreciation of the risks of longterm hormonal contraception (7), more couples are likely to consider sterilization. Assessment of the female partner should be undertaken in each case and hysterectomy considered as the most appropriate sterilizing procedure when a gynecologic problem exists, especially when the patient is over 35 years of age.
ACKNOWLEDGMENT Table II. Relationship between sterilization and development of problem necessitating hysterectomy. Problem Presterilization (N = 19)
Tubal occlusion Vasectomy
Problem Poststerilization (N = 17)
No.
%
No.
%
9 10
45.0 62.5
11 6
55.0 37.5
ilization of either partner leads to an unnecessarily high incidence of subsequent hysterectomy for unsuspected disease. This sequel was more common when the male had been sterilized. Vasectomy is not usually performed by a gynecologist and our data show that a problem frequently preexisted in the female partner leading to hysterectomy within five years. Dysfunctional uterine bleeding was the problem necessitating hysterectomy in the majority of our sterilized patients. As noted by others (2, 5), this was often the result of diminished tolerance of menstruation, especially when cessation of oral contraceptives or pregnancy immediately preceded sterilization. Cervical cytologic atypia and uterovaginal prolapse are likely to be more common in sterilized patients because of their association with parity a n d coitus (4), although such a preponderance was only slight in our series. T h e particular advantages of hysterectomy as a
IntJ Gynaecol Obstet 17
T h e authors are grateful to Professor J. S. Scott for his help in preparation of this article.
REFERENCES 1. Burchell R C : Decision regarding hysterectomy. Am J O b stet Gynecol /27.113, 1977. 2. Chamberlain G V , Foulkes J : Late complications of sterilisation by laparoscopy. Lancet 2:878, 1975. 3. Hysterectomy a n d sterilisation (editorial). Br Med J 2.715, 1977. 4. Haynes D N , Wolff VVM: T u b a l sterilization in an indigent population. Am J Obstet Gynecol /06V1O44, 1070. 5. Late complications of female sterilisation (editorial). Lancet /:573, 1976. 6. Muldoon M J : Gynaecological illness after sterilisation. Br Med J /:84, 1972. 7. Royal College of General Practitioners Study: Mortality a m o n g oral contraceptive users. Lancet 2:727, 1977. 8. Winston R M : W h y 103 asked for reversal of sterilisation. Br Med J 2:305, 1977.
Address for reprints: C. O'Herlihy Dept of Obstetrics and Gynaecology University of Melbourne Parkville, Victoria 3052 Australia
Hysterectomy Following Sterilization C. O'Herlihy and C. Chandler Department of Obstetrics and Gynaecology, University of Leeds, Leeds, England
ABSTRACT O'Herlihy C, Chandler C (Dept of Obstetrics and Gynaecology, University of Leeds, Leeds, England). Hysterectomy following sterilization. Inl J Gynaecol Obstet 17: 263-264, 1979 In a review of ¿08 cases of consecutively selected women undergoing hysterectomy for nonmalignant disease, it was found that one third of the patients or their husbands had previously been sterilized. In many instances, the gynecologic problem necessitating hysterectomy antedated the sterilizing procedure. It is postulated that, when couples request sterilization, two operations might be avoided if routine consideration were given to any condition that might lead to hysterectomy.
women; in 36 cases (33.3%) either the patient or her husband had previously been sterilized. RESULTS Indication for hysterectomy T h e chief indications for hysterectomy are listed in Table I. T h e frequency of dysfunctional uterine bleeding, cervical dysplasia and dysmenorrhea was higher in the previously sterilized group. Among these women, 20 (55.5%) had undergone tubal occlusion, while the husbands of the remaining 16 patients had undergone vasectomy. Time of indication
INTRODUCTION Surgical sterilization for social rather than medical indications has recently become more acceptable to relatively young women. Concurrently, the traditional indications for hysterectomy have expanded to include functional uterine disorders or simply sterilization (1, 3). Not surprisingly, therefore, many patients who now must undergo hysterectomy have already been sterilized. This report analyzes such a group, including women whose partners had been vasectomized. The authors have attempted to identify circumstances where two operations could have been avoided by consideration of any possible indication for hysterectomy at the time when sterilization was requested.
PATIENTS A N D M E T H O D S All patients under 45 years of age, undergoing hysterectomy for nonmalignant disease in the Professorial Unit of the Hospital for Women at Leeds, England, were prospectively studied over an eightmonth period from March to November, 1977. This consecutively selected group was comprised of 108
In a majority of cases (52.7%), it could be deduced that the ultimate indication for hysterectomy h a d been present at the time of sterilization (Table II). This was more often the case after the husband had been sterilized. When the problem developed following sterilization, in almost one third of the cases symptoms commenced immediately on cessation of oral contraception or after puerperal sterilization. Patient characteristics T h e mean age at hysterectomy was 36.5 years (range from 23 to 44 years) in previously sterilized patients compared with 39.7 years in the nonsterilized group (range from 26 to 44). T h e women in the former group were of higher parity, and for 80.5% of them hysterectomy was performed vaginally; only 58.3% of the nonsterilized women had a vaginal operation. Where the male partner had undergone vasectomy, the mean interval to hysterectomy was 3.4 years, compared with 6.9 years following tubal occlusion.
DISCUSSION This study confirms that omission of gynecologic assessment, including cervical cytology, prior to ster-
InlJ Gynaecol Obstet 17
264
O'Herlihy and Chandler
Table I. Chief indication for hysterectomy in 108 patients. Previously Sterilized (N = 36) Indication Dysfunctional uterine bleeding Abnormal cervical cytology Uterine myomata Dysmenorrhea Prolapse Endometriosis Termination of pregnancy
Nonsterilized (N = 72)
No.
%
No.
%
21
58.5
36
50.0
6 3 3 3 -
16.6 8.3 8.3 8.3 -
9 11 1 6 5
12.5 15.4 1.4 8.3 6.9
-
-
4
5.5
sterilizing procedure include avoidance of future risks of uterine malignancy and menstrual symptoms (6). Because of its absolute irreversibility, it is certainly not the method of choice for relatively young women or those with an unstable marriage or in the puerperium (8). With increasing appreciation of the risks of longterm hormonal contraception (7), more couples are likely to consider sterilization. Assessment of the female partner should be undertaken in each case and hysterectomy considered as the most appropriate sterilizing procedure when a gynecologic problem exists, especially when the patient is over 35 years of age.
ACKNOWLEDGMENT Table II. Relationship between sterilization and development of problem necessitating hysterectomy. Problem Presterilization (N = 19)
Tubal occlusion Vasectomy
Problem Poststerilization (N = 17)
No.
%
No.
%
9 10
45.0 62.5
11 6
55.0 37.5
ilization of either partner leads to an unnecessarily high incidence of subsequent hysterectomy for unsuspected disease. This sequel was more common when the male had been sterilized. Vasectomy is not usually performed by a gynecologist and our data show that a problem frequently preexisted in the female partner leading to hysterectomy within five years. Dysfunctional uterine bleeding was the problem necessitating hysterectomy in the majority of our sterilized patients. As noted by others (2, 5), this was often the result of diminished tolerance of menstruation, especially when cessation of oral contraceptives or pregnancy immediately preceded sterilization. Cervical cytologic atypia and uterovaginal prolapse are likely to be more common in sterilized patients because of their association with parity a n d coitus (4), although such a preponderance was only slight in our series. T h e particular advantages of hysterectomy as a
IntJ Gynaecol Obstet 17
T h e authors are grateful to Professor J. S. Scott for his help in preparation of this article.
REFERENCES 1. Burchell R C : Decision regarding hysterectomy. Am J O b stet Gynecol /27.113, 1977. 2. Chamberlain G V , Foulkes J : Late complications of sterilisation by laparoscopy. Lancet 2:878, 1975. 3. Hysterectomy a n d sterilisation (editorial). Br Med J 2.715, 1977. 4. Haynes D N , Wolff VVM: T u b a l sterilization in an indigent population. Am J Obstet Gynecol /06V1O44, 1070. 5. Late complications of female sterilisation (editorial). Lancet /:573, 1976. 6. Muldoon M J : Gynaecological illness after sterilisation. Br Med J /:84, 1972. 7. Royal College of General Practitioners Study: Mortality a m o n g oral contraceptive users. Lancet 2:727, 1977. 8. Winston R M : W h y 103 asked for reversal of sterilisation. Br Med J 2:305, 1977.
Address for reprints: C. O'Herlihy Dept of Obstetrics and Gynaecology University of Melbourne Parkville, Victoria 3052 Australia
