In Deutschland wird Frauen viel häufiger auf Grund von Myomen die Gebärmutter entfernt als in Frankreich und England!

Dies geht aus der folgenden Studie hervor!
http://www.jmig.org/article/S1553-4650(08)00977-1/abstract

10. November 2008 in der Journal of Minimally Invasive Gynecology

Measurements and Main Results

We identified the number and type of hospital admissions involving surgical or radiologic interventions for uterine myomas, through the analysis of national hospital activity databases from each country. We calculated the costs of these hospitalizations to payers in these countries using the diagnosis-related group reimbursement rates.
In 2005, the number (rate) of hospital admissions involving interventions for uterine myomas was 64 299 (1.53/1000 women) in Germany, 37 787 (1.17/1000 women) in France, and 18 274 (0.71/1000 women) in England. The annual costs of these interventions to payers were €212 313 090 in Germany, €73 278 270 in France (excluding surgeon and anesthetist fees for interventions in the private sector), and €52 674 672 in England.

The percentage of interventions for uterine myomas that included a hysterectomy was 84.9% in Germany, 59.7% in France, and 64.1% in England.

Conclusion

The number of admissions and costs associated with interventions for uterine myomas are substantial in the 3 European countries studied. Hysterectomy is the most frequent surgical intervention used to treat uterine myomas. The results in this article provide useful information for policy makers wishing to evaluate the cost effectiveness and budget impact of new, less invasive interventions.


Operationszahlen:

New York Times:
The New York Times
In a Culture of Hysterectomies, Many Question Their Necessity
Article Tools Sponsored By
By NATALIE ANGIER
Published: February 17, 1997
Whatever happens tomorrow, hysterectomies are a staple of gynecological surgery. By the age of 60, 1 in 3 American women will have had their uteri removed. In Italy, by comparison, the figure is 1 in 6 women, while in France, it is only 1 in 18.

http://query.nytimes.com/gst/fullpage.html?sec=health&res=9C00E5D8103FF9


„Auch wenn Hysterektomie mit Ovarektomie in Frankreich weniger häufig praktiziert wie wie in anderen Ländern, ist diese Operation oft der letzte Ausweg um schweren gynäkologischen Problemen zu begegnen: Fibrome des Uterus, schwere genitale Blutungen, und vor allem Endometriose“, erklärt uns Herr Prof. Pierre Mares, Chef der Gynäkologie des CHU in Nîmes. Seltener sind diese Operationen wegen Gebärmuttervorfall (Prolaps), Unterleibsschmerzen, einer abnormalen Verdickung des Endometriums, gynäkologischem Krebs, Unterbauchinfektionen und Schwangerschaftskomplikationen notwendig ….

Man rechnet also mit an einer Million Frauen im Alter von 20 bis 74, die sich in der chirurgischen Menopause befinden. Trotz dieser Zahlen handelt es sich auch heute noch um ein Tabuthema.

http://www.doctissimo.fr/html/sexualite/troubles/8273-viagra-feminin-commercia


Rosa-Luxemburg-Stiftung - Seminiarreihe Zukunft sozialer Sicherung - August 2005
1Viola Schubert-Lehnhardt
Gender Mainstreaming und Gender Budgeting in der Gesundheitsförderung in der Gesundheitspolitik
Ein weiterer Aspekt zum Thema unterschiedliche Versorgungsqualität sind auch die international unterschiedlichen Operationszahlen zur Entfernung der Gebärmutter. Diese lassen sich nicht, so die Meinung der ExpertInnen, durch Unterschiede in der Erkrankungshäufigkeit erklären. G. Buse beschreibt dazu folgende Fakten: je 100.000

Frauen waren gab es 1995 folgende Zahl von Hysterektomien

476 in der BRD
130 in Norwegen
90 in Frankreich.

In einzelnen Regionen eines Landes differieren die Zahlen ebenfalls, je nach Zahl der niedergelassenen Frauenärztinnen und verfügbaren Betten. In Deutschland kommt noch die Notwendigkeit des Nachweises einer bestimmten Anzahl dieser Operationen für die angehenden FachärztInnen der Gynäkologie hinzu. Über die Risiken dieser Operation (auch nach abgeschlossenem Kinderwunsch) werde dagegen wenig gesprochen. Diese bestehen in Beckenboden- und Blasenfunktionsstörungen, häufigeres Auftreten von Osteoporose und kardiovaskulärer Erkrankungen, Nierenkrebs, sowie psychischen Problemen für die betroffenen Frauen. Generell bestünde auch eine Forschungslücke zu Langzeitfolgen dieser Operation.5

http://www.rosalux.de/cms/fileadmin/rls_uploads/pdfs/Themen/Sozialpolitik/GM_und_GB_in_der_Gesundheitspolitik.pdf


Häufigkeit von Hysterektomien von Land zu Land verschieden:

In den 90er-Jahren schwankte die Zahl der Hysterektomien pro 100.000 Frauen zwischen 550 in USA und 90 in Frankreich.
Für Deutschland wird der Anteil der Hysterektomien pro 100.000 Einwohnerinnen zwischen 350 und 181 (Durchschnitt der Jahre 1995 bis 1997, alte Bundesländer) angegeben. Allgemein wird davon ausgegangen, dass in Deutschland jede 3. Frau im Laufe ihres Lebens von einer Hysterektomie betroffen ist.  Allgemein wird davon ausgegangen, dass die Hysterektomiehäufigkeit
in Deutschland heute deutlich niedriger ist als in den 80er-Jahren. Die bereits erwähnte BIPSBefragung im Jahr 2000 wurde im Rahmen eines EUProjektes mit finnischen, spanischen, britischen und portugiesischen Kooperationspartner/innen durchgeführt.

Erste Ergebnisse zeigen, dass von den verglichenen Regionen der Anteil der hysterektomierten Frauen in Bremen am höchsten ist. Als Fazit ist festzuhalten, dass es keine Zweifel daran gibt, dass die Hysterektomie in westlichen Ländern zu häufig durchgeführt wird. Dies hängt damit zusammen, dass noch immer die Hysterektomie bei gutartigen Erkrankungen den schonenderen und organerhaltenden Vorgehensweisen vorgezogen wird. Eine bessere Information der Frauen und höhere Transparenz von Seiten der Krankenhäuser könnte die Situation bessern.

http://www2.bremen.de/info/frauengesundheitsbericht/Downloads/kap1_5.pdf

---

"Im Jahr 2002 wurden in Deutschland 88.700 Hysterektomien dokumentiert (BQS  2003). Insbesondere die Zahl von Hysterektomien bei Patientinnen unter 35 Jahren mit  benigner (d.h. gutartiger) Erkrankung wird als sehr hoch bewertet (BQS 2003, 2004)."  Letztere betrugen im Jahr 2002 N=2.322, 2003: N=2.482.

Die BQS-Berichte finden Sie unter: http://www.bqs-online.de/
Ende Januar bringt das Robert Koch Institut einen Bericht dazu heraus, also bitte dahin wenden bzgl. Zahlen.

Feministisches Frauen Gesundheits Zentrum e.V., Berlin
Internet: http://www.ffgz.de

Behandlungsqualität in Kliniken: Mehr Daten, aber nicht mehr Transparenz für Laien
Mittwoch, 16. August 2006
…………………………………………………..
Marion Rink, Patientenvertreterin im Gemeinsamen Bundesausschuss, lobte die Arbeit der BQS wie auch die Mitarbeit der Krankenhäuser. Sie forderte aber, der so genannte strukturierte Dialog zwischen der BQS und den Krankenhäusern, aus deren Datenlieferungen auf Qualitätsprobleme geschlossen wird, müsse vereinfacht und transparenter werden. Noch sei häufig unklar, ob und wie erkannte Defizite beseitigt würden. Als Beispiel für notwendige Qualitätsverbesserungen verwies sie auf Angaben, wonach seit drei Jahren bei rund einem Viertel aller Eierstockentfernungen ein unauffälliger histologischer Befund folgte. © Rie/aerzteblatt.de

http://www.aerzteblatt.de/v4/news/news.asp?id=25306

Lancet. 1988 Dec 24-31;2(8626-8627):1470-3. Links
Effect of information campaign by the mass media on hysterectomy rates.

• Domenighetti G,
• Luraschi P,
• Casabianca A,
• Gutzwiller F,
• Spinelli A,
• Pedrinis E,
• Repetto F.

Department of Social Affairs, Cantonal Health Office, Bellinzona, Switzerland.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&list_uids=2904581&cmd=Retrieve&indexed=google

1: Maturitas. 1983 Aug;5(2):69-75. Links
Hysterectomy in six European countries.

• van Keep PA,
• Wildemeersch D,
• Lehert P.

Gynaecologists have been criticized in recent years because of their attitude towards hysterectomy; it is often stated that they are too ready to consider hysterectomy to be indicated and that hysterectomies are carried out too frequently. In order to obtain insight into the incidence of hysterectomy, 2066 women between 40 and 70 yr of age, composing a sample covering 6 European countries, were asked whether they had undergone this operation. Of the total sample, 11.4% had been hysterectomized, the highest percentage being found in Italy (15.5%) and the lowest in France (8.5%). The most important factor that influenced the relative frequency of hysterectomy was age: the percentage of women who had undergone hysterectomy increased with age up to 55-59 yr, but fell thereafter. Another significant factor was civil status; there were fewer divorcees or widows at the moment of operation than married or never-married women. The relationship between the incidence of hysterectomy and age is a parabolic one. To explain this curve the authors postulate that two trends must have played a role: firstly; a greater need for hysterectomy with increasing age and, secondly a decrease in the reluctance of the gynaecological profession to perform a hysterectomy and/or of women to undergo this operation. Statistical analysis confirms the existence of this second trend over the period 1960-1975. The chances of a young woman losing her uterus before her 70th year went up linearly to 19.8% in 1975. By extrapolation a figure of 21% is obtained for 1980. Satisfaction with the result of the operation was lowest in Italy and Germany; satisfaction was also lowest in rural areas.

PMID: 6633270 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Retrieve&list_uids=6633270

1: BJOG. 2004 Jul;111(7):688-94. Links
Severe complications of hysterectomy: the VALUE study.

• McPherson K,
• Metcalfe MA,
• Herbert A,
• Maresh M,
• Casbard A,
• Hargreaves J,
• Bridgman S,
• Clarke A.

Nuffield Department of Obstetrics and Gynaecology, Oxford, UK.
OBJECTIVES: To model the determinants of serious operative and post-operative complications of hysterectomy and their potential risk factors. DESIGN: A prospective cohort of women undergoing hysterectomies for benign indications in 1994/1995, with a six-week postsurgery follow up. POPULATION AND SETTING: A total of 37,512 women from 276 NHS and 145 private hospitals in England, Wales and Northern Ireland, originally recruited to compare the outcomes of endometrial destruction with those of hysterectomy. METHODS: Gynaecologists reported hysterectomies for non-malignant indications carried out during a 12-month period beginning in October 1994 and follow up data were obtained at outpatient follow up six weeks postsurgery. Odds ratios of severe complications by indication and method, adjusting for measured intrinsic risk factors, were calculated. MAIN OUTCOME MEASURES: Severe operative and post-operative complications. RESULTS: Severe operative complications occurred in 3%. The risk decreased with age and increased with greater parity and history of serious illness. Women with symptomatic fibroids (4.4%, 95% CI 3.9-4.9) experienced more complications than women with dysfunctional uterine bleeding (3.6%, 3.2-3.8), adjusted odds ratio (OR) = 1.3 (95% CI 1.1-1.6). Laparoscopic procedures (6.1%) doubled the risk of operative complications of abdominal hysterectomy (3.6%) (adjusted OR = 1.9, 1.5-2.5). Post-operative complications occurred in around 1% of women, with a slight decrease with increasing age, and the strongest risk factor was a history of operative complications. Relative to dysfunctional uterine bleeding (1.0%), a higher risk for fibroids (1.2%) persisted after adjustments (RR = 1.5, 1.1-2.0). Both vaginal (1.2%) and laparoscopic (1.7%) techniques had significantly higher adjusted risks than abdominal operations (0.9%), RR = 1.4 (1.0-1.9) and RR = 1.6 (1.0-2.7). There were no operative deaths; 14 women died within the six-week postsurgery (a crude mortality rate of 3.8/1000, 2.5-6.4). CONCLUSIONS: Hysterectomy is a common, routine surgery with comparatively rare serious complications. However, younger women, women with more vascular pelvis, who undergo hysterectomy, especially laparoscopically assisted vaginal surgery for symptomatic fibroids, are at most risk of experiencing severe complications both operatively and post-operatively. Therefore, a less invasive alternative treatment for symptomatic fibroids could particularly benefit this group of women, while less invasive treatments for dysfunctional uterine bleeding, such as various methods of endometrial ablations or resections, would need to meet the current low levels of clinical complications in order to replace hysterectomy.
PMID: 15198759 [PubMed - indexed for MEDLINE]

Related Links

• The VALUE national hysterectomy study: description of the patients and their surgery. [BJOG. 2002] PMID: 11950186
• Psychosexual health 5 years after hysterectomy: population-based comparison with endometrial ablation for dysfunctional uterine bleeding. [Health Expect. 2005] PMID: 16098153
• Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals. [Hum Reprod. 2007] PMID: 16950826
• A two years audit of complications of hysterectomy at Ayub Teaching Hospital Abbottabad. [J Ayub Med Coll Abbottabad. 2005] PMID: 16092651
• Hysterectomy and race. [Obstet Gynecol. 1993] PMID: 8414322
• See all Related Articles...

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Apr 30 2007 04:56:27

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15198759

Am J Public Health. 2000 September; 90(9): 1455-1458.

Copyright notice
Biosocial determinants of hysterectomy in New Zealand.
A Dharmalingam, I Pool, and J Dickson
Population Studies Centre, University of Waikato, Hamilton, New Zealand. dharma@waikato.ac.nz

Abstract
OBJECTIVES: This study examined the prevalence and biosocial correlates of hysterectomy. METHODS: Data were from a 1995 national survey of women aged 20 to 59 years. We applied piecewise nonparametric exponential hazards models to a subsample aged 25 to 59 to estimate the effects of biosocial correlates on hysterectomy likelihood. RESULTS: Risks of hysterectomy for 1991 through 1995 were lower than those before 1981. University-educated and professional women were less likely to undergo hysterectomy. Higher parity and intrauterine device side effects increased the risk. CONCLUSIONS: This study confirms international results, especially those on education and occupation, but also points to ethnicity's mediating role. Education and occupation covary independently with hysterectomy. Analysis of time variance and periodicity showed declines in likelihood from 1981.

Full Text
The Full Text of this article is available as a PDF (73K).
Selected References
This list contains those references that cite another article in PMC or have a citation in PubMed. It may not include all the original references for this article.

• Pokras R, Hufnagel VG. Hysterectomy in the United States, 1965-84. Am J Public Health. 1988 Jul;78(7):852-853. [PubMed]
• Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med. 1993 Mar 25;328(12):856-860. [PubMed]
• Scott HM, Scott WG. Hysterectomy for nonmalignant conditions: cost to New Zealand society. N Z Med J. 1995 Oct 27;108(1010):423-426. [PubMed]
• Bachmann GA. Hysterectomy. A critical review. J Reprod Med. 1990 Sep;35(9):839-862. [PubMed]
• Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med. 1988;27(9):987-994. [PubMed]
• Borman B, McKenna S, Findlay J. Hysterectomies in New Zealand. N Z Med J. 1986 Jun 25;99(804):470. [PubMed]
• McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982 Nov 18;307(21):1310-1314. [PubMed]
• Pokras R. Hysterectomy: past, present and future. Stat Bull Metrop Insur Co. 1989 70(4):12-21.Oct-Dec; [PubMed]
• Macintosh MC. Incidence of hysterectomy in New Zealand. N Z Med J. 1987 Jun 10;100(825):345-347. [PubMed]
• Santow G. Education and hysterectomy. Aust N Z J Obstet Gynaecol. 1995 Feb;35(1):60-69. [PubMed]
• Santow G, Bracher M. Correlates of hysterectomy in Australia. Soc Sci Med. 1992 Apr;34(8):929-942. [PubMed]
• Yusuf F, Briggs DK. Incidence of hysterectomy and tubal ligation in public hospitals in south Australia, 1980-82. J Biosoc Sci. 1988 Oct;20(4):453-459. [PubMed]
• Roos NP. Hysterectomies in one Canadian Province: a new look at risks and benefits. Am J Public Health. 1984 Jan;74(1):39-46. [PubMed]
• Paul C, Skegg DC, Smeijers J, Spears GF. Contraceptive practice in New Zealand. N Z Med J. 1988 Dec 14;101(859):809-813. [PubMed]
• Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988-1990. Obstet Gynecol. 1994 Apr;83(4):549-555. [PubMed]
• Kjerulff K, Langenberg P, Guzinski G. The socioeconomic correlates of hysterectomies in the United States. Am J Public Health. 1993 Jan;83(1):106-108. [PubMed]
• Brett KM, Marsh JV, Madans JH. Epidemiology of hysterectomy in the United States: demographic and reproductive factors in a nationally representative sample. J Womens Health. 1997 Jun;6(3):309-316. [PubMed]
• Meilahn EN, Matthews KA, Egeland G, Kelsey SF. Characteristics of women with hysterectomy. Maturitas. 1989 Dec;11(4):319-329. [PubMed]
• Dickinson JA, Leeder SR, Sanson-Fisher RW. Frequency of cervical smear-tests among patients of general practitioners. Med J Aust. 1988 Feb 1;148(3):128-131. [PubMed]
• Ryan M, Dennerstein L. Hysterectomy and tubal ligation. Adv Psychosom Med. 1986;15:180-198. [PubMed]
• Muldoon MJ. Gynaecological Illness after Sterilization. Br Med J. 1972 Jan 08;1(5792):84-85. [PubMed]
• Selwood T, Wood C. Incidence of hysterectomy in Australia. Med J Aust. 1978 Aug 26;2(5):201-204. [PubMed]
• Templeton AA, Cole S. Hysterectomy following sterilization. Br J Obstet Gynaecol. 1982 Oct;89(10):845-848. [PubMed]
• Stergachis A, Shy KK, Grothaus LC, Wagner EH, Hecht JA, Anderson G, Normand EH, Raboud J. Tubal sterilization and the long-term risk of hysterectomy. JAMA. 1990 Dec 12;264(22):2893-2898. [PubMed]
• Bunker JP, Brown BW Jr. The physician-patient as an informed consumer of surgical services. N Engl J Med. 1974 May 9;290(19):1051-1055. [PubMed]
• Domenighetti G, Casabianca A, Gutzwiller F, Martinoli S. Revisiting the most informed consumer of surgical services. The physician-patient. Int J Technol Assess Health Care. 1993 9(4):505-513.Fall; [PubMed]
• Marks NF, Shinberg DS. Socioeconomic differences in hysterectomy: the Wisconsin Longitudinal Study. Am J Public Health. 1997 Sep;87(9):1507-1514. [PubMed]
• Schacht PJ, Pemberton A. What is unnecessary surgery? Who shall decide? Issues of consumer sovereignty, conflict and self-regulation. Soc Sci Med. 1985;20(3):199-206. [PubMed]
• van Keep PA, Wildemeersch D, Lehert P. Hysterectomy in six European countries. Maturitas. 1983 Aug;5(2):69-75. [PubMed]
• Domenighetti G, Luraschi P, Casabianca A, Gutzwiller F, Spinelli A, Pedrinis E, Repetto F. Effect of information campaign by the mass media on hysterectomy rates. Lancet. 2(8626-8627):1470-1473. [PubMed]

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CMAJ. 1994 December 15; 151(12): 1713-1719.
Copyright notice
Variations in hysterectomy rates in Ontario: does the indication matter?
R E Hall and M M Cohen
Institute for Clinical Evaluative Sciences in Ontario, North York.
See letter "Variations in hysterectomy rates in Ontario." in volume 152 on page 1185a.
This article has been cited by other articles in PMC.

Abstract
OBJECTIVES: To examine variations in rates of hysterectomy for the five main indications for the procedure in regions of Ontario.

 

DESIGN: Cross-sectional population-based analysis of hospital discharge abstracts. SETTING: All acute care facilities in Ontario.

 

PARTICIPANTS: All 65,599 women whose hospital record contained a procedure code indicating that a hysterectomy was performed between Apr. 1, 1988, and Mar. 31, 1991. Duplicate cases, records of cancelled procedures and nonresidents were excluded. MAIN OUTCOME MEASURES: Crude and age-adjusted rates of hysterectomy, by indication, for each region of Ontario.

 

RESULTS: Five indications accounted for more than 80% of hysterectomies performed. The median age-adjusted rate of hysterectomy for Ontario regions during the study period was 6.25 per 1000 women, with a 2.7-fold variation among regions. The regions with rates of hysterectomy in the highest quartile tended to be rural, and those with rates in the lowest quartile tended to be urban areas with teaching hospitals. When rates of hysterectomy for specific indications were examined, they showed substantial variations among regions in the rate of the procedure for menstrual hemorrhage (18-fold variation), uterine prolapse (9.3-fold) and endometriosis (6.3-fold). A smaller but still significant variation was shown in the rate of hysterectomy for leiomyoma (2.3-fold). Regional variation in the rate of hysterectomy for cancer (2.5-fold) was not statistically significant.

 

CONCLUSIONS: There are large interregional variations in rates of hysterectomy, especially for indications that are more discretionary than others (i.e., menstrual hemorrhage, uterine prolapse and endometriosis) and less variation in rates when treatment options and diagnosis are clear-cut. This result suggests the need for more definitive practice guidelines on treatment of the indications for which the rate is more variable.

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Selected References
This list contains those references that cite another article in PMC or have a citation in PubMed. It may not include all the original references for this article.

• Pokras R, Hufnagel VG. Hysterectomy in the United States, 1965-84. Am J Public Health. 1988 Jul;78(7):852-853. [PubMed]
• Westphalen JB, Fraser S, Rea EE, Coulthard AC, Ng KH, Walters WA. Medical audit of hysterectomy in the Hunter Area of New South Wales. Aust Clin Rev. 1992;12(3):125-129. [PubMed]
• Wennberg JE, McPherson K, Caper P. Will payment based on diagnosis-related groups control hospital costs? N Engl J Med. 1984 Aug 2;311(5):295-300. [PubMed]
• McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982 Nov 18;307(21):1310-1314. [PubMed]
• Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984 3(2):6-32.Summer; [PubMed]
• Vessey MP, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynaecol. 1992 May;99(5):402-407. [PubMed]
• Walker AM, Jick H. Temporal and regional variation in hysterectomy rates in the United States, 1970--1975. Am J Epidemiol. 1979 Jul;110(1):41-46. [PubMed]
• Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med. 1993 Mar 25;328(12):856-860. [PubMed]
• Olive DL, Schwartz LB. Endometriosis. N Engl J Med. 1993 Jun 17;328(24):1759-1769. [PubMed]
• Roos NP, Roos LL Jr. Surgical rate variations: do they reflect the health or socioeconomic characteristics of the population? Med Care. 1982 Sep;20(9):945-958. [PubMed]
• Diehr P, Cain K, Connell F, Volinn E. What is too much variation? The null hypothesis in small-area analysis. Health Serv Res. 1990 Feb;24(6):741-771. [PubMed]
• Blais R. Variations in surgical rates in Quebec: does access to teaching hospitals make a difference? CMAJ. 1993 May 15;148(10):1729-1736. [PubMed]
• Diehr P. Small area statistics: large statistical problems. Am J Public Health. 1984 Apr;74(4):313-314. [PubMed]
• Dyck FJ, Murphy FA, Murphy JK, Road DA, Boyd MS, Osborne E, De Vlieger D, Korchinski B, Ripley C, Bromley AT, Innes PB. Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. N Engl J Med. 1977 Jun 9;296(23):1326-1328. [PubMed]
• Gambone JC, Reiter RC, Lench JB, Moore JG. The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy. Am J Obstet Gynecol. 1990 Aug;163(2):545-550. [PubMed]
• Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am. 1982 Apr;246(4):120-134. [PubMed]
• Domenighetti G, Luraschi P, Casabianca A, Gutzwiller F, Spinelli A, Pedrinis E, Repetto F. Effect of information campaign by the mass media on hysterectomy rates. Lancet. 2(8626-8627):1470-1473. [PubMed]

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BMJ 1996;312:592-593 (9 March)
Editorials
Gynaecology--medical or surgical?
A more medical approach could reduce inappropriate surgical procedures

Historically, obstetrics and gynaecology brought together medically interested obstetricians and surgically interested gynaecologists,1 2 but gynaecology has always been seen as a surgical specialty. However, the increasing complexity of the subject and women's enhanced awareness of their reproductive health have opened up four subspecialties within obstetrics and gynaecology--reproductive medicine, maternofetal medicine, urogynaecology, and gynaecological oncology--all of which involve growing elements of medical expertise. So, should gynaecology remain a surgical specialty, or has it changed so much over the past 30 years that its training requirements need to be reviewed? And might a more medical approach to gynaecological disease lead to fewer women undergoing inappropriate surgical interventions?

One of the great achievements of obstetrics and gynaecology has been to establish a specialty in which women and not a disease or organ are the focus. There can be few other specialties in which the views of patients are so paramount, and there is a clear need to establish a culture in which patients have choice on the basis of unbiased information and truly informed consent. The gynaecologists' bias against medical treatments is unlikely to be reduced while general practitioners, understandably less knowledgeable as they are, embark on ineffective medical treatments before referring patients to specialists.

Gynaecology has been the focus of growing concern about inappropriate interventions. In particular, hysterectomy--perhaps the archetypal gynaecological procedure--has become increasingly controversial.3 4 There is no doubt that many women have benefited from hysterectomy5 6; but the wide variations in hysterectomy rates between countries,7 and even between regions in the same country,3 suggest uncertainty about the indications for hysterectomy6 and show the complex interaction by which women and doctors decide to resort to surgery. Would medically based specialists advise their patients differently? In Sweden, half as many women undergo hysterectomy as in Britain. If gynaecologists in Britain reduced their rates to this level, they would undoubtedly have a great deal less work to do.

Subspecialisation both reflects and drives the move towards a more medical approach to gynaecology. Reproductive medicine--including as it does menstrual dysfunction, gynaecological endocrinology, infertility, post-reproductive endocrinology, and fertility regulation--did not exist as a subspecialty 20 years ago but is now established as a key area of gynaecology. The medical aspects of urogynaecology have undergone a similar expansion.

Meanwhile, proposed changes in the organisation of another subspecialty, gynaecological oncology, cast further doubt on the appropriateness of the existing surgical bias in gynaecology. The Calman proposals for cancer centres in Britain highlight the need for highly trained surgeons with access to a large enough throughput of cases to maintain their surgical skills.8 If the most difficult surgery is to be undertaken by a smaller number of expert surgeons, training the rest to such a high level will not be necessary.

Chemotherapy and radiotherapy (whose practitioners are medically trained) already take an appreciable share of the therapeutic load in gynaecological cancer. Developments in protein and gene therapies are likely to further erode the position of surgery, as is the increase in endoscopic procedures, which are no longer the sole domain of surgeons.

The process of subspecialisation is well advanced in most teaching hospitals where there are enough specialists, but it is likely to create immense organisational difficulties for district general hospitals. Where subspecialisation is feasible, hospitals should have at least one gynaecologist with a special interest in the medical aspects of gynaecology. As regards training, the question remains: should gynaecology be a medically based subject in which specialists learn specific operative procedures, or should it be a surgical speciality in which specialists learn some medicine? Implementation of the new structured training programme, which recognises the increasing importance of medicine to the specialty, provides the framework for the shift in basic training.9

There is no suggestion of abandoning the surgical skills that are needed to practice gynaecology. However, specialties must evolve to incorporate new developments and the changing needs and lifestyles of patients. Gynaecological training needs to accommodate medical aspects more fully. Such a change would have important consequences for women's health care and should be influenced not just by debate within the profession but by the informed opinions of women.

Professor of obstetrics and gynaecology Department of Obstetrics and Gynaecology, University of Cambridge Clinical School, Rosie Maternity Hospital, Cambridge CB2 2SW

S K Smith

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2. Peterson R. The future of obstetrics and gynaecology as a specialty. JAMA 1920;74:1361-4.
3. Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988;27:987-94.
4. Dally A. Women under the knife: a history of surgery. London: Random Century, 1991.
5. Pinion SB, Parkin DE, Abramovich DR, Naji A, Alexander DA, Russell IT, et al. Randomised trial of hysterectomy, endometrial laser ablation, and transcervical endometrial resection for dysfunctional uterine bleeding. BMJ 1994;309:979-83. [Abstract/Free Full Text]
6. Clarke A, Black N, Rowe P, Mott S, Howle K. Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study. J Obstet Gynaecol 1995;102:611-20.
7. Domenighetti G, Luraschi P, Gutzwiller F, Pedrinis E, Casabianca A, Spinelli A, et al. Effect of information campaign by the mass media on hysterectomy rates. Lancet 1988;ii:1470-3.
8. Calman K. A policy framework for commissioning cancer centres: consultative document for Expert Advisory Group on Cancer. London: Department of Health, 1994.
9. Report of the Royal College of Obstetricians and Gynaecologists Working Party on Structured Training. London: The Royal College of Obstetricians and Gynaecologists. 1993.

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Artikel aus Kanada: Frauenzeitschrift "Gazette des femes"
zur Hysterektomiehäufigkeit:
Touchez pas à mon utérus! / Halpern, Sylvie. -- Gazette des femmes, Vol. 23, no 5, Janvier-Février 2002, p. 23-25. -- Dossier.

...Und sogar in Frankreich, dem westlichen Land wo dieser Eingriff immerhin der am wenigsten durchgeführte ist (14% der Frauen von 50 Jahren wurden diesem chirurgischen Eingriff unterzogen, im Vergleich dazu sind es 50% in den Niederlanden und 32% in Großbritannien)
hat eine Studie der Union der Krankenversicherungen in der Bretagne ergeben, dass die Hysterektomie in zu zahlreichen Fällen durchgeführt wurde, ohne irgendeine medizinische Behandlung vorher den Patienten anzubieten.

Man muss sich tatsächlich Fragen stellen, wenn man weiß, dass die ärmsten kanadischen Provinzen, die am wenigsten mit Gynäkologen versorgt sind, Rekordhalter bei den Hysterektomieraten sind: eine Bewohnerin aus Terre neuve hat ein 61% höheres Risiko dranzukommen als eine Bewohnerin von Saskatchewan!

....Doktor Robert Sabbah, Chef der gynäkologischen Abteilung des Spitals „Sacré Coeur“:
„Heute weiß man es: man muss alles tun um die Gebärmutter der Frau zu erhalten!“
Um mehr darüber zu erfahren:
Mein Uterus und meine Ovarien gehören mir - und die Entscheidung auch,
eine exzellente allgemeinverständliche Broschüre,
herausgegeben vom Zentrum für Frauengesundheit Montreal