To the Editor:
Excluding cesarean section, hysterectomy is the most frequent surgical procedure performed on women of reproductive age in the United States. Several studies have examined hysterectomy patterns in the United States.1-3 Little is known about hysterectomy procedures in HIV-infected women, however. To compare indications for hysterectomy hospitalizations, we used data from the National Hospital Discharge Survey (NHDS). The NHDS is a national probability sample of patients discharged from nonfederal short-stay hospitals that is conducted annually by the National Center for Health Statistics (NCHS). The NHDS provides weighted estimates of hospitalizations for the United States by regions. The data for each discharge also include as many as 7 diagnoses and 4 procedures using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes.
HIV infection was defined as having at least 1 ICD-9-CM diagnosis code of 042, 795.71, or V08. Hysterectomy was defined by ICD-9-CM procedure codes of 68.3 to 68.7 or 68.9. An ICD-9-CM code of 68.8 indicates pelvic evisceration and was excluded from the definition of hysterectomy. Oophorectomy was defined as having ICD-9-CM procedure codes of 65.3 through 65.6. Indications for hysterectomy were defined using ICD-9-CM codes for commonly known indications. Women could have more than 1 indication for hysterectomy. HIV-infected women who had a hysterectomy were all less than 50 years old. To have comparable groups, the analysis was restricted to women less than 50 years old.
Estimates of totals, frequencies, and the related standard errors as well as associated tests of significance were calculated using SAS-callable SUDAAN. All procedures were coded with NCHS-recommended stratification parameters. Tests of association between HIV status and various indications were performed using the Cochran-Mantel-Haenszel test statistic option in SUDAAN.4
An estimated 2,168,898 women who were less than 50 years old had a hysterectomy in the United States during 1996 through 2000. Of these women, an estimated 4246 (0.2%) also had an ICD-9-CM code for HIV infection. HIV-infected women had a slightly longer hospital stay; the mean length of stay for HIV-infected women was 3.7 days, whereas all other women had a mean length of stay of 2.9 days (P = 0.02). A concomitant oophorectomy occurred in 33.5% of the HIV-infected women and 56.6% of all other women (P = 0.13).
HIV-infected women were more likely to have an indication of cervical intraepithelial neoplasia (CIN) at the time of their hysterectomy (Table 1). This result is not unexpected. HIV-infected women are more likely to be infected with human papillomavirus (HPV)5-7 and are more likely to develop CIN.8,9 The most common indications for hysterectomy were leiomyoma, endometriosis, and disorders of the menstrual cycle and did not differ by HIV status.
There are several limitations to this analysis. HIV status was defined by the presence or absence of ICD-9-CM diagnosis codes. The status of women known to be HIV infected may not have been included in hysterectomy hospitalization records. Only a small number of women with a hysterectomy were identified as being HIV infected. The unweighted number of HIV-infected women with a hysterectomy was 30. With such small numbers, our estimates could be unstable.
The number of sampled cases of women with a hysterectomy and HIV in this national sample is too small for in-depth study or for conclusive findings on this topic. Nevertheless, data from the NHDS point to a need for further study. Research is needed to evaluate the effect of CD4 counts and highly active antiretroviral therapy on hysterectomy rates in HIV-infected women.
Pangaja Paramsothy, MPH*
Chadd Crouse, MSc†
Yusuf Ahmed, BM†
Ann Duerr, MD, PhD, MPH†‡
Xiaohong M. Davis, PhD†
Denise J. Jamieson, MD, MPH†
*CONRAD Program, Arlington, VA †Centers for Disease Control and Prevention Atlanta, GA ‡Fred Hutchinson Cancer Research Center Seattle, WA
1. Lepine L, Hillis S, Marchbanks P, et al. Hysterectomy surveillance-United States, 1980-1993. MMWR CDC Surveill Summ
2. Keshavarz H, Hillis S, Kieke BA, et al. Hysterectomy surveillance-United States 1994-1999. MMWR CDC Surveill Summ
3. Farquhar C, Steiner C. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol
. 2002; 99:229-234.
4. Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Manual
, release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
5. Ahdieh L, Klein RS, Burk R, et al. Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women. J Infect Dis
. 2001;184: 682-690.
6. Palefsky JM, Minkoff H, Kalish LA, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIV-negative women. J Natl Cancer Inst
7. Sun XW, Kuhn L, Ellerbrock TV, et al. Human papillomavirus infection in women infected with the human immunodeficiency virus. N Engl J Med
8. Conti M, Agarossi A, Parazini F, et al. HPV, HIV infection and risk of cervical intraepithelial neoplasia in former intravenous drug abusers. Gynecol Oncol
9. Wright TCJ, Ellerbrock TV, Chiasson MA, et al. Cervical intraepithelial neoplasia in women infected with human immunodeficiency virus: prevalence, risk factors and validity of Papanicolaou smears: New York Cervical Disease study. Obstet Gynecol