102 AWHONN Lifelines Volume 6, Issue 2

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The U.S. rate of hysterectomy didnot change significantly from

1990 to 1997, with hysterectomyremaining the most common non-pregnancy-related surgical procedurein the U.S., reports a study in theFebruary issue of Obstetrics & Gyne-cology. However, there was a changein the type of hysterectomies per-formed, with laparoscopic hysterecto-my procedures increasing thirtyfold,accounting for 9.9 percent of all U.S.hysterectomies in 1997.

The study, by members of theAgency for Healthcare Research andQuality (AHRQ), used the Nation-wide Inpatient Sample of the Health-care Cost and Utilization Project, aresearch database produced at AHRQ.

At a rate of 5.6 per 1,000 women,the U.S. hysterectomy rate is three tofour times higher than that of Aus-tralia, New Zealand and most Euro-pean countries. Abdominal hysterec-tomy is still the most frequent hys-terectomy procedure in the U.S. (63percent of all U.S. hysterectomies in1997). Abdominal procedures have asignificantly higher hospital stay,postoperative recovery time and costthan those of the laparoscopic orvaginal hysterectomy procedures. InFrance and Australia, 40 to 50 per-cent of hysterectomy patients undergovaginal procedures: in the U.S., only25 percent do.

Uterine fibroids remained the mostfrequent diagnosis for hysterectomies(accounting for 40 percent or more ofabdominal procedures). The authorsnoted that the management offibroids with symptoms such as painor heavy bleeding is challengingbecause of the lack of clinical trialsand reports on long-term outcomes.More clinical data are needed, evenfor such promising procedures asuterine artery embolization—whichcan destroy fibroids but spare theuterus. “If further declines in the U.S.hysterectomy rates are to occur,” theauthors note, “future research needsto focus on non-surgical alternativesfor fibroid management.”

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In response to reports that somehospitals are denying epidural pain

relief to women in labor until theyhave reached a certain stage of labor,The American College of Obstetri-cians and Gynecologists (ACOG) hasreaffirmed its position that a woman’srequest for pain relief during anystage of labor is sufficient medicalindication to provide it.

ACOG has received informationthat some hospitals are requiring thatwomen in labor reach four to fivecentimeters of dilation before beinggiven epidural pain relief. Hospitalsare doing so because some studieshave indicated that the risk of cesare-an delivery is increased when epidu-rals are given early in labor. ACOGsupports waiting to give laboringwomen epidurals until they havedilated four to five centimeters.However, since labor produces severepain for many women, ACOGbelieves that a woman’s request foran epidural should be the decidingfactor, even if she hasn’t yet reachedfour to five centimeters dilation.

ACOG reaffirms its earlier commit-tee opinion, published jointly with theAmerican Society of Anesthesiologists(ASA), that while under a physician’scare, in the absence of a medical con-traindication, women in labor shouldbe given pain relief upon request.According to ACOG/ASA, there is noother circumstance where it’s consid-ered acceptable for a person to expe-rience untreated severe pain that isamenable to safe intervention. ForAWHONN position statements relatedto epidurals, go to www.awhonn.org.

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Fertility drugs don’t put women ata higher than average risk of

ovarian cancer, according to thelargest analysis to date on the topic,conducted by University of PittsburghGraduate School of Public Healthresearchers and published in the Feb-

ruary 1 issue of the American Journalof Epidemiology.

For more than a decade, contro-versy has surrounded the relation-ships among infertility, fertility druguse and the risk of ovarian cancer.“This analysis helps put to rest thequestions that have been troublingphysicians and the women whoendure arduous fertility treatments,”the study’s lead author wrote.

While no association was foundbetween ovarian cancer and fertilitydrugs, the study does point out a linkbetween ovarian cancer and certainspecific causes of infertility—namely,endometriosis and “unknown” rea-sons for infertility. The study suggeststhat some women who receive fertili-ty treatments develop ovarian cancerbecause of underlying conditions thatcause infertility, not because of thetreatments themselves.

Investigators collected interviewdata on infertility and fertility druguse from eight case-control studiesconducted between 1989 and 1999 inthe U.S., Denmark, Canada and Aus-tralia, including 5,207 women withovarian cancer, and 7,705 womenwithout ovarian cancer. In the study,infertility was signaled by prolongedunsuccessful episodes of trying toconceive and by seeking medical helpin conceiving. Results showed that wo-men who spent more than five yearstrying to conceive were at a 2.7-foldhigher risk for ovarian cancer thanthose who tried for less than one year.Women who had used fertility drugswere not more likely to develop ovar-ian cancer than those who had neverused fertility drugs. The risk of ovariancancer dropped with each pregnancy.

Also, the infertile women whowere most likely to develop ovariancancer were those whose infertilityresulted from endometriosis or fromunknown causes.

Endometriosis is a condition inwhich cells from the uterine lining, orendometrium, migrate to various sitesthroughout the pelvis and attach toother organs, causing inflammationand pain, as well as infertility. In thenewly published paper, the authorssuggest that the local inflammation