Racial and ethnic differences in risk for hysterectomy following insertion of a levonorgestrel-releasing intrauterine device: A retrospective cohort study

Abstract

Objectives

Evidence regarding risk for hysterectomy following treatment for benign gynecological conditions with a levonorgestrel-releasing intrauterine device (LNG-IUD) is limited. We assess whether race and ethnicity are associated with hysterectomy risk and moderate associations between other patient characteristics and hysterectomy risk.

Study design

From health care records (US South; 2014–2019), we identified a retrospective cohort of 783 patients (aged 18–44 years; non-Hispanic White n = 455; non-Hispanic Black n = 208; Hispanic n = 120) receiving LNG-IUD treatment for a benign condition, followed to hysterectomy or study end (September 18, 2019). Indices measuring preinsertion bleeding, gynecological pain, and bulk symptom severity were abstracted from 4 months’ medical records preceding insertion. Associations between race and ethnicity, age, symptom severity, presence of fibroids and endometriosis, prior IUD use, parity, and insurance and hysterectomy risk were investigated with Kaplan-Meier estimates and Cox regression.

Results

Seventy-six patients (9.7%) underwent hysterectomy (median follow-up: 1.7 years). Hysterectomy rates were 7.0% within 1 year, climbing to 14.9% at 4 years post-insertion. Hysterectomy rates did not differ significantly by race and ethnicity. Age at treatment, symptom severity, fibroids, parity, and insurance status were associated with hysterectomy, but only age (hazard ratio per unit increase: 1.04 [95% CI: 1.00–1.09]), bleeding severity (1.05 [1.00–1.10]), and bulk severity (1.15 [1.00–1.32]) remained associated with adjustment. There was no evidence that race and ethnicity moderated these associations.

Conclusions

We did not find statistically significant differences in hysterectomy risk for Black, Hispanic, and White LNG-IUD patients. Patients who were older and had more severe pre-insertion uterine bleeding and bulk symptoms were more likely to undergo hysterectomy. These associations did not differ by race and ethnicity.

Implications

Among patients being treated with LNG-IUDs for benign gynecological conditions, Black, Hispanic, and White patients did not differ significantly in hysterectomy risk, but older patients and those with more severe bleeding and bulk symptoms were more likely to undergo hysterectomies.