Arch Gynecol Obstet
DOI 10.1007/s00404-012-2415-2
GENERAL GYNECOLOGY
Prevalence-corrected hysterectomy rates by age and indication
in Germany 2005–2006
Andreas Stang • Ray M. Merrill • Oliver Kuss
Received: 4 November 2011 / Accepted: 4 June 2012
Ó Springer-Verlag 2012
Abstract
Purpose Few studies have examined the age-specific use
of hysterectomy by indication. The aim of this study was to
provide detailed nationwide age-specific prevalence-
corrected hysterectomy rates for several indications in
Germany, representing a population of 42 million women.
Methods Nationwide population-based diagnosis related
group data of the years 2005 and 2006 were used to cal-
culate the prevalence-corrected hysterectomy rates by age
and indication group.
Results Prevalence-corrected age-standardized hysterec-
tomy rates (any indication) was 362.9 (295.0 for benign
diseases of the genital tract and 44.0 for primary malignant
tumors of the genital tract) per 100,000 person-year. Cor-
rected hysterectomy rates become increasingly greater than
the uncorrected hysterectomy rates, such that they are
about 68 % greater for women in the age groups 75–79,
80–84, and 85–89 years. Age-specific hysterectomy rates
showed quite different patterns depending on the indication
of hysterectomy. For example, hysterectomy rates closely
follow the cancer incidence rates up to age 44 for cervical
A. Stang (&)
Institut für Klinische Epidemiologie, Medizinische Fakultät,
Martin-Luther-Universität Halle-Wittenberg,
Magdeburger Str. 8, 06097 Halle (Saale), Germany
e-mail: andreas.stang@medizin.uni-halle.de
R. M. Merrill
Department of Health Science, College of Life Sciences,
Brigham Young University, Provo, UT 84602, USA
O. Kuss
Institut für Medizinische Epidemiologie, Biometrie und
Informatik, Universitätsklinikum Halle und Medizinische
Fakultät, Martin-Luther-Universität Halle-Wittenberg,
Halle (Saale), Germany
cancer and age 69 for uterine cancer, diverging noticeably
in ages thereafter.
Conclusions The prevalence-corrected hysterectomy
rates presented in this study provide a more accurate
indication of the use of hysterectomy, which has implica-
tions in terms of costs and resource allocation. Under-
standing the role of hysterectomy in treating selected
diseases across the age span is also important for patients
and doctors as they consult together about an appropriate
course of treatment.
Keywords Hysterectomy
Age
Indication

Population-based
Germany
Introduction
Hysterectomy is the most frequently performed major sur-
gical procedure in gynecology across many places in the
world [1]. Several studies have shown marked variations of
hysterectomy rates among and within industrialized coun-
tries [2–7] and over time [2, 7–9]. Selected factors have
been shown to influence hysterectomy rates beyond the
incidence of genital tract diseases, such as availability of
obstetricians and gynecologists, the number of hospital beds
per capita, the type of health-care insurance available, the
gender of the gynecologists, the social class of the patient
[10, 11], available information about the different treatment
modalities among patients [12], and cultural norms related
to fertility-sparing, less-definitive procedures. The growing
prevalence of obesity has also contributed to an increased
rate of abnormal uterine bleeding, which in turn, may
contribute to greater use of hysterectomy [13, 14].
Hysterectomy surveillance provides an indication of
female reproductive health and how women are being
123

treated for problems of the reproductive system. In 2004,
Germany introduced the diagnosis related group (DRG)
system for reimbursement of inpatient hospital services.
All hospitalizations with individual diagnostic and thera-
peutic codes contribute to the nationwide DRG statistics
that provide a useful data source for epidemiologic pur-
poses, as recent studies with these data have shown. DRG
data are virtually a complete registry of hysterectomy in
Germany, because it is extremely rare for this type of
surgery to be performed outside of the hospital setting.
Analyses of DRG data for the years 2005 and 2006 have
shown that overall 3.6 per 1,000 women (any age, preva-
lence-corrected) each year underwent hysterectomy for
benign diseases of the genital tract in Germany [15].
Comparable rates were 4.9 per 1,000 women in the United
States and 2.1 per 1,000 women in Sweden [3, 9]. Overall,
4.8 % of all hysterectomies for benign diseases of the
genital tract in Germany were performed as subtotal hys-
terectomies requiring ongoing cervical-cancer screening.
Bilateral oophorectomies were performed in 12 % of all
hysterectomies performed for benign diseases of the genital
tract [15].
Publications on representative, population-based hys-
terectomy rates rarely present precise estimates of the age-
specific hysterectomy rates by indication. The aim of this
study was to provide detailed nationwide age-specific
analyses of prevalence-corrected hysterectomy rates for
several indications in Germany, representing a population
of 42 million women.
Materials and methods
Based on an amendment of the hospital financing system in
Germany in 1999 (Statutory Health Insurance Reform Act),
the DRG reimbursement system became compulsory for
hospitals in 2004. According to Section 21 of the hospital
financing law (Krankenhausentgeltsgesetz, KHEntG), all
hospitals that are re-compensated by the DRG-system
annually transfer their individual hospitalization data to a
DRG data center [Institute for the Hospital Remuneration
System (InEK)]. Psychiatric and psychotherapeutic
departments are not re-compensated by the DRG system
and are not included in the nationwide data file. The InEK
undertakes a plausibility check of the data and generates a
plausibility protocol that is sent back to the corresponding
hospital. Hospitals can re-submit their corrected data files.
Thereafter, InEK forwards anonymized data to the Federal
Bureau of Statistics. Based on confidentiality regulations
(Bundesstatistikgesetz, BStatG), individual hospitalization
data are available for research purposes.
DRG-based hospitalization data include one primary
diagnosis and up to 89 secondary diagnoses coded by
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Arch Gynecol Obstet
ICD-10 (International Classification of Diseases, 10th
edition, [16, 17]) and up to 100 medical procedures
according to a national classification of operations and
procedures (OPS, [18, 19]). The data set neither contains
histology information beyond ICD-10 nor information
about the insurance status of hospitalized women (private
or national health insurance) making histology-specific
analyses (beyond ICD-10) and stratifications by insurance
status impossible. The current study accessed overall
17.4 million hospitalizations among women for the years
2005 and 2006. Since day-surgery hysterectomy is rare in
Germany, the hospital data accurately reflect the rates of
hysterectomy in this country.
We identified hysterectomies by use of the OPS codes
5-682: subtotal hysterectomy, 5-683: total hysterectomy, or
5-685: radical hysterectomy. For the years 2005 and 2006,
307,230 hysterectomies were performed among 42 million
women in Germany. We excluded 2,215 (0.7 %) hyster-
ectomies from the analyses, because the women resided
outside of Germany (N = 1,645; 0.5 %), were homeless
(N = 321; 0.1 %), or their places of residence were
unknown (N = 249, 0.1 %). This left 305,015 hysterecto-
mies for evaluation.
A hierarchical algorithm was used to derive the leading
causes (indications) of hysterectomy, which was based on a
similar algorithm applied in the previous studies [3, 20].
The primary and all secondary diagnoses were used to
assign hysterectomies to one of the six indication groups in
the following hierarchical fashion. First, any record of a
primary malignant neoplasm of the cervix uteri (C53),
uterus (C54-C55), ovary (C56), other and unspecified
female genital organs (C57), or placenta (C58) were
grouped as ‘‘primary malignant tumors of the genital
organ.’’ Second, any hysterectomy with a record of ICD-10
code of N85.1 in the absence of a primary malignant tumor
of the genital was classified as ‘‘endometrial adenomatous
hyperplasia’’. Third, any hysterectomy with codes in situ
neoplasm of the cervix uteri (D06), other and unspecified
part of the uterus (D07.0), and other and unspecified female
genital organs (D07.3) were grouped as ‘‘in situ neoplasms
of the genital organs.’’ Fourth, a hysterectomy associated
with ICD-10 code D39 was classified as ‘‘neoplasms of
uncertain or unknown behaviour of genital organs’’ and
lastly, hysterectomies associated with records indicating a
‘‘primary malignant cancer not of the genital tract’’ were
grouped; these typically reflecting debulked cancers of the
urinary or intestinal tract. Remaining hysterectomies were
classified into the sixth group, ‘‘benign disease of the
genital tract.’’ Although hospitalizations for hysterectomy
associated with benign diseases of the genital tract usually
contained more than one diagnosis of a benign disease
of the genital tract, we used the primary diagnosis for
subclassification of these hysterectomies. In a sensitivity
Arch Gynecol Obstet
analysis, we analyzed the occurrence of a pre-specified list
of 24 frequent benign indications of hysterectomies at any
ICD-10 code position in the data set, that is, either as
primary or any secondary diagnosis (for details see [15]).
Statistical methods
Crude and age-standardized hysterectomy rates and corre-
sponding standard errors were calculated, with the
denominator in the rates consisting of the midyear female
populations in the years 2005 and 2006. Rates were age-
standardized using the European standard population [21].
We used cubic splines to dampen the roughness of the
1-year age-specific hysterectomy rates.
We calculated hysterectomy rates both uncorrected and
corrected for women who are no longer at risk of having
hysterectomy, because they already had undergone this
medical procedure. The age-specific prevalence of hyster-
ectomy in the general population was estimated from a
regional survey in Bremen for women aged 45–74 years
[22]. Age-specific prevalence of hysterectomy revealed an
S-shaped pattern in Bremen, Germany, as well as in a
survey in Utah, USA [23]. Thus, 1-year age-specific
probabilities of hysterectomy prevalence and extrapolated
hysterectomy probabilities (outside the observed age
range) were estimated using this pattern from a logistic
regression model. The model yielded an upper limit of
hysterectomy prevalence in the population of 40.7 %. This
value minimized the Pearson goodness-of-fit statistic from
an iterative search across a range (30–60 %) of upper limits
of the hysterectomy prevalence. Hysterectomy rates in
Germany for all age groups were then recalculated using
the prevalence-corrected person-years at risk. Statistical
analyses were performed using SAS 9.2 [24].
Results
The prevalence-corrected age-standardized hysterectomy
rate (any indication) was 362.9 per 100,000 person-years in
Germany. Benign diseases of the genital tract (295.0 per
100,000 person-years) and primary malignant tumors of
the genital tract (44.0 per 100,000 person-years) were the
two main indication groups. Within the group of hyster-
ectomies involving benign diseases of the genital tract
(N = 248,220), leiomyoma of the uterus (53.4 %), genital
prolapse (23.1 %), excessive frequent and irregular men-
struation (9.5 %) and endometriosis (4.0 %) were the most
frequent primary diagnoses, accounting for 90.0 % of all
hysterectomies for benign diseases of the genital tract.
Median age of hysterectomy differed by indication group.
For example, the lowest median ages of hysterectomy
involved excessive frequent and irregular menstruation
(43 years), endometriosis (43 years), and in situ cancer of
the genital tract (43 years). The highest median ages at
hysterectomy were for uterine cancer (68 years), other
cancer as primary diagnosis (debulking HEs) (66 years),
and genital prolapse (65 years). Prevalence-correction
resulted in varying degrees of relative increases of the age-
standardized hysterectomy rates between 5 % (bleeding)
and 45 % (uterine cancer) (Table 1).
The effect of the prevalence correction depended on age.
The overall corrected hysterectomy rate within the age
group 0–49 years was very similar with the uncorrected
rate. However, among women aged 50 years or older, the
corrected hysterectomy rates became higher than the
uncorrected rate. Hysterectomy rates showed the largest
increase after correction of the person-time at risk for
5-year age groups 75–79, 80–84, and 85–89 years (67, 68,
68 %, respectively, relative to the uncorrected rates)
(Fig. 1).
Age-specific hysterectomy rates for endometrial ade-
nomatous hyperplasia, neoplasia of uncertain behavior, and
benign diseases of the genital tract showed bimodal dis-
tributions with an early and late peak in the late 40s and the
late 60s/70s, respectively. Whereas hysterectomy rates
associated with in situ cancer showed an early age peak in
the 40s, the rates associated with primary malignant cancer
of the genital tract or other primary cancers had a late peak
in the 70s (Fig. 2). Age-specific hysterectomy rates for
endometriosis, frequent and irregular menstruation, and
leiomyoma each showed symmetric age-distributions with
single age peaks of 42, 44, 46 years, respectively. In con-
trast, age-specific hysterectomy rates for genital prolapse
showed a left-skewed distribution with an age peak at age
73 years (Fig. 3).
The comparison of selected population-based cancer
incidence rates (cervical, and uterine) and corresponding
hysterectomy rates for these sites shows that hysterectomy
rates resemble closely the incidence age patterns up to age
69 years (uterine cancer) and 44 years (cervical cancer). In
older ages, the hysterectomy rates become considerably
lower than the cancer-specific incidence rates (Fig. 4).
Discussion
Hysterectomy is a primary treatment for several diseases
and conditions of the female reproductive system [e.g.,
uterine leiomyoma (fibroids), endometriosis, cancer, uter-
ine prolapse, uterine bleeding and pain]. Because these
diseases and conditions tend to affect women at varying
ages in life, the use of hysterectomy varies considerably
across the age span, according to the indication it is used to
treat. Few countries including Italy [25] and the US [20, 26, 27]
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Table 1 Age distribution and hysterectomy rates (per 100,000 person-years) by indication in Germany, 2005–2006
Indication N Age distribution Hysterectomy rates (uncorrected Hysterectomy rates (corrected
(years) population at risk) population at risk)
Median P10 P90 Crude Age- Crude Age-
standardized standardized
Rate SE Rate SE Rate SE Rate SE

Any 305,015 48 39 72 362.4 0.7 310.3 0.6 417.5 0.8 362.9 0.7
Genital tract cancer 37,037 64 43 80 44.0 0.2 32.6 0.2 50.7 0.3 44.0 0.2
Cervix uteri 6,444 47 35 70 7.7 0.1 6.8 0.1 8.8 0.1 7.8 0.1
Corpus uteri 19,710 68 52 81 23.4 0.2 15.9 0.1 27.0 0.2 23.0 0.2
Ovary 8,898 62 43 77 10.6 0.1 8.2 0.1 NA NA
Endometrial adenomatous hyperplasia 5,063 56 44 73 6.0 0.1 5.1 0.1 6.9 0.1 6.4 0.1
In situ cancer genital tract 6,337 43 34 64 7.5 0.1 6.8 0.1 8.7 0.1 7.6 0.1
Neoplasia of uncertain behaviour 5,646 54 41 77 6.7 0.1 5.5 0.1 7.7 0.1 6.8 0.1
Other cancer as primary diagnosis 2,712 66 46 81 3.2 0.1 2.3 0.0 3.7 0.1 3.2 0.1
Benign diseases genital tract 248,220 47 39 69 294.9 0.6 258.0 0.5 339.7 0.7 295.0 0.6
Leiomyoma of the uterus 132,514 46 39 54 157.4 0.4 145.1 0.4 181.4 0.5 157.2 0.4
Genital prolapse 57,260 65 45 78 68.0 0.3 50.7 0.2 78.4 0.3 69.3 0.3
Endometriosis 10,041 43 36 52 11.9 0.1 11.0 0.1 13.7 0.1 11.7 0.1
Bleeding 23,537 43 36 50 28.0 0.2 26.0 0.2 32.2 0.2 27.2 0.2
Analyses of single entities (cervical cancer, uterine cancer, ovarian cancer, leiomyoma, genital prolaps, endometriosis, and bleeding) were based
on the primary diagnosis associated with the hospitalization; age standard: European standard population
P10 10th percentile, P90 90th percentile, NA not applicable

hysterectomy rates were greater than uncorrected rates,

Fig. 1 Nationwide age-specific hysterectomy rates of any indication
(per 100,000 person-years) without and with correction for the
prevalence of hysterectomy. Person-year at risk correction for the
prevalence of hysterectomy in Germany by use of survey data from
Bremen (45–74 years) [22] and the assumption of an S-shaped age-
specific prevalence pattern (see ‘‘Materials and methods’’); the upper
graph used hysterectomy-corrected person-time at risk for the rate
estimation
have examined the age-specific use of hysterectomy by
indication. Age-specific analyses were often based on
broad age categories (e.g., 35–49 years vs. 50? years [25])
and small number of women. In addition, prevalence-cor-
rected hysterectomy rates have never been used for such an
evaluation in the German population. Prevalence-corrected
more so in older aged women. This reflects the higher
prevalence of hysterectomy in older ages. A similar result
was observed in prevalence-corrected hysterectomy inci-
dence rates in the US population [27].
Prevalence-corrected hysterectomy rates more accu-
rately reflect the extent of hysterectomy in the population,
especially in older aged women where the prevalence of
hysterectomy is greatest. For example, across the whole
age range the prevalence-corrected age-adjusted hysterec-
tomy rate was 17 % greater than the uncorrected rate. For
corpus uterine cancer and prolapse, which tend to affect
women later in life, the corrected rates were 45 and 37 %
greater, as opposed to bleeding and endometriosis, which
affects women earlier in life, where the corrected rates
were 5 and 6 % greater, respectively.
The association between hysterectomy rates and age has
been described for selected indications elsewhere. During
2001–2005, 3.1 million hysterectomies were performed in
the US [3]. Hysterectomies associated with cancer and
prolapse explained 12 % of this surgical procedure in
patients aged 18–44 years, 28 % in patients aged
45–64 years, and 75 % in patients aged 65 years and older.
In contrast, hysterectomies associated with endometriosis,
pain, and bleeding was used to treat 50 % of patients aged
18–44 years, 24 % in patients aged 45–64 years, and 4 %
in patients aged 65 years and older.

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Arch Gynecol Obstet

Fig. 2 Prevalence-corrected
and uncorrected age-specific
hysterectomy rates per
100,000 person-years by
indication in Germany,
2005–2006. Gray line smoothed
age-specific hysterectomy rates;
upper graphs within each figure
used hysterectomy-corrected
person-time at risk for the rate
estimation

Consistent with previous studies [3, 20, 28–30], uterine
leiomyoma (fibroids) is the most frequent diagnosis asso-
ciated with hysterectomies performed in Germany, being
most common among women in their 40s. However, while
leiomyoma has been shown to account for about 31 % of
hysterectomies among all women ages 18 years and older
in the US [3], in the current study, it accounts for 43 % of
all hysterectomies. The higher percentage of hysterecto-
mies used to treat leiomyoma in Germany may be because
of lower use of uterine artery embolization for treating
leiomyomas [31, 32]. In addition, leiomyomas increase in
size with higher levels of estrogen and progesterone, which
are influenced by birth control and pregnancy [33–35].
Thus, the higher percent of leiomyomas treated with
hysterectomy in Germany may also be influenced by
differential use of birth-control pills and number of preg-
nancy among women.
Hysterectomy rates closely follow the cancer incidence
rates up to age 44 for cervical cancer and age 69 years for
uterine cancer, diverging noticeably in ages thereafter.
Other data show that surgery, in general, becomes less-
frequently recommended in the older ages for women with
these cancers. For example, in the US in 2005–2006 sur-
gery was not recommended for 20 % of cervical-cancer
patients, 17 % of uterine-cancer patients, and 4 % of
ovarian-cancer patients in their 20s [36]. Corresponding
percentages not recommended for surgery among patients
at least age 80 were 76, 20, and 58. This is partly because
old-aged patients tend to have more advanced-stage disease
at diagnosis, wherein radiation and chemotherapy are more

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Fig. 3 Prevalence-corrected
and uncorrected age-specific
hysterectomy rates per
100,000 person-years for the
treatment of uterine leiomyoma,
genital prolapse, excessive,
frequent and irregular
menstruation and endometriosis,
Germany, 2005–2006. Gray line
smoothed age-specific HE rates;
upper graphs within each figure
used hysterectomy-corrected
person-time at risk for the rate
estimation

Fig. 4 Comparison of selected

population-based cancer
incidence rates (per 100,000
person years) and indication-
specific hysterectomy rates (per
100,000 person-years) in
Germany 2005–2006. GEKID:
German-wide incidence
estimates 2005–2006 of
cervical, uterine, and ovarian
cancer based on the population-
based cancer registries in
Germany (http://www.gekid.de,
accessed August 28, 2011) and
hysterectomy rates of the years
2005–2006; incidence and hys-
terectomy rates for cervical and
uterine cancer (main diagnoses)
were both corrected for hyster-
ectomy prevalence estimates

appropriate treatments. For example, the percentage with
localized stage disease was 68 % for cervical cancer and
71 % for uterine cancer among women in their 20s, as
opposed to 22 and 56 % for patients aged 80 years and
older, respectively. Consistent with the fact that advancing
age is less strongly associated with later-stage disease at
diagnosis in uterine cancer patients in the US data, the
difference in hysterectomy and uterine cancer rates in the
older age groups is smaller than that for cervical cancer in
the older age groups (see Fig. 4).
The median age for women with cervical cancer is much
smaller than that for women with uterine cancers. As such,
the overall percentage of cervical cancer patients treated
with hysterectomy is smaller. This is likely because, women
in their earlier years are more likely to select alternative
forms of surgery (e.g., cryosurgery, laser surgery, loop

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electrosurgical excision procedures, and conisation [37]), to
preserve their reproductive capacity. Thus, two forces are at
play: younger age tends to be correlated with earlier-stage
disease such that hysterectomy is a viable treatment, but
women in their reproductive years are more likely to elect
reproductive sparing surgery.
A few limitations to the study need mention. First,
although we used a hierarchical algorithm similar to those
that have been repeatedly used in other studies to group
indications of hysterectomies [2, 15, 20, 26, 38], small
fraction of indications of hysterectomies have likely been
misclassified. Second, a more detailed stratification of
hysterectomy rates within the indication groups by primary
diagnoses (e.g., uterine leiomyoma) rests on the assump-
tion that the indication for hysterectomy can be assigned to
a single diagnosis. For example, women with symptomatic
uterine leiomyoma and symptomatic endometriosis have
two potential indications for hysterectomy and the analysis
restricted to one primary diagnosis may not reflect the
entire complexity of diagnoses for women undergoing
hysterectomies [39] although the primary diagnosis in the
German DRG data is the main diagnosis that prompted the
hospitalization as reviewed at the end of the hospital stay
by the treating clinicians. Among the 132,514 hysterecto-
mies for uterine leiomyoma, 10.0 % were accompanied by
a secondary diagnosis of endometriosis. Third, we based
our prevalence correction on survey data of one Federal
State in Germany that may not be generalizable to other
Federal States in Germany. Unfortunately, population-
based hysterectomy prevalence in the 16 Federal States of
Germany is not available.
The use of hysterectomy for treating selected diseases of
the female reproductive system depends in large part on
the age-distribution of the specific disease and, in the case
of cancer, the stage of the disease at diagnosis. More
advanced-stage cancer is better treated by alternative
treatments (e.g., radiation, chemotherapy). In addition, the
use of hysterectomy for treating disease also depends on
whether the women is still in her reproductive years and
wishes to retain the ability to bear children. Less-aggres-
sive forms of surgery are more common for cervical cancer
than the uterine cancers.
The prevalence-corrected hysterectomy rates presented
in this study provide a more accurate indication of the use
of hysterectomy, which has implications in terms of costs
and resource allocation. Understanding the role of hyster-
ectomy in treating selected diseases across the age span is
also important for patients and doctors as they consult
together about an appropriate course of treatment. Finally,
the results also provide a reference that can be compared
with data in other places in the world and across time.
Conflict of interest None.
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