Vaginal Hysterectomy - Clinical Indications


	UM Guidelines

Vaginal Hysterectomy

Inpatient and Surgical Care (ISC) ORG: S-660

BCBST modification effective August 29, 2008*

Deleted from: Clinical Indications

Milliman Care Guidelines Clinical Indications were deleted.

Added to: Clinical Indications

Definitions for Hysterectomy Criteria

Abnormal Uterine bleeding: profuse bleeding or repetitive periods lasting > 8 days.

Conservative Treatment may include, but is not limited to, ANY of the following:

Non-steroidal anti-inflammatory therapy (NSAIDS)

Laparoscopic procedures

Cyclical hormonal therapy

Suppressive hormonal therapy

Uterine artery embolization (UAE)

D&C

Hysterectomy

Endometrial ablation or resection

Myomectomy

LEEP

Pain:

Mild = Intermittent, not interfering with ability to work, analgesics required but not chronically.

Moderate = Continuous, not interfering with work, requires chronic analgesic, such as NSAIDS, for > 3 months.

Severe = Continuous, causing absence from work, > 3 months of NSAIDS have failed & narcotics required for pain relief.

Postmenopausal: Cessation of menstruation for > 12 months.

Suppressive Hormonal Therapy: Hormonal therapy of sufficient potency to inhibit ovulation in a pre or peri-menopausal female. Such therapies include a combination of an estrogen and progestin (as in combination oral contraceptive pills), progestin only suppression (as in a "mini-pill" or depo-medroxyprogesterone) or GnRH agonist. A smoker > age 35 does not represent a contra-indication to progestin only or GnRH agonist suppressive therapy.

Uterine Size is described in terms of gestational weeks determined by physical exam.

Hysterectomy remains one of the most debated surgical procedures. Probably 80% of hysterectomies are discretionary in that there is at least one reasonable alternative. This may include observation, hormonal therapy, NSAID's, GnRH inhibitors, conservative procedures including endometrial ablation and myomectomy. Informed collaboration with documented active participation of patient in decision-making is appropriate.

The appropriate route of hysterectomy, abdominal, vaginal or laparoscopic (LAVH) depends on the patient's anatomy and pathology and the surgeon's experience and skills. The decision-making process can be expected to vary within communities, institutions, and surgeons. In general, LAVH is used for a very low percentage of hysterectomies.

NOTE: Hysterectomy for sterilization is not indicated.

Procedure is indicated for ANY ONE of the following:

Emergency Situation with ANY ONE of the following:

Postpartum complications

Extensive uterine infection with sepsis

Operative complications

Ruptured uterus

Malignancy with ANY ONE of the following:

Ovarian

Uterine

Invasive carcinoma

Microinvasive carcinoma

Endometrial adeno-carcinoma in situ

Trophoblastic disease unresponsive to chemotherapy

Cervical

Invasive carcinoma, biopsy diagnosed

Microinvasive carcinoma, biopsy diagnosed

Adenocarcinoma (any stage), biopsy diagnosed

Premalignant Conditions with ANY ONE of the following:

Cervical Dysplasia (CIN III or greater) - Recurrent CIN III on repeat-cone biopsy (within 2 years of first conization)

Endometrial hyperplasia diagnosed by endometrial sampling with ANY ONE of the following:

Complex atypical hyperplasia

Endometrial hyperplasia not described as complex atypical, with ALL of the following:

Biopsy-proven persistence after 6 months of intermittent or continuous progestin therapy

No desire for future fertility

Nonmetastatic gestational trophoblastic disease in a woman not desiring further fertility

Prophylactic Hysterectomy/oophorectomy with a high risk of hereditary ovarian cancer with ANY ONE of the following:

Two or more first-degree relatives with ovarian or breast cancer

One first-degree relative and one second-degree with ovarian or breast cancer before the age of 50 years

One first-degree relative and two or more second-degree or third-degree relatives with ovarian or breast cancer

Presence of BRCA1 or BRCA2 mutation

Note: Prophylactic hysterectomy for individuals receiving estrogen receptor antagonist for treatment of breast cancer is NOT indicated.

Uterine Leiomyoma with ANY of the following:

12 week gestational size by pelvic exam or ultrasound, a single myoma > 8 cm documented size by ultrasound or documented growth of a single myoma > 2 cm/year by ultrasound

Palpable myomatous enlargement that is symptomatic

Note: For criteria regarding symptoms, see other sections of this tool, i.e., Abnormal Uterine Bleeding, Pain, etc.

Confirmation of Endometriosis by biopsy or direct visualization, or a positive therapeutic response to a 3-month trial with gonadotropin-releasing hormone (GnRH) agonist analog (e.g., Lupron Depot® or Leuprolide acetate for depot suspension) and ANY ONE of the following:

Documented failure of conservative treatment (3 consecutive months of suppressive hormonal therapy) or procedure

Significant involvement of other organ systems, affecting normal physiologic function

Abnormal Uterine Bleeding in Postmenopausal Women and ALL of the following:

Moderate to severe bleeding where all other common causes for uterine bleeding, including endometrial cancer, have been excluded

Bleeding persists after 3-month trial of hormonal treatment (unless both estrogen and progesterone hormonal treatments are contraindicated)

Correctable pathology, such as submucosal fibroids, endometrial polyp, or other conditions, ruled out by an endometrial stripe < 5 mm on vaginal probe ultrasound or one of either hysteroscopy or hysterosonogram, with the past 12 months

The bleeding is not iatrogenic due to HRT

Abnormal Uterine Bleeding in Peri or Premenopausal Women with ALL of the following:

Patient continues to have severe uterine bleeding as demonstrated by ANY ONE of the following:

Repetitive periods lasting > 8 days

Anemia (Hct < 30) due to blood loss

An inter-menstrual interval consistently less than 20 days

Menses of normal duration with extraordinary blood loss

All other common causes for uterine bleeding such as endometrial cancer and iatrogenic have been excluded

Bleeding persists after 3-month trial of suppressive hormonal therapy (unless both estrogen and progesterone hormonal treatments are contraindicated)

Correctable pathology, such as submucosal fibroids, endometrial polyp, or other conditions, ruled out by an endometrial stripe < 5 mm on vaginal probe ultrasound or one of either hysteroscopy or hysterosonogram, within the past 12 months

Chronic Pelvic Pain or Dyspareunia with ALL of the following:

Greater than or equal to 6 consecutive months of moderate to severe pain

Unresponsive to conservative treatment including nonnarcotic analgesics and hormonal suppressive therapy

Pathology and/or other sources (GI, GU, psychological reasons) for pelvic pain have been ruled out

Laparoscopy within the past 2 years to exclude pathologic causes

Pelvic Inflammatory Disease with ALL of the following:

Documented persistent or recurrent infection

Failure of appropriate parenteral antibiotic therapy

Uterine Prolapse with ANY ONE of the following:

Uterine cervix at or below introitus (hymenal ring) during standing or Valsalva (not with examiner’s traction)

Uterine cervix at or below the ischial spines during standing or Valsalva (not with examiner’s traction) with the need for rectocele and / or cystocele repair

Note: Removal of a normal, well-supported uterus is not shown to improve the cure rate for operations designed to correct stress incontinence. Hysterectomy should be reserved for gynecologic indications alone (ACOG 1995).

Adenomyosis is a histological diagnosis which cannot be made by exam or imaging. Certain persistent symptoms, despite conservative therapy, may suggest adenomyosis as a diagnosis of exclusion. Criteria for these symptoms are as noted above for:

Bleeding (See Abnormal Uterine Bleeding)

Pain (See Chronic Pelvic Pain or Dyspareunia)

Sources

ACOG. Clinical Management Guidelines for Obstetricians-Gynecologist. Practice Bulletin. Endometrial Ablation, No. 81, May 2007.

ACOG. Clinical Management Guidelines for Obstetricians-Gynecologist. Practice Bulletin. Management of anovulatory bleeding, No. 14, March 2000.

ACOG. Committee on Ethics. Committee Opinion. Sterilization of women, including those with mental disabilities, No. 371, March 2007.

BlueCross BlueShield of Tennessee network physicians. April - June 2008.

Ely, J. W., Kennedy, C. M, Clark, E. C., & Bowdler, N. C. (2006). Abnormal uterine bleeding: A management algorithm. Journal of American Board Family Medicine, 19, (6). 590 - 602.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Deleted from: Clinical Indications


	Milliman Care Guidelines Clinical Indications were deleted.

	Added to: Clinical Indications


	Definitions for Hysterectomy Criteria Abnormal Uterine bleeding: profuse bleeding or repetitive periods lasting > 8 days. Conservative Treatment may include, but is not limited to, ANY of the following: Non-steroidal anti-inflammatory therapy (NSAIDS) Laparoscopic procedures Cyclical hormonal therapy Suppressive hormonal therapy Uterine artery embolization (UAE) D&C Hysterectomy Endometrial ablation or resection Myomectomy LEEP Pain: Mild = Intermittent, not interfering with ability to work, analgesics required but not chronically. Moderate = Continuous, not interfering with work, requires chronic analgesic, such as NSAIDS, for > 3 months. Severe = Continuous, causing absence from work, > 3 months of NSAIDS have failed & narcotics required for pain relief. Postmenopausal: Cessation of menstruation for > 12 months. Suppressive Hormonal Therapy: Hormonal therapy of sufficient potency to inhibit ovulation in a pre or peri-menopausal female. Such therapies include a combination of an estrogen and progestin (as in combination oral contraceptive pills), progestin only suppression (as in a "mini-pill" or depo-medroxyprogesterone) or GnRH agonist. A smoker > age 35 does not represent a contra-indication to progestin only or GnRH agonist suppressive therapy. Uterine Size is described in terms of gestational weeks determined by physical exam. Hysterectomy remains one of the most debated surgical procedures. Probably 80% of hysterectomies are discretionary in that there is at least one reasonable alternative. This may include observation, hormonal therapy, NSAID's, GnRH inhibitors, conservative procedures including endometrial ablation and myomectomy. Informed collaboration with documented active participation of patient in decision-making is appropriate. The appropriate route of hysterectomy, abdominal, vaginal or laparoscopic (LAVH) depends on the patient's anatomy and pathology and the surgeon's experience and skills. The decision-making process can be expected to vary within communities, institutions, and surgeons. In general, LAVH is used for a very low percentage of hysterectomies. NOTE: Hysterectomy for sterilization is not indicated. Procedure is indicated for ANY ONE of the following: Emergency Situation with ANY ONE of the following: Postpartum complications Extensive uterine infection with sepsis Operative complications Ruptured uterus Malignancy with ANY ONE of the following: Ovarian Uterine Invasive carcinoma Microinvasive carcinoma Endometrial adeno-carcinoma in situ Trophoblastic disease unresponsive to chemotherapy Cervical Invasive carcinoma, biopsy diagnosed Microinvasive carcinoma, biopsy diagnosed Adenocarcinoma (any stage), biopsy diagnosed Premalignant Conditions with ANY ONE of the following: Cervical Dysplasia (CIN III or greater) - Recurrent CIN III on repeat-cone biopsy (within 2 years of first conization) Endometrial hyperplasia diagnosed by endometrial sampling with ANY ONE of the following: Complex atypical hyperplasia Endometrial hyperplasia not described as complex atypical, with ALL of the following: Biopsy-proven persistence after 6 months of intermittent or continuous progestin therapy No desire for future fertility Nonmetastatic gestational trophoblastic disease in a woman not desiring further fertility Prophylactic Hysterectomy/oophorectomy with a high risk of hereditary ovarian cancer with ANY ONE of the following: Two or more first-degree relatives with ovarian or breast cancer One first-degree relative and one second-degree with ovarian or breast cancer before the age of 50 years One first-degree relative and two or more second-degree or third-degree relatives with ovarian or breast cancer Presence of BRCA1 or BRCA2 mutation Note: Prophylactic hysterectomy for individuals receiving estrogen receptor antagonist for treatment of breast cancer is NOT indicated. Uterine Leiomyoma with ANY of the following: 12 week gestational size by pelvic exam or ultrasound, a single myoma > 8 cm documented size by ultrasound or documented growth of a single myoma > 2 cm/year by ultrasound Palpable myomatous enlargement that is symptomatic Note: For criteria regarding symptoms, see other sections of this tool, i.e., Abnormal Uterine Bleeding, Pain, etc. Confirmation of Endometriosis by biopsy or direct visualization, or a positive therapeutic response to a 3-month trial with gonadotropin-releasing hormone (GnRH) agonist analog (e.g., Lupron Depot® or Leuprolide acetate for depot suspension) and ANY ONE of the following: Documented failure of conservative treatment (3 consecutive months of suppressive hormonal therapy) or procedure Significant involvement of other organ systems, affecting normal physiologic function Abnormal Uterine Bleeding in Postmenopausal Women and ALL of the following: Moderate to severe bleeding where all other common causes for uterine bleeding, including endometrial cancer, have been excluded Bleeding persists after 3-month trial of hormonal treatment (unless both estrogen and progesterone hormonal treatments are contraindicated) Correctable pathology, such as submucosal fibroids, endometrial polyp, or other conditions, ruled out by an endometrial stripe < 5 mm on vaginal probe ultrasound or one of either hysteroscopy or hysterosonogram, with the past 12 months The bleeding is not iatrogenic due to HRT Abnormal Uterine Bleeding in Peri or Premenopausal Women with ALL of the following: Patient continues to have severe uterine bleeding as demonstrated by ANY ONE of the following: Repetitive periods lasting > 8 days Anemia (Hct < 30) due to blood loss An inter-menstrual interval consistently less than 20 days Menses of normal duration with extraordinary blood loss All other common causes for uterine bleeding such as endometrial cancer and iatrogenic have been excluded Bleeding persists after 3-month trial of suppressive hormonal therapy (unless both estrogen and progesterone hormonal treatments are contraindicated) Correctable pathology, such as submucosal fibroids, endometrial polyp, or other conditions, ruled out by an endometrial stripe < 5 mm on vaginal probe ultrasound or one of either hysteroscopy or hysterosonogram, within the past 12 months Chronic Pelvic Pain or Dyspareunia with ALL of the following: Greater than or equal to 6 consecutive months of moderate to severe pain Unresponsive to conservative treatment including nonnarcotic analgesics and hormonal suppressive therapy Pathology and/or other sources (GI, GU, psychological reasons) for pelvic pain have been ruled out Laparoscopy within the past 2 years to exclude pathologic causes Pelvic Inflammatory Disease with ALL of the following: Documented persistent or recurrent infection Failure of appropriate parenteral antibiotic therapy Uterine Prolapse with ANY ONE of the following: Uterine cervix at or below introitus (hymenal ring) during standing or Valsalva (not with examiner’s traction) Uterine cervix at or below the ischial spines during standing or Valsalva (not with examiner’s traction) with the need for rectocele and / or cystocele repair Note: Removal of a normal, well-supported uterus is not shown to improve the cure rate for operations designed to correct stress incontinence. Hysterectomy should be reserved for gynecologic indications alone (ACOG 1995). Adenomyosis is a histological diagnosis which cannot be made by exam or imaging. Certain persistent symptoms, despite conservative therapy, may suggest adenomyosis as a diagnosis of exclusion. Criteria for these symptoms are as noted above for: Bleeding (See Abnormal Uterine Bleeding) Pain (See Chronic Pelvic Pain or Dyspareunia) Sources ACOG. Clinical Management Guidelines for Obstetricians-Gynecologist. Practice Bulletin. Endometrial Ablation, No. 81, May 2007. ACOG. Clinical Management Guidelines for Obstetricians-Gynecologist. Practice Bulletin. Management of anovulatory bleeding, No. 14, March 2000. ACOG. Committee on Ethics. Committee Opinion. Sterilization of women, including those with mental disabilities, No. 371, March 2007. BlueCross BlueShield of Tennessee network physicians. April - June 2008. Ely, J. W., Kennedy, C. M, Clark, E. C., & Bowdler, N. C. (2006). Abnormal uterine bleeding: A management algorithm. Journal of American Board Family Medicine, 19, (6). 590 - 602.