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Bower conducted the analyses and led the writing. Schreiner provided guidance for all analyses and served in a supervisory role for the study. All authors helped to conceptualize ideas, interpret findings, and review drafts of the article. We evaluated the cross-sectional association between race and hysterectomy prevalence in a population-based cohort of US women and investigated participant characteristics associated with racial differences. We used logistic regression to examine unadjusted and multivariable adjusted odds ratios.

In both unadjusted and multivariable adjusted models, Black women, compared with White women, had increased odds of hysterectomy that persisted despite adjustment for participant characteristics. The increased odds are possibly related to decisions to undergo hysterectomy.

Hysterectomy is one of the most frequently performed surgeries among women in the United States. Rates of hysterectomy far exceed those in a majority of other Western countries, which may be partially because of nonclinical factors. In fact, most available studies are not population-based or have otherwise restricted samples that preclude adequate assessment of contributors to racial differences. Because most hysterectomies are performed for noncancer causes, 5 there is growing interest in understanding differences in antecedents to hysterectomy that may explain the disproportionately higher frequency among Black women.

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The initial step in this investigation was to identify individual characteristics that may help to explain why more Black women undergo hysterectomy in the United States compared with White women. Individual physiological and nonclinical characteristics likely influence one's decision to undergo hysterectomy or a clinician's recommendation for treatment. In addition to clinical indications, including presence of fibroids or persistent vaginal bleeding for which the most appropriate method of treatment is not always clearthose attributes most strongly related include differences in access to health care, highest level of education, body mass index BMIand various lifestyle behaviors.

Alternately, information about less radical treatments may be differentially communicated to or accepted by patients. With a large, biethnic, population-based cohort of women, we cross-sectionally examined differences in hysterectomy prevalence between Black and White women and potential correlates of racial differences. Our primary objective was to identify characteristics associated with observed racial differences. We hypothesized that racial differences could be explained by statistically controlling for participant characteristics related to hysterectomy status—most notably psychosocial factors and medical history.

The establishment of attributes that explain current racial disparities may reveal potential modifiable factors that influence decisions to undergo hysterectomy—with the ultimate goal of better identifying candidates for alternative and less radical treatments. Further, this could lead to tailored interventions that more effectively help women consider the multiple treatment options available.

The sample was recruited to obtain balanced subgroups by gender, race non-Hispanic Black or non-Hispanic Whiteeducation, and age. At baseline, women Black women and White women were enrolled. At each examination, study participants completed questionnaires regarding health status, health behaviors, medical history, and psychosocial characteristics. Additionally, participants contributed blood samples and underwent various physiological measurements. In the CWS, researchers examined associations of serum androgens, polycystic ovaries assessed with ultrasonography, and clinical features of polycystic ovarian syndrome PCOS in relation to coronary artery calcium development.

Other CWS exclusion criteria were current pregnancy or less than 3 months postdeliveryuncertainty about pregnancy status, or bilateral oophorectomy. A total of women who met eligibility criteria agreed to participate in CWS. One hundred nineteen eligible women chose not to participate in CWS, most commonly because they lived too far from the clinic or were unwilling or unable to attend the additional assessment session.

An institutional review board at each site approved all study procedures; written informed consent was obtained from study participants prior to assessments. Hysterectomy status was ascertained by self-report at baseline and at each follow-up examination to determine total self-reported hysterectomy prevalence by year Women were asked if they had undergone a hysterectomy and, if yes, to specify existing conditions at the time of hysterectomy including abnormal Papanicolaou test, endometriosis, infection, fibroids, prolapse, pregnancy complications, and cancer.

Participants were also excluded if data were missing for the characteristics under study. Sample size ranged from todepending on the analysis. Participants self-reported race, years of education completed, smoking and alcohol-use history, ability to obtain needed health services, and difficulties in paying for medical services. Items assessing access to health services were measured on a 4- or 5-point Likert scale and subsequently reduced to dichotomous indicators ifying presence or absence of a barrier to care.

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Blood pressure and lipids were measured with methods described ly. Participants with a score of 16 or higher were characterized with depressive symptoms. Physical activity was measured with an interviewer-administered modified version of the Minnesota Leisure Time Physical Activity Questionnaire.

The instrument assesses 13 activity covering various intensity levels and obtains the following information: whether the activity was performed at any time in the prior year, of months that the activity was performed, and of months that the activity was performed frequently.

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The total score represented total amount of moderate-to-vigorous physical activity expressed in exercise units. Further details of the scoring system have been described ly. Certified technicians measured height, weight, and waist circumference with a standardized protocol ly described.

Efforts were made to conduct transvaginal ultrasound examinations during the first 10 days of the cycle for women with regular menstrual cycles. Sixty-four percent of exams occurred within this time frame. For women whose cycles were greater than 34 days, who were amenorrheic, or who reported current oral contraceptive pill use, no preference for day of examination was specified. The ultrasound determined of ovaries, presence of a uterus, and and size of fibroids and ovarian follicles or cysts.

Sonographers were certified by the American Registry of Diagnostic Sonographers and used a 5- to 7. Examinations were standardized across study centers; quality control measures performed throughout the data collection process ensured adherence to the protocol. Total testosterone, sex hormone—binding globulin, follicle-stimulating hormone, and luteinizing hormone levels were measured. Free testosterone was computed with a ly described method based on total testosterone and sex hormone—binding globulin.

We examined participants with self-reported or ultrasound-confirmed hysterectomy without bilateral oophorectomy 1 or 2 ovaries remaining and with bilateral oophorectomy. We also examined the same characteristics separately by hysterectomy status no evidence or report of hysterectomy and any type of hysterectomy comparing Black and White women. We used logistic regression to examine the relationship between race and self-reported hysterectomy, with hysterectomy coded as a dichotomous variable yes or no.

In the primary analysis, we pooled women with hysterectomy with or without oophorectomy. We evaluated the following characteristics as potential confounders of the association between race and hysterectomy: age, age at menarche, geographic site, education, access to medical care, ability to pay for medical care, depressive symptoms, BMI weight in kilograms divided by height in meters squaredPCOS, and tubal ligation.

We also evaluated potential statistical interactions between race and those factors that differed by race. The final model examined unadjusted and multivariable adjusted odds ratios in the full sample. In a secondary analysis, we applied our final model to the subsample of women with self-reported fibroid history women who had hysterectomy and those who participated in CWS, which included an ultrasound examination.

Analyses were cross-sectional and used combined prevalence data from years 15 and All analyses were conducted with SAS version 8. Women with complete oophorectomy status data were categorized as having no evidence or report of hysterectomy, hysterectomy without oophorectomy, or hysterectomy with oophorectomy.

Black women who underwent hysterectomy without oophorectomy were on average older and had higher total and low-density lipoprotein cholesterol levels, higher follicle-stimulating hormone and luteinizing hormone levels, younger age at menarche, higher self-reported prevalence of PCOS, and higher prevalence of self-reported history of fibroids compared with Black women with no hysterectomy Table 1.

Black women who underwent hysterectomy with oophorectomy were on average older than were those with no history of hysterectomy, had a higher BMI and waist circumference, were more likely to report depressive symptoms, were less physically active, and self-reported higher prevalence of PCOS and fibroid history. White women who underwent hysterectomy without oophorectomy had higher diastolic blood pressure, higher BMI, larger waist circumference, lower high-density lipoprotein levels, lower prevalence of smoking history, lower prevalence of alcohol use, lower prevalence of self-reported past or current use of oral contraceptives, and higher prevalence of self-reported history of fibroids compared with those with no history of hysterectomy Table 2.

Compared with those without hysterectomy, White women who underwent hysterectomy with bilateral oophorectomy had higher mean systolic blood pressure, larger waist circumference, and higher triglyceride levels; were less likely to be alcohol drinkers; and had higher prevalence of self-reported fibroid history.

Because of lack of a statistical difference between groups by hysterectomy status and because of the limited of women with oophorectomy, subsequent analyses pooled these groups. Sample sizes vary within groups because some data on individual responses among women attending the Year 15 Cardia exam were missing. Table 3 compares key participant characteristics by race, pooling women with hysterectomy regardless of oophorectomy status.

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White women with no history of hysterectomy were on average older, reported older age at menarche, completed more years of schooling, had lower BMI and smaller waist circumference, were less likely to report depressive symptoms, had a lower percentage of smoking history and prior pregnancy, were more likely to drink alcohol at least occasionally, were more physically active, and had lower prevalence of fibroids and self-reported tubal ligation history.

Eight hundred fifty-two Black women and White women had no report or evidence of hysterectomy; these women served as the reference group for odds ratio OR calculations. As presented in Table 4the unadjusted odds of hysterectomy were 3.

Other ificant predictors that contributed to the odds of hysterectomy were age, PCOS, and geographic site. Fibroid information was collected in a subset of CARDIA participants who self-reported history of fibroids at year 15 or attended the CWS year examination 19 of the women in CWS were excluded because of missing data on 1 or more characteristics in the model. Fibroid volumes ranged from 0. As a secondary analysis, we considered the importance of racial differences in fibroid history prevalence. The association between race and hysterectomy was not modified by education, BMI, depressive symptoms, fibroids, or geographic site.

For completeness, we also explored the independent associations of additional items related to those formally evaluated in the main analysis: self-reported ability to pay for perceived needed medical care, parity, oral contraceptive use, menstrual cycle changes associated with middle age, and menstrual flow intensity and duration. None of these characteristics ificantly altered OR estimates or helped to explain observed racial differences. In this large, population-based sample of US women, hysterectomy prevalence differed markedly by race.

After we adjusted for factors believed to contribute to racial differences age, age at menarche, education, access to medical care, BMI, PCOS, tubal ligation, depressive symptoms, and geographic locationthe odds of hysterectomy among Black compared with White participants were almost 4 times higher. Moreover, past studies have asserted that fibroid prevalence tends to be higher among Black women and that fibroids also tend to be larger in volume when clinically identified, 212 — 14 suggesting that this may partially explain why Black women undergo hysterectomy more frequently.

However, in the subset of women with fibroids assessed, findings were similar; the adjusted OR was only slightly attenuated. We should note that our fibroid measurement was imperfect because fibroids were not assessed by ultrasound in all women in the CARDIA study but rather only in women enrolled in CWS and who had a uterus. It is possible that some women with hysterectomy or without fibroids detected by ultrasound had fibroids removed that were not self-reported or that some women who had undergone hysterectomy were never told that they had fibroids.

However, given the most complete data available using both self-reported and ultrasound-detected fibroidsfibroid prevalence did not appear to be the dominant risk factor for hysterectomy prevalence. The findings of this study are important for several reasons. First, epidemiological data have demonstrated variable differences in hysterectomy rates within and among various ethnic, cultural, geographic, and socioeconomic groups. Our are consistent with research, including the Study of Women's Health Across the Nation, which also identified socioeconomic correlates of hysterectomy status including education and geographic location.

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The factors we evaluated add to the existing body of evidence, although they failed to explain the observed racial disparity. Because this analysis was cross-sectional cumulative hysterectomy prevalencewe cannot infer causality or temporality, but can only hypothesize on the nature of the relationship between race and hysterectomy. In this light, we are limited by the fact that CARDIA included only 1 minority group and simply recruited participants in 2 nonspecific ethnic non-Hispanic Black vs non-Hispanic White. It is unknown whether factors related to hysterectomy differ in other ethnic and racial groups not included in the study or in subgroups within those examined.

A unique strength of our study is that a ificant proportion of the women were also evaluated with ultrasound, which provided the ability to verify self-reported measures of surgery history for these participants.

The CARDIA study was not deed specifically to differentiate hysterectomy procedures that did or did not include bilateral oophorectomy, and therefore, these data were incomplete. We recognize that the association with participant characteristics may differ by type of hysterectomy received and whether 1 or both ovaries were preserved. Although the prevalence was small for known bilateral oophorectomy, we observed similar participant characteristics between the 2 hysterectomy groups. A larger sample of this group in future studies could allow for more-definitive evaluation of these relationships.

We were unable to attribute racial differences in hysterectomy to commonly measured psychosocial, socioeconomic, and other participant demographics. Because data heavily relied on self-report, we cannot rule out potential biases associated with this data collection method as well as residual confounding. However, both with and without adjustment, the odds of hysterectomy among Black women remained ificantly higher than among White women; after we controlled for characteristics strongly related to racial differences, we were unable to for the disparity in hysterectomy status by race.

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We must consider the possibility that there are real biological differences that might partially explain racial differences in hysterectomy, which may include genetic heterogeneity, differences in hormone levels prior to hysterectomy, or other unmeasured clinical characteristics.

However, nonclinical factors such as patient education about alternatives to hysterectomy, environmental attributes, cultural or religious beliefs, issues related to patient—provider communication, physician preference, or other psychosocial factors are likely important contributors.

Reasons for within- and between-population differences in hysterectomy prevalence are not well understood. Our study builds upon evidence that nonclinical factors play an important role in decisions to undergo hysterectomy. We found that in a population-based sample, ificant racial differences in hysterectomy were observed even after we ed for measured participant characteristics.

In fact, adjustment for a wide variety of potential confounding factors minimally altered crude observed associations. These findings emphasize the need for further investigation into the practice of hysterectomy and the importance of efforts to disseminate information regarding nonhysterectomy alternatives during or prior to the decisionmaking process, particularly among minority populations.

The Coronary Artery Risk Development in Young Adults study has had continuous institutional review board approval at all clinic sites since it began in National Center for Biotechnology InformationU. Am J Public Health.

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Julie K. Author information Article notes Copyright and information Disclaimer. Bower and Pamela J. Cora E. Corresponding author. Requests for reprints should be sent to Pamela J. Contributors J. Accepted July 5, This article has been cited by other articles in PMC. Abstract Objectives. Statistical Analyses We examined participants with self-reported or ultrasound-confirmed hysterectomy without bilateral oophorectomy 1 or 2 ovaries remaining and with bilateral oophorectomy. Sample Characteristics Women with complete oophorectomy status data were categorized as having no evidence or report of hysterectomy, hysterectomy without oophorectomy, or hysterectomy with oophorectomy.

Open in a separate window. Race and Hysterectomy Eight hundred fifty-two Black women and White women had no report or evidence of hysterectomy; these women served as the reference group for odds ratio OR calculations.

White 4 black women only

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Black–White Differences in Hysterectomy Prevalence: The CARDIA Study