Female Veterans Face Higher Rates of Hysterectomies

Research tells us that one of the unique healthcare needs for female military veterans is an increased prevalence of hysterectomy compared to nonveterans.

A hysterectomy is a major operation. The procedure is done to treat health problems that affect the female reproductive system. It is usually considered only after less invasive treatments have been tried first.

Having a hysterectomy is not a light decision, and recovery can be lengthy. Before discussing the increased prevalence of hysterectomy in female veterans, it's vital to understand the procedure itself.

Hysterectomy is the second most commonly performed surgical procedure for women of reproductive age in the United States. Approximately 600,000 women undergo the procedure annually, and one-third of women have a hysterectomy by the age of 60, according to 2016 research by the National Cancer Institute published in the medical journal Frontiers in Oncology.

Predominantly, a hysterectomy involves the surgical removal of a woman's uterus. However, this removal can be extended to include the cervix, ovaries and fallopian tubes if medically recommended.

Uterine fibroids are the most common reason to have a hysterectomy, according to the American College of Obstetricians and Gynecologists (ACOG). Other conditions that could lead to a hysterectomy include:

• Uterine prolapse
• Endometriosis
• Gynecological cancer
• Chronic pelvic pain
• Abnormal uterine bleeding

There are three different ways of performing a hysterectomy: laparoscopic (keyhole surgery), vaginal and abdominal. As mentioned, recovery can be lengthy, lasting around six to eight weeks for an abdominal hysterectomy. This recovery time is often shorter after a vaginal or laparoscopic hysterectomy.

Studies indicate the number of hysterectomies performed in female veterans is more than in civilian society. Although it is difficult to pinpoint why, researchers suggest it may be due to two overarching reasons: the higher risk of experiencing sexual assault and post-traumatic stress disorder (PTSD).

Two conditions that can lead to hysterectomy are chronic pelvic pain and abnormal uterine bleeding. Both have been observed to be more prevalent in women who have experienced sexual assault.

For women who have been sexually assaulted, reproductive health care can be particularly triggering. Women's health care focuses on the body parts and systems where the sexual assault may have occurred. Therefore, women who have experienced sexual assault might avoid pelvic examinations and gynecological treatment. This means some diagnoses might be missed, eventually resulting in a hysterectomy if treatment is not sought soon enough.

Women with a history of sexual assault or PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms, according to a 2015 study published in the American Journal of Obstetrics & Gynecology.

The study also found that of approximately 1,000 participants, 62 percent of reproductive-age female veterans had experienced attempted or completed sexual assault. This is significantly higher than the lifetime risk of sexual assault in the civilian female population, which stands at 15 percent to 20 percent, according to the study authors.

Rates of sexual assault are higher during wartime than peacetime, and 15 percent of women serving in the U.S. military in Iraq and Afghanistan reported being sexually assaulted or harassed.

In a mid-1990s survey of more than 800 female veterans seeking care at the Baltimore Veterans Affairs Medical Center, 41 percent reported being raped, 55 percent reported sexual abuse, and 27 percent stated they were raped, sexually abused and physically abused. These incidents occurred both during and outside of military service.

The high risk of sexual trauma is one of the suggested reasons for a higher number of female veterans having hysterectomies compared to the general population.

"Sexual trauma is well known to be associated with pelvic pain, and chronic pain can lead to a hysterectomy in an attempt to make the pain go away," confirmed Nanette Santoro, M.D., professor and E. Stewart Taylor chair of obstetrics & gynecology at the University of Colorado in Denver.

A history of sexual assault is not an indication for hysterectomy per se, noted the U.S. Department of Veterans Affairs (VA), Veterans Health Administration, Office of Women's Health.

"While there is some research that suggests higher rates of hysterectomy among those veterans who have experienced sexual assault, the reason for this is unknown," the VA said in a statement to Giddy.

The VA stated that in general, people who have experienced sexual assault in any situation—not specific to military sexual assault—tend to report gynecologic symptoms, such as pelvic pain, at a higher rate compared with people who do not report sexual assault.

The second reason proposed for the higher number of hysterectomies in female veterans is PTSD.

Diagnosis of PTSD in female veterans ranges from 4 percent to 21 percent, according to an analysis published in 2018 by the American Journal of Preventive Medicine. In comparison, 8 percent of all women are estimated to develop PTSD at some point in their lives. "Because of the range of reported rates and restricted sampling (i.e., veterans enrolled in VA), it is difficult to compare the prevalence of current PTSD with civilian samples," the analysis authors noted.

The VA said PTSD, like sexual assault, is not an indication for hysterectomy.

"While some research suggests higher rates of hysterectomy among those veterans who have a diagnosis of PTSD, the reason for this is unknown," the VA stated, adding that in general, people diagnosed with PTSD may report gynecological symptoms, such as pelvic pain, at a higher rate than people who do not have a diagnosis of PTSD.

"PTSD, especially from sexual trauma, can also manifest as pelvic pain," Santoro confirmed, noting that this might link to having a hysterectomy to lessen pain.

Although the connection between PTSD and hysterectomy prevalence remains unclear, research suggests women with PTSD have more than double the risk of developing ovarian cancer compared to other women. Research is still emerging on the relationship between PTSD and gynecological conditions, and at present, the link remains unknown.

The VA offers comprehensive mental health services and support for veterans who have experienced sexual assault and/or have PTSD. It also provides a wide variety of reproductive health services, including gynecology specialty care to veterans.

In settings such as comprehensive women's health clinics in the VA, primary care providers, gynecologists, mental health specialists, social workers, pharmacists and pelvic floor physical therapists may work together to provide integrated, patient-centered and trauma-informed care to help veterans receive care that is aligned with their preferences.