Several gynecologic conditions associated with hysterectomy,
including abnormal bleeding and pelvic pain, have been observed at increased
rates in women who have experienced sexual assault. Previous findings have
suggested that one of the unique healthcare needs for female military veterans
may be an increased prevalence of hysterectomy, and that this increase may be
partially due to their higher risk of sexual assault history and posttraumatic
stress disorder (PTSD). While associations between trauma, PTSD, and gynecologic
symptoms have been identified, little work has been done to date to directly
examine the relationship between sexual assault, PTSD, and hysterectomy within
the rapidly growing female veteran population.
To assess prevalence of hysterectomy in premenopausal-aged
female veterans, compare to general population prevalence, and examine
associations between hysterectomy and sexual assault, posttraumatic stress
disorder (PTSD), and gynecologic symptoms in this veteran population.
We performed a computer-assisted telephone interview between July 2005
and August 2008 of 1004 female VA-enrolled veterans ≤52 years old from 2
Midwestern US Veterans Affairs medical centers and associated community based
outreach clinics. Within the veteran study population, associations between
hysterectomy and sexual assault, PTSD, and gynecologic symptoms were assessed
with bivariate analyses using chi-square, Wilcoxon-Mann-Whitney, and t-tests;
multivariate logistic regression analyses were used to look for independent
associations. Hysterectomy prevalence and ages were compared to large civilian
populations represented in the BRFSS and ACS NSQIP databases from the similar
timeframes using chi-square and t-tests.
Prevalence of hysterectomy was significantly higher (16.8%
vs 13.3%, p=.0002), and mean age at hysterectomy significantly lower (35 yo vs
43 yo, p<.0001), in this VA-enrolled sample of female veterans compared to
civilian population-based datasets. Sixty-two percent of subjects had
experienced attempted or completed sexual assault in their lifetimes. A history
of completed lifetime sexual assault with vaginal penetration (LSA-V) was a
significant risk factor for hysterectomy (age-adjusted OR 1.85), with those
experiencing their first LSA-V in childhood or in military at particular risk.
A history of PTSD was also associated with hysterectomy (age-adjusted OR 1.83),
even when controlling for LSA-V. These associations were no longer significant
when controlling for the increased rates of gynecologic pain, abnormal
gynecologic bleeding, and pelvic inflammatory disease seen in those veterans
with a history of LSA-V.
Premenopausal-aged veterans may be at higher overall risk
for hysterectomy, and for hysterectomy at younger ages, than their civilian
counterparts. Veterans who have experienced completed sexual assault with
vaginal penetration in childhood or in military and those with a history of
PTSD may be at particularly high risk for hysterectomy, potentially related to
their higher risk of gynecologic symptoms. If confirmed in future studies,
these findings have important implications for women's healthcare providers and
policy makers within both the VA and civilian healthcare systems related to primary
and secondary prevention, costs, and the potential for increased chronic
disease and mortality.
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By:
- 1Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa; Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa. Electronic address: Ginny-ryan@uiowa.edu.
- 2Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region (VRHRC-CR), Iowa City VA Health Care System, Iowa City, Iowa.
- 3Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
- 4Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
- 5Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Departments of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa.
- 6Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa.
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