2014년 12월 23일자
Journal of Obstetrics and Gynecology에 실린 논문을 보면, 비정상 자궁출혈 및 기타 양성질환으로 자궁절제술을 받기 전 수술 대신 시행해 볼 수 있는 치료를 적게 하는 것으로 밝혀졌습니다.
The American Congress of Obstetricians and Gynecologists(ACOG)는 자궁절제술 대신 호르몬치료, 자궁경수술, 자궁내막 소작술, 미레나(MIRENA) 삽입술 등을 우선적으로 사용해보도록 권장하고 있습니다. 이러한 치료법들로 인해 자궁절제술이 감소하는 추세이긴 하나 적정성을 평가해 보면 16-70% 정도는 과잉수술로 판단되고 있습니다.
6042명의 대상 환자중 3397명(56.2%)가 자료 분석에 적합한 환자들이고 이중 1281명(37.7%)은 수술전 다른 치료 가능성에 대한 기술이 없고, 18.3%는 수술을 해야할 만한 조직 소견이 없었습니다. 즉, 18.3%는 자궁근종, 자궁내막증, 자궁내막증식증, 자궁선근증, 난소 이상, 악성종양 등 이상 소견이 없었다는 뜻입니다.
어디까지나 미국의 예이긴 하지만, 우리나라도 크게 다르지 않을 것으로 판단됩니다. 환자가 원해서 자궁절제술을 한 경우도 있겠지만 담당 의사가 수술 이외의 다른 옵션에 대해서는 언급하지 않고 자궁절제술을 시행하는 경우가 생각보다 많다는 것입니다. 18.3%가 조직에서 이상 소견이 없었다고 하니 조금 충격적이긴 합니다. 아마도 비정상 자궁출혈로 수술했는데 조직검사상 이상 소견이 없었을 것으로 추정되는데, 이런 환자들은 미레나 같은 치료나 자궁내막절제술로도 충분히 치료될 수 있다고 보기 때문입니다.
그러므로 의사-환자 간 신뢰가 매우 중요하긴 하지만 중요한 결정을 할때는 다른 의사의 second opinion을 꼭 들어보고 결정하는 것이 좋겠습니다. 미국처럼 전문의 진료가 어려운 나라도 아닌데, 다른 의사의 의견을 들어보고 결정해도 늦지 않습니다.
Alternatives to hysterectomy are underused in women with abnormal uterine bleeding (AUB) and other benign conditions, according to an analysis of perioperative hysterectomy data
published online December 23, 2014, in the
Journal of Obstetrics and Gynecology. When women with these conditions undergo hysterectomy, 18.3% have unsupportive pathology.
"The American Congress of Obstetricians and Gynecologists...supports the use of alternatives to hysterectomy including hormonal management, operative hysteroscopy, endometrial ablation, and use of the levonorgestrel intrauterine device (IUD) as primary management of these conditions in many cases," write Lauren E. Corona, BS, from Wayne State University School of Medicine, Detroit, Michigan, and colleagues. "Although use of these alternative treatments has recently led to a decrease in the utilization of hysterectomy, assessing the appropriateness of hysterectomy continues to be a target for quality improvement. Applying appropriateness criteria to hysterectomy, overutilization has been estimated to range from 16-70%."
Using data from 52 hospitals in the Michigan Surgical Quality Collaborative from January 1 through November 8, 2013, the researchers analyzed use of alternative treatments and pathology among women who underwent hysterectomy for benign indications, including uterine fibroids, AUB, endometriosis, or pelvic pain. AUB was the most common indication.
Of 6042 women who had hysterectomy during the study period, 3397 (56.2%) met inclusion criteria for analysis. More than one third of these (1281; 37.7%) had no documentation of alternative treatment before hysterectomy, and 621 (18.3%) had "unsupportive" pathology, meaning that hysterectomy showed no evidence of fibroids, endometriosis, endometrial hyperplasia, adenomyosis, adnexal pathology, or unexpected cancer.
Factors independently associated with receiving alternative treatment before hysterectomy, based on multivariable analysis, were larger uterine size and age younger than 40 years compared with ages 40 to 50 years and older than 50 years (68% vs 62% vs 56%;
P < .001).
Factors independently associated with unsupportive pathology were smaller uterine size, indication of endometriosis or pain vs uterine fibroids and/or AUB, and younger age. Rates of unsupportive pathology were 37.8% in women younger than 40 years of age, 12.0% in those aged 40 to 50 years, and 7.5% in those older than 50 years (
P < .001).
Limitations of this study include reliance on medical records, potential for selection bias, and lack of access to preoperative imaging.
"The fact that 18% of women did not have pathology supportive of the need for hysterectomy and that the majority of women consider at most 1 alternative treatment prior to hysterectomy indicates that there are opportunities to decrease the utilization of hysterectomy," the study authors conclude. "The levonorgestrel IUD, which is one of the most effective alternative treatments for AUB and pelvic pain, may be vastly underutilized. These are prime targets for quality improvement and cost savings by avoiding hysterectomy."
The Pelvic Floor Research Group receives research support from American Medical Systems, Johnson & Johnson, Kimberly Clark, and Proctor & Gamble through the University of Michigan. The authors have disclosed no relevant financial relationships.
J Obstet Gynecol. Published online December 23, 2014.
Abstract
