Racial and ethnic differences in risk for hysterectomy following insertion of a levonorgestrel-releasing intrauterine device: A retrospective cohort study

Michael J. Green, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States.
Kemi M. Doll, Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States.
Mollie E. Wood, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Annie G. Howard, Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Lauren G. Anderson, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States.
Joacy G. Mathias, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States.
Natalie A. Rivadeneira, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Erin T. Carey, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Timothy S. Carey, Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Wanda Nicholson, Department of Prevention and Community Health, Milken Institute School of Public Health and Department of Obstetrics and Gynecology, George Washington School of Medicine and Health Sciences, George Washington University, Washington, DC, United States.
Til Stürmer, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Evan R. Myers, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States; Margolis Center for Health Policy, Duke University, Durham, NC, United States.
Whitney R. Robinson, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States; Margolis Center for Health Policy, Duke University, Durham, NC, United States; Duke-UNC Alzheimer's Disease Research Center, Durham, NC, United States. Electronic address: whitney.robinson489@duke.edu.

Document Type

Journal Article

Publication Date

11-1-2025

Journal

Contraception

Volume

151

DOI

10.1016/j.contraception.2025.111046

Keywords

Abnormal uterine bleeding; Cohort study; Disparities; Gynecological symptoms; Hysterectomy; Intrauterine device

Abstract

OBJECTIVES: Evidence regarding risk for hysterectomy following treatment for benign gynecological conditions with a levonorgestrel-releasing intrauterine device (LNG-IUD) is limited. We assess whether race and ethnicity are associated with hysterectomy risk and moderate associations between other patient characteristics and hysterectomy risk. STUDY DESIGN: From health care records (US South; 2014-2019), we identified a retrospective cohort of 783 patients (aged 18-44 years; non-Hispanic White n = 455; non-Hispanic Black n = 208; Hispanic n = 120) receiving LNG-IUD treatment for a benign condition, followed to hysterectomy or study end (September 18, 2019). Indices measuring preinsertion bleeding, gynecological pain, and bulk symptom severity were abstracted from 4 months' medical records preceding insertion. Associations between race and ethnicity, age, symptom severity, presence of fibroids and endometriosis, prior IUD use, parity, and insurance and hysterectomy risk were investigated with Kaplan-Meier estimates and Cox regression. RESULTS: Seventy-six patients (9.7%) underwent hysterectomy (median follow-up: 1.7 years). Hysterectomy rates were 7.0% within 1 year, climbing to 14.9% at 4 years post-insertion. Hysterectomy rates did not differ significantly by race and ethnicity. Age at treatment, symptom severity, fibroids, parity, and insurance status were associated with hysterectomy, but only age (hazard ratio per unit increase: 1.04 [95% CI: 1.00-1.09]), bleeding severity (1.05 [1.00-1.10]), and bulk severity (1.15 [1.00-1.32]) remained associated with adjustment. There was no evidence that race and ethnicity moderated these associations. CONCLUSIONS: We did not find statistically significant differences in hysterectomy risk for Black, Hispanic, and White LNG-IUD patients. Patients who were older and had more severe pre-insertion uterine bleeding and bulk symptoms were more likely to undergo hysterectomy. These associations did not differ by race and ethnicity. IMPLICATIONS: Among patients being treated with LNG-IUDs for benign gynecological conditions, Black, Hispanic, and White patients did not differ significantly in hysterectomy risk, but older patients and those with more severe bleeding and bulk symptoms were more likely to undergo hysterectomies.

Department

Prevention and Community Health

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