Status and treatment of patients with uterine fibroids in hospitals in central China: a retrospective study from 2018 to 2021

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • These large retrospective data were representative of hospitalised patients with uterine fibroids in central China.

  • The limitation of this study was that the characteristics data on the cover sheet of medical records lacked treatment histories, tissue types, quantity and volume of fibroids, which may also play important roles in surgical decision-making.

  • The retrospective design of the study makes it impossible to identify causal relationships between fibroids and influencing factors.

Introduction

Uterine fibroids (UFs, also known as leiomyomas or myomas) are the most common form of benign uterine tumours of the uterine muscle layer.1 Although malignancy exists, it is rare. The prevalence of UFs has been estimated at 4.5–68.6%, depending on study population and diagnostic methodology.2 Because of their hormonally responsive nature, fibroids affect mainly women during their reproductive years, rising to 70% by the age 50 years; they are extremely rare prior to menarche and typically regress following menopause.3 For most women, fibroids, either asymptomatic or symptomatic, arise progressively with time. Approximately 30% of cases present with severe symptoms, which can include abnormal uterine bleeding, anaemia, pelvic pain and pressure, back pain, urinary frequency, constipation, infertility, bulk symptoms or obstetric complications.4

The main current management strategies for hospital-treated patients are surgical interventions, including myomectomy, hysterectomy, uterine artery embolisation (UAE) and high-frequency MRI-guided focused ultrasound surgery (MRgFUS), with treatment choice guided by the patient’s age and fertility preservation. Laparoscopic myomectomy allows for a more rapid recovery than laparotomy (2–4 weeks vs 4–6 weeks for return to regular activities).5 As compared with hysterectomy, myomectomy is associated with more intraoperative blood losses but less risk of injury to other pelvic organs.6 Indeed, hysterectomies are the most effective in relieving symptoms caused by fibroids. However, the large size of the fibroids often limits the ability to perform the surgery by laparoscopic hysterectomy.7 UAE is performed by placing a catheter into the femoral artery and accessing both uterine arteries in a retrograde fashion.8 Although UAE is highly effective for relieving symptoms, there are real risks of reoperation and impacts on ovarian reserve. MRgFUS is a relatively new method of thermal ablation fibroid treatment, using high-intensity focused ultrasound to increase the local temperature of targeted tissue, leading to necrosis within seconds. It can lead to clinical improvement with few significant clinical complications or adverse events,9 and prevent adjacent tissue injury.10 Current fibroid treatments are expensive and constitute an increasing global public health issue because of their significant prevalence and associated health burdens.

Prevailing treatment choices can provide valuable insights into directions of current disease diagnosis and treatment. Yet, research on the treatment patterns for fibroids has been limited in central China. Therefore, to better describe the epidemiological characteristics of hospital-treated patients with fibroids, and to characterise the therapeutic directions of treatment for fibroids in central China, information from a cover sheet was collected for all patients treated for fibroids at any class A or class B secondary or tertiary hospital in Hubei Province, the population of which ranked fourth in central China, from 1 January 2018 to 31 December 2021.

Materials and methods

Study population and data collection

Hospitals in China are organised according to a three-tier system that recognises their ability to provide medical care and education, and to conduct medical research. Based on this, hospitals are designated as primary, secondary or tertiary institutions. Furthermore, based on their level of service provision, size, medical technology, equipment, management and medical quality, these three grades are further subdivided into three subsidiary levels: A, B and C (online supplemental material).

Supplemental material

Patients with UFs, diagnosed based on the International Classification of Disease 10th revision code, were identified by reviewing inpatient lists, from 1 January 2018 to 31 December 2021, of all gynaecology departments of class A and class B secondary and tertiary hospitals in Hubei Province of central China. Study data were retrospectively extracted from the Information Center of the Hubei Health Commission. Data source was real and reliable. Data elements were collected from the cover sheet of medical records, including patient demographics, hospital levels, diagnosis at discharge and treatments.

Study variables

Patient ethnicity was categorised as Han or non-Han. A total of 13 different occupational groups were included, among which, excluding others, we divided the occupational groups into three categories: those with occupations (employed, including workers, farmers, office staff, civil servants, servicemen, managers, professionals, self-employed and freelancers), those without occupations (unemployed, including students and unemployed individuals) and retirees. Hospitals were categorised following their official designation as class A secondary, class B secondary, class A tertiary or class B tertiary.

Because fibroids can cause heavy menstrual bleeding with subsequent, potentially life-threatening anaemia, this comorbidity was included in analyses following the WHO’s definition of anaemia in non-pregnant women as haemoglobin <120 g/L and limits for mild (110–120 g/L), moderate (80–110 g/L) and severe (<80 g/L).11

Six surgical treatments were analysed: laparoscopic myomectomy (total or laparoscopic-assisted vaginal); laparoscopic hysterectomy (total or laparoscopic-assisted vaginal); open myomectomy (vaginal or abdominal); open hysterectomy (vaginal or abdominal); MRgFUS and UAE.

Automated data collection errors led to some missing descriptive data, including ethnicity (813 cases), marital status (2637 cases) and occupation (6 cases).

Statistical analyses

Categorical variables are presented as frequencies (N) and percentages (%). Rates were examined for each 5-year age range group during each study year. Treatment pattern trends were assessed by patient age group, hospital grade and occupational group. All statistical analyses were performed using SPSS V.26.0.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

Patient characteristics

A total of 101 008 women with fibroids were treated at class A/B secondary/tertiary hospitals in Hubei Province during the 4-year study period. Table 1 shows their demographic and clinical characteristics. The diagnostic rate of fibroids increased with age, reaching a peak at ages 45–49 years (34.17%), after which it gradually decreased. Within the overall sample, 97.99% were of Han ethnic background and 92.12% were married. Most patients were unemployed or had ‘other’ occupations (53.61%), whereas others were office staff (12.57%), farmers (10.38%) or freelancers (9.72%). Anaemia symptoms were experienced by 19.05% of the sample, with moderate anaemia the most common (9.46%), followed by mild (8.38%) and severe (1.21%) anaemia.

Table 1

Characteristics of UF cases in 2018–2021 (n=101 008)

Hospitalised patients with fibroids across age groups and study years

Forty-five to 49 years old was the highest diagnostic age of women suffering from fibroids (figure 1A). The diagnostic rate of fibroids was lower in 2018 and 2021, and higher in 2019 and 2020 (highest, 28 456 in 2020) (online supplemental table 1). However, the diagnostic rate of fibroids was highest for women aged 45–49 years and peaked at 36.51% in 2018, followed by 35.05% in 2019, 31.62% in 2020 and 33.63% in 2021 (online supplemental table 1). Fibroids manly affected women during their reproductive years, rising to 55.50% at ages 40–49 years from 2018 to 2021, and typically regressing following menopause (online supplemental table 1). The age distribution of patients with fibroids combined with different degrees of anaemia from 2018 to 2021 was similar to that of all patients with fibroids (figure 1B).

Figure 1
Figure 1

The age distribution of patients with UFs from 2018 to 2021. (A) The status of all patients with UFs. (B) The status of patients with UFs combined with anaemia. X-axis: ages; y-axis: numbers of cases. UFs, uterine fibroids.

Fibroid treatments by age group, hospital class and occupational group

Treatment choice is guided by patient age and fertility preservation. During the study period, women aged 20–44 years were more likely to undergo laparoscopic myomectomy (highest, 62.22% among those aged 25–29 years), followed by open myomectomy (highest, 34.58% among those aged 20–24 years) (figure 2). Women over 45 years who had entered perimenopause tended to undergo hysterectomy, particularly by laparoscopy (highest, 64.85% for those aged 65–69 years). Among those women, less than 7% were treated with MRgFUS, whereas most undergoing this treatment were aged 25–29 years (6.50%). The rate of MRgFUS treatment decreased significantly among postmenopausal women. UAE was rarely performed in women with fibroids. Other age groups were not included in the analysis of the different treatment patterns mentioned above, which may be because they had received conservative treatment.

Figure 2
Figure 2

The tendency of treatment patterns for patients with UFs with different ages from 2018 to 2021. X-axis: ages; y-axis: percentage of different treatments. Lap-Hys, laparoscopic hysterectomy; Lap-Myo, laparoscopic myomectomy; MRgFUS, high-frequency MRI-guided focused ultrasound surgery; Open-Hys, open hysterectomy; Open-Myo, open myomectomy; UAE, uterine artery embolisation; UFs, uterine fibroids.

During the study period, patients with fibroids were treated most often at class A hospitals, with the highest rate of treatment at class A tertiary hospitals, followed by class A secondary hospitals, class B tertiary hospitals and class B secondary hospitals, regardless of treatment type between 2018 and 2021 (online supplemental figure 1). Among treatment types, UAE and MRgFUS treatment were mainly performed at class A tertiary hospitals (highest, 100% in 2021 and 73.33% in 2019, respectively). Taking the hospital as a whole, we found that the proportion of patients who chose laparoscopic hysterectomy for fibroids was similar to that of patients who chose laparoscopic myomectomy (figure 3A, 31.38% vs 31.14%). Only 2.08% of UFs were treated with MRgFUS (figure 3A). After stratifying by hospital grade (figure 3B), we found that during the 4 years, women treated at class A tertiary hospitals were more likely to have laparoscopic than open surgery (66.12% vs 31.26%), whereas the proportions undergoing laparoscopic myomectomy (34.23%) and laparoscopic hysterectomy (31.89%) were similar. At class A secondary hospitals, the proportion of women undergoing laparoscopic hysterectomy was the highest (30.74%), followed by open hysterectomy (27.05%), open myomectomy (22.18%), laparoscopic myomectomy (19.72%), MRgFUS (0.19%) and UAE (0.12%). Myomectomy was used to treat 61.9% of the patients at class B secondary hospitals. By contrast, hysterectomy was used to treat 57.70% of the patients at class B tertiary hospitals. MRgFUS was rare at class B hospitals. The proportion of UFs treated by different patterns at the hospitals of the same grade in each year from 2018 to 2021 was shown in online supplemental figure 2. Over time, more and more patients with fibroids were opting for laparoscopic surgery, either laparoscopic myomectomy or laparoscopic hysterectomy (figure 3C–H). The proportion of patients opting for open myomectomy dropped to the lowest level in 2019 (19.16%). The number of patients who choose MRgFUS treatment was also increasing year by year.

Figure 3
Figure 3

The distribution of UF treatments in hospitals from 2018 to 2021. (A) The proportion of different treatments for UFs from 2018 to 2021. (B) The proportion of UFs treated by different patterns at the hospitals of the same grade from 2018 to 2021. (C) The proportion of UFs treated by open myomectomy in 4 years. (D) The proportion of UFs treated by laparoscopic myomectomy in 4 years. (E) The proportion of UFs treated by open hysterectomy in 4 years. (F) The proportion of UFs treated by laparoscopic hysterectomy in 4 years. (G) The proportion of UFs treated by MRgFUS in 4 years. (H) The proportion of UFs treated by UAE in 4 years. Class A-S, class A secondary hospitals; Class B-S, class B secondary hospitals; Class A-T, class A tertiary hospitals; Class B-T, class B tertiary hospitals; Lap-Hys, laparoscopic hysterectomy; Lap-Myo, laparoscopic myomectomy; MRgFUS, high-frequency MRI-guided focused ultrasound surgery; Open-Hys, open hysterectomy; Open-Myo, open myomectomy; UAE, uterine artery embolisation; UFs, uterine fibroids.

The treatment patterns and hospital selection for patients with fibroids and varying degrees of anaemia between 2018 and 2021 were shown in figure 4. Patients with fibroid with mild anaemia tended to have myomectomy, while patients with moderate-to-severe anaemia mostly chose hysterectomy (52.49% in moderate anaemia and 68.87% in severe anaemia, respectively) (figure 4A). Patients treated with MRgFUS and UAE was rare. Regardless of the degree of anaemia combined with fibroids, patients were more likely to seek treatment at class A tertiary hospitals, followed by class A secondary hospitals (figure 4B).

Figure 4
Figure 4

The tendency of treatment patterns for patients with UFs combined with anaemia from 2018 to 2021. (A) The distribution of UFs with varying degrees of anaemia treated by different treatments in the hospitals. (B) The distribution of UFs with varying degrees of anaemia in hospitals of different grades. Class A-S, class A secondary hospitals; Class B-S, class B secondary hospitals; Class A-T, class A tertiary hospitals; Class B-T, class B tertiary hospitals; Lap-Hys, laparoscopic hysterectomy; Lap-Myo, laparoscopic myomectomy; MRgFUS, high-frequency MRI-guided focused ultrasound surgery; Open-Hys, open hysterectomy; Open-Myo, open myomectomy; UAE, uterine artery embolisation; UFs, uterine fibroids.

In online supplemental figure 3A, we found that 54% of patients with occupation underwent myomectomy, while 80.84% of retired patients underwent hysterectomy. For patients without occupations, 54.94% chose hysterectomy treatment and 43.08% opted for myomectomy treatment. MRgFUS treatment was highest in patients with occupation (2.01%). Regardless of the different occupations, patients were more likely to seek treatment at class A tertiary hospitals, followed by class A secondary hospitals (online supplemental figure 3B).

Discussion

In this study, using a large, hospital-based registry of patients diagnosed with fibroids in Hubei Province of central China, we observed that the diagnostic rate of UFs increased with age, peaking at 45–49 years, and then decreased with menopause, consistent with other findings.12–15 Zimmermann et al demonstrated that the prevalence of fibroids increases with age, reaching 14.1% in those over 40 years.12 In a large cohort of teachers in California, over 30% of those newly diagnosed with fibroids were aged 45–49 years.14 According to Selo-Ojeme et al, women aged over 40 years were four times more likely to have a fibroid and twice as likely to have multiple fibroids.16 Lurie et al also found that women aged 41–60 years were more likely to have fibroids than those aged 21–30 years in a retrospective, single-centre study.15 Previous studies have also confirmed that the mean age of natural menopause in China is 50 years.17 These cumulative findings indicate that premenopausal women are mostly the ones hospitalised for UFs.

Clinical treatment choices can help explain current directions in disease diagnosis and treatment. Medical treatment capacities of the hospital may also contribute to available treatment options. Increasing numbers of women and their doctors prefer minimally invasive uterus-sparing alternatives for fibroid treatment, including UAE and MRgFUS.18 However, few women with UFs meet the inclusion criteria for MRgFUS and chose UAE therapy; thus, these treatments were rare in our sample. More studies focusing on these two treatments will be needed in the future.

Hysterectomy is the definitive surgery, with outstanding outcomes, guaranteed complete cessation of menstruation and no risk of fibroid recurrence. However, hysterectomy should be considered when other treatment options have failed, are contraindicated or are declined by the patient, or if she no longer wishes to retain her uterus and fertility. Indeed, our data show that the rate of laparoscopic hysterectomy was highest during the study period among perimenopausal and postmenopausal women. Moreover, patients with moderate-to-severe anaemia were more likely to choose hysterectomy in our study. As known, patients with anaemia are in a state of high cardiac output. Despite the compensatory mechanisms, the complications of chronic anaemia left untreated are not minor and can adversely affect cardiovascular function, worsen chronic conditions and ultimately lead to the development of multiple organ failure and even mortality.19 Of course, the most important risk factors of anaemia are the patient’s mental, social and personal problems. Furthermore, intraoperative bleeding during hysterectomy is relatively low. These may be the reasons why patients choose hysterectomy. More research on UFs combined with anaemia will be needed in the future. In addition, the vast majority of retired patients with UFs were more likely to undergo hysterectomy, which may be due to their old age and lack of fertility requirements.

For women wishing to preserve their fertility, the more conservative procedure is myomectomy. The women in our sample were more likely to undergo laparoscopic myomectomy than open myomectomy. Of note, leiomyomas are usually removed laparoscopically with a morcellator. Although leiomyosarcoma is very rare,20 its potential harm must be seriously considered. It is important to note that fibroids usually recur following myomectomy. A meta-analysis of nine trials concluded that there was no evidence of difference in recurrence risk between laparoscopy and open myomectomy.21 However, Kotani et al found that the cumulative recurrence rate was higher in their laparoscopic myomectomy group compared with their open myomectomy group 8 years postoperatively.22 Importantly, when fibroids are treated with myomectomy, there is a concern regarding risk of uterine rupture in any subsequent pregnancy. The overall risk of uterine rupture after myomectomy has been reported at 79 per 10 000 deliveries.23 Gil et al found that the number of uterine ruptures per 1000 myomectomies was 4.2 after laparotomy and 10.6 after laparoscopy.24 In their systematic review, Gambacorti-Passerini et al found that trial of labour after myomectomy was associated with a 0.47% increased risk of uterine rupture.25 However, the incidence of uterine rupture in women without labour experience (1.52%) exceeded that of those with a trial of labour post-myomectomy.25 Therefore, these investigators speculated that uterine rupture may not be significantly influenced by post-myomectomy labour trial, and that this option could be considered feasible and relatively safe for women who would become pregnant. This may be why women in our sample aged 20–24 years were more likely to undergo open myomectomy. In addition, there was a decrease in the number of patients treated with myomectomy at the age of 40–49 years, and a significant decrease at the age of 45–49 years, which may be due to the population at this age had less reproductive needs and was approaching menopause, so they chose hysterectomy. The proportion of open versus laparoscopic hysterectomy was relatively stable, which may be related to the difficulty of removing the uterus itself or the disease itself, regardless of age.

The treatment options for patients with UFs varied by occupation. Most retired patients and patients without occupations chose hysterectomy, while patients with occupations chose myomectomy, which may be related to the younger age of patients with occupations. In terms of hospital level, regardless of the degree of anaemia or different occupations, class A tertiary hospitals were the choice of most people, which was determined by the medical resources and qualifications of the hospitals.

Our study has multiple strengths. The hospitalised patients with UFs were from hospitals in Hubei Province of central China, which are partly representative of the general population. We analysed treatment trends among patients with fibroids based on age, hospital grade and occupation, to describe the current context and provide fibroid treatment guidance in China. This study was not without limitations. One was our limited clinical data without the treatment histories, tissue types, quantity and volume of fibroids, which may not have had adequate power to detect significant trends. Due to the lack of information on the pregnancy histories and comorbidities such as hypertension or diabetes, we overlooked the impact of fibroids on female infertility and organ health. The diagnostic rate of fibroids among the general population, including asymptomatic patients, has been underestimated. Thus, our research team is conducting a large-scale population study to explore the diagnostic rate and related risk factors of UFs which would also verify the findings in Chinese women. While there are notable ethnic effects on fibroid prevalence,26 most of our sample was ethnic Han, making it impossible to analyse ethnic differences. We focused on age effects on fibroid diagnostic rate but did not address other risk factors like obesity, nulliparity, early menarche, late menopause, environmental factors, and caffeine and alcohol use.4 27 Variance in diagnostic methods and management differences across hospitals may have resulted in detection bias. Moreover, we did not analyse cost-effectiveness, which is an important factor that both patients and policymakers use to decide among treatment options. This is clearly an area in which further research and collaborations are needed.

Conclusion

The majority of patients with UFs tended to seek medical treatment in class A tertiary hospitals, among which laparoscopic myomectomy was the mainstream surgical method for patients in Hubei Province. Treatment of patients with fibroids should be individualised, according to their age, desire to preserve fertility, physical condition and the hospital’s medical capacity. Results from these retrospective data may serve as a foundation to guide clinicians and healthcare systems toward improved treatment plans for women with fibroids.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the Medical Ethics Committee of Tongji Hospital, which is affiliated with the Tongji Medical College of Huazhong University of Science and Technology (TJ-IRB20220644). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank the staff at the Information Center of the Hubei Health Commission for collecting patient study data.

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