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REFERENCE ONLY UNIVERSITY OF LONDON THESIS Degree b Year ^ J O O (o Name of Author 0 ^ 0 f COPYRIGHT This is a thesis accepted for a Higher Degree of the University of London. It is an unpublished typescript and the copyright is held by the author. All persons consulting the thesis must read and abide by the Copyright Declaration below. COPYRIGHT DECLARATION I recognise that the copyright of the above-described thesis rests with the author and that no quotation from it or information derived from it may be published without the prior written consent of the author. LOAN Theses may not be lent to individuals, but the University Library may lend a copy to approved libraries within the United Kingdom, for consultation solely on the premises of those libraries. Application should be made to: The Theses Section, University of London Library, Senate House, Malet Street, London WC1E 7HU. 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A LIFE COURSE APPROACH TO HYSTERECTOMY: Working towards an improved understanding of the predictors and long-term health consequences of a common surgical procedure Rachel Cooper Thesis submitted for the Degree of Doctor of Philosophy of the University of London Department of Epidemiology and Public Health University College London 2006 UMI Number: U592788 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U592788 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Abstract Abstract The epidemiology of hysterectomy is not fully understood. This has allowed a long­ standing, emotive debate about the necessity of this common surgical procedure to continue without resolution. This thesis informs the debate by examining some of the main potential predictors and long-term health consequences of hysterectomy, using a life course approach. The National Survey of Health and Development, a cohort of 5,362 British males and females followed-up since birth in March 1946 was used. Of 1,797 women with appropriate data, 403 had undergone hysterectomy by age 57 years. Using survival analyses the associations between lifetime socioeconomic position, body mass index (BMI), reproductive characteristics and subsequent hysterectomy rates were investigated. Linear and logistic regression models were used to examine the relationships between hysterectomy and subsequent BMI, musculoskeletal and psychological health and quality of life. Education, age at menarche, parity, irregular/infrequent menstrual cycles and BMI in adulthood all predicted subsequent hysterectomy rates independently of each other. The association between hysterectomy and higher subsequent BMI could be explained by the greater exposure to risk factors for poor health of hysterectomised women. This difference in risk profiles only partially explained associations found between young age at hysterectomy and poor musculoskeletal and psychological health. The majority of hysterectomised women believed that their hysterectomy had a positive effect on their quality of life. This work suggests that hysterectomy rates are determined by a complex of factors that operate via medical need as well as supply and demand. The UK’s Chief Medical Officer’s recent call to reduce hysterectomy rates to the same low levels across all areas of the country may not be achievable or beneficial. Although there is no clear evidence to suggest that hysterectomy directly influences subsequent health, hysterectomised women are a defined group who may require more support to maintain good health with age. 2 Acknowledgements Acknowledgements There are a number of people I would like to thank for the support they have provided over the past three years. Firstly I would like to thank my supervisors Professor Diana Kuh and Dr Rebecca Hardy for their many valuable ideas, guidance and encouragement. Many thanks also to Suzie Butterworth, Dr Gita Mishra, Lucy Okell, Warren Hilder, Professor Michael Wadsworth and all other members of the National Survey of Health and Development research group for the help they have provided and, to Dr Debbie Lawlor for her contribution to the work presented in this thesis on the association between socioeconomic position and hysterectomy. For helping me to keep everything in perspective I thank my friends, including those in the PhD study room, and my family. Finally, I would like to acknowledge the financial support I have received from the Medical Research Council which I am very grateful for. 3 Contents C ontents Abstract ...................................................................................................................................2 Acknowledgements.................................................................................................................3 Contents..................................................................................................................................4 List of figures........................................................................................................................13 List of tables..........................................................................................................................15 Abbreviations .......................................................................................................................19 Chapter 1: Introduction..................................................................................................... 20 1.1 Introduction................................................................................................................. 20 1.2 History of hysterectomy.............................................................................................. 21 1.3 Reasons for hysterectomy...........................................................................................22 1.4 Guidelines on the ‘appropriate’ reasons for hysterectomy.........................................24 1.5 Changes in the reasons for hysterectomy considered appropriate over time............. 25 1.6 The arguments for and against hysterectomy..............................................................26 1.6.1 Arguments for hysterectomy...............................................................................26 1.6.2 Arguments against hysterectomy........................................................................27 1.7 Summary..................................................................................................................... 29 1.8 Life course epidemiology............................................................................................ 30 Chapter 2: Introduction to the d ata..................................................................................33 2.1 Introduction................................................................................................................. 33 2.2 Background information............................................................................................. 33 2.2.1 History of the study.............................................................................................. 33 2.2.2 Sampling frame.................................................................................................... 33 2.2.3 Timing and methods of data collection................................................................34 2.2.4 Follow-up and representativeness of the cohort...................................................34 2.2.5 Benefits of the NSHD..........................................................................................35 2.3 Information specific to this thesis...............................................................................36 2.3.1 Study sample for analyses in the thesis................................................................36 2.3.2 Main variables used in analyses ...........................................................................36 2.3.2.1 Ascertainment of hysterectomy status..........................................................36 2.3.2.2 Descriptive analyses of hysterectomy status.................................................38 2.3.2.3 Ascertainment of reason for hysterectomy...................................................38

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