Full length article| Volume 265, P130-136, October 2021

Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery



      Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery.


      A narrative review of 33 articles identified from a Pubmed using the following search criteria; “race”; “ethnicity”; “socioeconomic status”; “disparity”; “inequity”; and “inequality”. Case reports and papers assessing gynaecological malignancy were excluded.


      Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management.


      Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.


      BAME (Black, Asian and Minority Ethnic), MBRACCE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries Audits and Confidential Enquiries across the UK), HMB (Heavy menstrual bleeding), MIH (Minimally invasive hysterectomy), BMI (Body mass index), MIM (Minimally invasive myomectomy), FDA (Food and Drug Administration EP – ectopic pregnancy)


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        • Khabele D.
        • Holcomb K.
        • Connors N.K.
        • Bradley L.
        A Perspective on James Marion Sims, MD, and Antiblack Racism in Obstetrics and Gynecology.
        J Minim Invasive Gynecol. 2021; 28: 153-155
      1. Public Health England. Disparities in the risk and outcomes of Covid 19. s.l. : PHE publications, 2020.

      2. Office of National Statistics. [Online] 2020.

      3. Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK. Saving Lives, Improving Mother’s care, Lessons learned to Inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-2017. s.l. : MBRRACE-UK, 2019.

      4. Statistics, Office of National. Cancer Research UK. [Online]

      5. Office of National Statistics. Cancer Research UK. [Online]

      6. Statistics, Office of National. Cancer Research UK. [Online]

        • Aarts J.W.
        • Nieboer T.E.
        • Johnson N.
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2015; 2015
        • Wu J.M.
        • Wechter M.E.
        • Geller E.J.
        • Nguyen T.V.
        • Visco A.G.
        Hysterectomy rates in the United States, 2003.
        Obstet Gynecol. 2007; 110: 1091-1095
        • Madhvani K.
        • Curnow T.
        • Carpenter T.
        Route of hysterectomy: a retrospective, cohort study in English NHS Hospitals from 2011 to 2017.
        BJOG. 2019; 126: 795-802
        • Vessey M.P.
        • Villard-Mackintosh L.
        • McPherson K.
        • Coulter A.
        • Yeates D.
        The epidemiology of hysterectomy: findings in a large cohort study.
        Br J Obstet Gynaecol. 1992; 99: 402-407
        • Abenhaim H.A.
        • Azziz R.
        • Hu J.
        • Bartolucci A.
        • Tulandi T.
        Socioeconomic and racial predictors of undergoing laparoscopic hysterectomy for selected benign diseases: analysis of 341487 hysterectomies.
        J Minim Invasive Gynecol. 2008; 15: 11-15
        • Smith L.H.
        • Waetjen L.E.
        • Paik C.K.
        • Xing G.
        Trends in the safety of inpatient hysterectomy for benign conditions in California, 1991–2004.
        Obstet Gynecol. 2008; 112: 553-561
        • Jacoby V.L.
        • Autry A.
        • Jacobson G.
        • Domush R.
        • Nakagawa S.
        • Jacoby A.
        Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches.
        Obstet Gynecol. 2009 Nov; 114: 1041-1048
        • Cohen S.L.
        • Vitonis A.F.
        • Einarsson J.I.
        Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy.
        JSLS. 2014; 18 (e2014.00096)
        • Patel P.R.
        • Lee J.
        • Rodriguez A.M.
        • et al.
        Disparities in use of laparoscopic hysterectomies: a nationwide analysis.
        J Minim Invasive Gynecol. 2014; 21: 223-227
        • Lonky N.M.
        • Mohan Y.
        • Chiu V.Y.
        • et al.
        Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery.
        Womens Health (Lond). 2017; 13: 17-26
        • Mehta A.
        • Xu T.
        • Hutfless S.
        • et al.
        Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications.
        Am J Obstet Gynecol. 2017; 216: 497
        • Lee S.
        • Butts S.F.
        Social determinants of access to minimally invasive hysterectomy: reevaluating the relationship between race and route of hysterectomy for benign disease.
        Am J Obstet Gynecol. 2017; 217: 572
        • Ranjit A.
        • Sharma M.
        • Romano A.
        • et al.
        Does universal insurance mitigate racial differences in minimally invasive hysterectomy?.
        J Minim Invasive Gynecol. 2017; 24: 790-796
        • Alexander A.L.
        • Strohl A.E.
        • Rieder S.
        • Holl J.
        • Barber E.L.
        Examining disparities in route of surgery and postoperative complications in black race and hysterectomy.
        Obstet Gynecol. 2019 Jan; 133: 6-12
        • Waldman I.
        • Wagner S.
        • Kulaylat A.S.
        • Deimling T.A.
        Physical Well-Being and Route of Benign Hysterectomy.
        Womens Health Issues. 2018; 28: 456-461
        • Bougie O.
        • Singh S.S.
        • Chen I.
        • McCarthy E.P.
        Relationship between race/ethnicity and hysterectomy outcomes for benign gynecologic conditions.
        J Minim Invasive Gynecol. 2019; 26: 456-462
        • Callegari L.S.
        • Katon J.G.
        • Gray K.E.
        • et al.
        Associations between Race/Ethnicity, Uterine Fibroids, and Minimally Invasive Hysterectomy in the VA Healthcare System.
        Womens Health Issues. 2019; 29: 48-55
        • Ko J.S.
        • Suh C.H.
        • Huang H.
        • Zhuo H.
        • Harmanli O.
        • Zhang Y.
        Association of race/ethnicity with surgical route and perioperative outcomes of hysterectomy for leiomyomas.
        J Minim Invasive Gynecol. 2021; 28: 1403-1410
        • Pollack L.M.
        • Olsen M.A.
        • Gehlert S.J.
        • Chang S.H.
        • Lowder J.L.
        Racial/ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery.
        J Minim Invasive Gynecol. 2020; 27: 1167-1177
        • Traylor J.
        • Simon M.
        • Tsai S.
        • Feinglass J.
        Patient and Hospital Characteristics Associated with Minimally Invasive Hysterectomy: Evidence from 143 Illinois Hospitals, 2016 to 2018.
        J Minim Invasive Gynecol. 2020; 27: 1337-1343
        • Lee J.
        • Jennings K.
        • Borahay M.A.
        • et al.
        Trends in the national distribution of laparoscopic hysterectomies from 2003 to 2010.
        J Minim Invasive Gynecol. 2014; 21: 656-661
        • Mahmood T.
        • van der Meulen J.
        Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit.
        BMJ Open. 2019; 9
        • Lounder P.J.
        • Ismail N.
        • Goughnour S.L.
        • Mansuria S.M.
        • Comerci J.T.
        • Linkov F.
        Racial and Socioeconomic Disparities in Hysterectomy Route for Benign Conditions.
        J Racial Ethn Health Disparities. 2018; 5: 758-765
        • Peddada S.D.
        • Laughlin S.K.
        • Miner K.
        • et al.
        Growth of uterine leiomyomata among premenopausal black and white women.
        Proc Natl Acad Sci U S A. 2008; 105: 19887-19892
        • Zaritsky E.
        • Ojo A.
        • Tucker L.Y.
        • Raine-Bennett T.R.
        Racial disparities in route of hysterectomy for benign indications within an integrated health care system.
        JAMA Netw Open. 2019; 2
        • Borah B.J.
        • Laughlin-Tommaso S.K.
        • Myers E.R.
        • Yao X.
        • Stewart E.A.
        Association between patient characteristics and treatment procedure among patients with uterine leiomyomas.
        Obstet Gynecol. 2016 Jan; 127: 67-77
        • Bhave Chittawar P.
        • Franik S.
        • Pouwer A.W.
        • Farquhar C.
        Minimally invasive surgical techniques versus open myomectomy for uterine fibroids.
        Cochrane Database Syst Rev. 2014; 21
        • Ji L.
        • Jin L.
        • Hu M.
        Laparoscopic myomectomy with temporary bilateral uterine artery occlusion compared with traditional surgery for uterine myomas: blood loss and recurrence.
        J Minim Invasive Gynecol. 2018; 25: 434-439
        • Matsushita T.
        • Sekizawa A.
        • Jacobs L.K.
        Racial disparities in response to a US food and drug administration safety communication regarding the use of power morcellation for the treatment of uterine leiomyoma.
        J Minim Invasive Gynecol. 2020; 27: 178-185
        • Eltoukhi H.M.
        • Modi M.N.
        • Weston M.
        • Armstrong A.Y.
        • Stewart E.A.
        The health disparities of uterine fibroid tumors for African American women: a public health issue.
        Am J Obstet Gynecol. 2014; 210: 194-199
        • Huyck K.L.
        • Panhuysen C.I.
        • Cuenco K.T.
        • et al.
        The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters.
        Am J Obstet Gynecol. 2008; 198: 168
        • Frost A.S.
        • McMahon M.E.
        • Smith A.J.
        • Patzkowsky K.E.
        Predictors of surgical approach to myomectomies by race.
        J Minim Invasive Gynecol. 2019; 26: S39
        • Pepin K.J.
        • Lebovitz O.
        • James K.
        • Styer A.
        • Brown D.N.
        Racial and ethnic disparities in complication rate in patients undergoing myomectomy.
        J Minim Invasive Gynecol. 2017; 24: S190-S191
        • Stentz N.C.
        • Cooney L.G.
        • Sammel M.D.
        • Shah D.K.
        Association of patient race with surgical practice and perioperative morbidity after myomectomy.
        Obstet Gynecol. 2018; 132: 291-297
        • Lum D.A.
        • Sokol E.R.
        • Berek J.S.
        • et al.
        Impact of the 2014 food and drug administration warnings against power morcellation.
        J Minim Invasive Gynecol. 2016; 23: 548-556
        • Sankaran S.
        • Brown A.
        • Kent A.
        • Odejinmi F.
        Laparoscopic specimen retrieval and attitudes towards morcellation: a questionnaire survey of gynaecology consultants in the United Kingdom.
        J Obstet Gynaecol. 2019; 39: 345-348
        • Hsu J.Y.
        • Chen L.
        • Gumer A.R.
        • et al.
        Disparities in the management of ectopic pregnancy.
        Am J Obstet Gynecol. 2017; 217: 49.e1-49.e10
        • Stulberg D.B.
        • Cain L.
        • Dahlquist I.H.
        • Lauderdale D.S.
        Ectopic pregnancy morbidity and mortality in low-income women, 2004–2008.
        Hum Reprod. 2016; 31: 666-671
        • Huff K.O.
        • Aref-Adib M.
        • Magama Z.
        • Vlachodimitropoulou E.K.
        • Oliver R.
        • Odejinmi F.
        Returning to work after laparoscopic myomectomy: a prospective observational study.
        Acta Obstet Gynecol Scand. 2018; 97: 68-73
        • Lovell R.
        • Yaghootkar H.
        • Tuke M.
        • et al.
        Height, body mass index, and socioeconomic status: mendelian randomisation study in UK Biobank.
        BMJ. 2016; 8i582
        • Kiran A.
        • Geary R.S.
        • Gurol-Urganci I.
        • et al.
        Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit.
        BMJ Open. 2018; 8
        • Sengoba K.S.
        • Ghant M.S.
        • Okeigwe I.
        • Mendoza G.
        • Marsh E.E.
        Racial/ethnic differences in women's experiences with symptomatic uterine fibroids: a qualitative assessment.
        J Racial Ethn Health Disparities. 2017; 4: 178-183
        • Creanga A.A.
        • Shapiro-Mendoza C.K.
        • Bish C.L.
        • Zane S.
        • Berg C.J.
        • Callaghan W.M.
        Trends in ectopic pregnancy mortality in the United States: 1980–2007.
        Obstet Gynecol. 2011; 117: 837-843
        • Papillon-Smith J.
        • Imam B.
        • Patenaude V.
        • Abenhaim H.A.
        Population-based study on the effect of socioeconomic factors and race on management and outcomes of 35,535 inpatient ectopic pregnancies.
        J Minim Invasive Gynecol. 2014; 21: 914-920
        • Smart G.
        • Tai A.
        • Wong J.C.
        • Oliver R.
        • Odejinmi F.
        Social prevalence of knowledge about ectopic pregnancy - tip of the 'health inequalities' iceberg?.
        J Obstet Gynaecol. 2021; 41: 428-433
        • Stulberg D.B.
        • Cain L.R.
        • Dahlquist I.
        • Lauderdale D.S.
        Ectopic pregnancy rates and racial disparities in the Medicaid population, 2004–2008.
        Fertil Steril. 2014; 102: 1671-1676
        • Butts S.F.
        • Gibson E.
        • Sammel M.D.
        • Shaunik A.
        • Rudick B.
        • Barnhart K.
        Race, socioeconomic status, and response to methotrexate treatment of ectopic pregnancy in an urban population.
        Fertil Steril. 2010; 94: 2789-2792
        • Hajenius P.J.
        • Mol F.
        • Mol B.W.
        • Bossuyt P.M.
        • Ankum W.M.
        • van der Veen F.
        Interventions for tubal ectopic pregnancy.
        Cochrane Database Syst Rev. 2007; 2007
        • Ranjit A.
        • Chaudhary M.A.
        • Jiang W.
        • et al.
        Disparities in receipt of a laparoscopic operation for ectopic pregnancy among TRICARE beneficiaries.
        Surgery. 2017; 161: 1341-1347
        • Sewell C.A.
        • Anderson J.R.
        Update on trends for inpatient surgical management of tubal ectopic pregnancy in Maryland.
        South Med J. 2011; 104: 488-494
        • Gingold J.A.
        • Janmey I.
        • Gemmell L.
        • Mei L.
        • Falcone T.
        Effect of methotrexate on salpingostomy completion rate for tubal ectopic pregnancy: a retrospective cohort study.
        J Minim Invasive Gynecol. 2021; 28: 1334-1342
      7. Commission on Race and Ethnic Disparities: The Report. 2021.

        • Marmot M.
        Health equity in England: the Marmot review 10 years on.
        BMJ. 2020; 24: 368
      8. Royal College of Obstetricians and Gynecologists position statement: Racial disparities in women’s healthcare.

        • Odejinmi F.
        • Oliver R.
        • Mallick R.
        Is ulipristal acetate the new drug of choice for the medical management of uterine fibroids? Res ipsa loquitur?.
        Womens Health (Lond). 2017; 13: 98-105
        • Wegienka G.
        • Stewart E.A.
        • Nicholson W.K.
        • et al.
        Black women are more likely than white women to schedule a uterine-sparing treatment for leiomyomas.
        J Womens Health (Larchmt). 2021; 30: 355-366
      9. Orellana M, Riggan KA, DSouza K et al. Perceptions of Ethnoracial Factors in the Management and Treatment of Uterine Fibroids. J Racial Ethn Health Disparities. 2021 May 19.

        • Stewart E.A.
        • Lytle B.L.
        • Thomas L.
        • Wegienka G.R.
        • Jacoby V.
        • Diamond M.P.
        • et al.
        The Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry: rationale and design.
        Am J Obstet Gynecol. 2018; 219: 95
        • Murji A.
        • Bedaiwy M.
        • Singh S.S.
        • Bougie O.
        CAPTURE registry steering committee. Influence of ethnicity on clinical presentation and quality of life in women with uterine fibroids: results from a prospective observational registry.
        J Obstet Gynaecol Can. 2020; 42: 726-733