OBJECTIVES:

Uterine fibroids (UF) are common benign tumors of the uterus often associated with heavy menstrual bleeding and pain. Surgical treatments include myomectomy (removal of fibroids) or hysterectomy (removal of uterus), which yield moderate and no risk of developing new fibroids, respectively. There is increasing evidence suggesting that hysterectomy, even with ovarian preservation, is associated with a 33% higher risk of developing coronary artery disease (CAD). We sought to compare the cost-effectiveness of three treatment approaches for UF (myomectomy, and hysterectomy with and without ovarian preservation) to understand the trade-offs among developing CAD, developing new fibroids, and the immediate benefit of UF symptom relief.

METHODS:

We developed a Markov model that followed a cohort of 40-year old patients with UF, who no longer desired children, over their lifetime, using a health system perspective. The primary outcomes of interest were quality-adjusted life years (QALYs) and total costs. We conducted one-way sensitivity analyses to test the impact of uncertain model inputs.

RESULTS:

Myomectomy was the least costly ($529,666) and most effective strategy (19.68 QALYs). Hysterectomy with ovarian preservation was more expensive ($534,990) and provided less benefits (18.93 QALYs) than myomectomy. Hysterectomy without ovarian preservation was the most expensive ($542,653) and least effective strategy (18.86 QALYs). In sensitivity analyses, we found that if the risk of developing new fibroids with myomectomy were >28% (base-case: 1.5%) or the quality of life after myomectomy were < 0.75 (base-case: 0.834), then myomectomy would no longer be cost-effective, under a willingness-to-pay of $100,000.

CONCLUSIONS:

Our results show that myomectomy is an optimal treatment for UF, compared to hysterectomy, in women at age 40. Despite the risk of retreatment after myomectomy, the increased risk of CAD with hysterectomy and its associated costs and impacts on morbidity and quality of life made hysterectomy a much costlier and less effective strategy in the long-term.