Systematic review of medical audits of hysterectomy practices in India

This review was conducted in accordance with PRISMA guidelines for systematic reviews 2020 and registered with PROSPERO (CRD42025623938). The research team performed a systematic search in April 2025 across PubMed, Scopus, and EMBASE, to identify relevant audit studies published between 2010 and 2024. Search terms were identified through an examination of indexing terms from individual medical audits and discussions among investigators. The final search strategy included the following keywords for each database: ‘hysterectomy’ AND ‘India’ AND (‘medical audit’ OR ‘clinical audit’ OR ‘retrospective study’ OR ‘quality assessment’) AND (‘histopathology’ OR ‘clinical indications’ OR ‘surgical outcomes’). Additionally, references from articles obtained through the primary search were reviewed to identify further relevant medical audits. For this review, the term ‘medical audit’ was used broadly to refer to studies that systematically evaluated hysterectomy practices within healthcare institutions through review of clinical records, hospital databases, or institutional reports. These studies typically examined parameters such as clinical indications, socio-demographic profiles, surgical routes, complications, and histopathological findings. Both retrospective and prospective institutional evaluations assessing hysterectomy practices were considered within the scope of this review. Medical audits were excluded if they were: conducted outside India; case reports, editorials, expert commentaries, opinion pieces, or unpublished studies, including conference abstracts without full data; or trial protocols and animal studies. Medical audits published in English in peer-reviewed journals were selected based on the inclusion and exclusion criteria. Study titles and abstracts were first screened for relevance, followed by full-text screening for final inclusion. Two independent reviewers carried out the selection process. Disagreements were resolved through discussion, and where necessary, a third reviewer was consulted. A standardised data extraction form was developed to extract study details, demographic characteristics, clinical indications, type of surgery, histopathological diagnosis, and complications. ( Supplementary Table I ) . Given the expected heterogeneity in methodological approach, study populations, outcomes measured, and reporting styles, a narrative synthesis approach was adopted with no meta-analysis. Key findings across medical audits were grouped under thematic domains: clinical indications, surgical route, complications, and histopathological correlations. Additional disaggregated analyses were conducted based on case type (gynaecological vs . obstetric) to capture potential differences in the age group, route of hysterectomy, indications, and complications. Supplementary Table I The selected medical audits were critically appraised by two reviewers using the Johanna Briggs Institute Critical Appraisal Tool, applying a 9-item checklist for cohort studies and an 8-item checklist for cross-sectional studies. Each statement in the checklist was rated as ‘yes’, ‘no’, or ‘partially’. Medical audits were rated as high, moderate, or low quality based on the number of criteria met. Discrepancies were resolved through discussion or consulting a third person.

We included 89 medical audits from the 8887 identified initially ( Figure ) . The 89 included medical audits were published between 2010 to 2024 and represent a wide geographical distribution across India (Full listing in Supplementary Table I ). A majority were conducted in 5 States: Karnataka (n=11), Maharashtra (n=9), Madhya Pradesh (n=6), Uttar Pradesh (n=6), and Tamil Nadu (n=6). The remaining medical audit spanned other States, such as Jammu and Kashmir, Punjab, Gujarat, West Bengal, and Telangana. The majority of audits examined gynaecological hysterectomies (n=54), used a retrospective design (n=78), and were conducted in tertiary care settings (n=79). The sample sizes of individual medical audits ranged from 12 10 to 1,285, 11 participants, reflecting variation in hospital capacities, catchment population, and study durations. The study characteristics of the included medical audits are provided in Table I . PRISMA flow diagram. Characteristics of included studies reporting medical audits of hysterectomy (N=89) Gynaecological hysterectomies were most commonly conducted in women between 41 and 50 years, with the majority being multiparous women. Pre-menopausal women formed the bulk of cases, although post-menopausal hysterectomies were also reported. Frequently documented clinical complaints included abnormal uterine bleeding, including heavy menstrual bleeding, irregular menstrual bleeding, intermenstrual bleeding, postmenopausal bleeding, as well as lower abdominal pain, pelvic organ prolapse, and whitish vaginal discharge. One-fourth of hysterectomies were performed in women under 40 years of age ( Table II ) . In contrast to gynaecological hysterectomy, obstetric hysterectomies were typically performed in younger women, often in the age group of 20–30 y, and almost exclusively in multiparous women. Obstetric hysterectomies were performed predominantly in cases of caesarean deliveries. Only a few medical audits reported information on socioeconomic status, rural–urban residence, and educational qualifications. Participant characteristics of the included medical audits of hysterectomy Key findings (Number of cases, %) The leading clinical indications for hysterectomy included fibroid uterus, abnormal or dysfunctional uterine bleeding (AUB/DUB), uterovaginal prolapse, adenomyosis, and cervical lesions. Fibroid uterus was consistently the most frequent, accounting for over one-third of the cases, followed by AUB/DUB and uterovaginal prolapse ( Table III ) . For obstetric hysterectomy, the major clinical indications were ruptured uterus, placenta accreta spectrum, and post-abortal complications. Indications for hysterectomy reported in medical audits Note: Medical audits often reported multiple indications for hysterectomy. However, within each study, women were classified under a mutually exclusive primary indication, ensuring that participants were not double counted across categories. AUB, abnormal uterine bleeding; AUB-L, abnormal uterine bleeding - leiomyoma; AUB-A, abnormal uterine bleeding- adenomyosis; AUB-P, abnormal uterine bleeding - polyps; DUB, dysfunctional uterine bleeding; PPH, postpartum haemorrhage; GT, gestational trophoblastic A total of 21 medical audits reported on the clinical indications and histopathological findings of hysterectomy specimens, while only 8 medical audits specifically examined their correlation ( Table IV ). 12 - 19 Analysis of clinical indications and corresponding histopathological findings revealed variable concordance across uterine, cervical, and ovarian lesions. Among uterine pathologies, leiomyoma was the most common preoperative diagnosis with high concordance. Other uterine conditions such as endometrial polyp, endometrial hyperplasia, and pelvic inflammatory disease (PID) showed high concordance, while uterovaginal prolapse demonstrated high agreement. For endometrial carcinoma, histopathology revealed more cases than clinically suspected, indicating clinical underdiagnosis. Correlation between clinical indications and histopathological findings in included medical audits of hysterectomy Carcinoma endometrium The abdominal route was the most commonly employed surgical approach across the included medical audits, followed by the laparoscopic and vaginal routes. Abdominal hysterectomy was reported in 13,649 of 18,697 women (73%) in the medical audits, while laparoscopic hysterectomy was reported in 3,973 of 13,509 women (29%) in the 24 audits that provided information on this route, and vaginal hysterectomy in 3,670 of 17,462 women (21%) in 36 audit studies that reported this approach. These percentages reflect the frequency with which each surgical route was reported across medical audits rather than pooled patient-level prevalence and therefore should not be interpreted as additive. Twenty audits on gynaecological hysterectomy included information on oophorectomy, encompassing a total sample of 6034 women, of whom 49% had ovaries removed with hysterectomy ( Table V ) . Complications associated with hysterectomy were not consistently reported across medical audits. Patterns differed between gynaecological and obstetric procedures ( Supplementary Table II ) . For gynaecological hysterectomies, intra-operative complications among 4024 women most commonly included haemorrhage (n=160, 4%), followed by bladder and ureteric injuries (n=44, 1.1% and n=18, 0.4% respectively). Post-operative morbidities reported among 4576 women primarily comprised febrile episodes (n=371, 8.1%), urinary tract infections (n=215, 4.7%), and wound-related issues (n=175, 3.8%). In contrast, obstetric hysterectomy was associated with substantially higher morbidity and mortality. Pre-operative anaemia and shock were frequently reported. Among 1,426 women, intra-operative complications included bladder injury (n=109, 7.6%) and disseminated intravascular coagulation (n=78, 5.5%). Post-operative complications among 2,074 women included ICU admission (n=548, 26.4%), maternal mortality (n=215, 10.4%), sepsis (n=111, 5.4%), and blood transfusion requirements (n=265, 12.8%). Fetal outcomes were also adversely affected, with high rates of stillbirth (n=363, 34%) and NICU admissions (n=213, 20%) reported among 1066 cases. Supplementary Table II Oophorectomy cases in the included medical audits * Among the 11 public-sector medical audits reporting on oophorectomy, six did not provide histopathological findings. Therefore, the histopathological data presented in the table include information from only five medical audits that reported these findings ** Among the nine private-sector medical audits reporting on oophorectomy, two did not report clinical indications, and two did not provide histopathological findings

This systematic review is a synthesis of hysterectomy data in India, using 89 medical audits conducted between 2010 and 2024. Most hysterectomies were performed for non-malignant conditions, most commonly fibroids (leiomyomas), followed by adenomyosis, endometrial polyps, chronic cervicitis, and dysfunctional uterine bleeding. While most procedures were performed on women in the late reproductive and perimenopausal stage (between 40-50 y), nearly one in four gynaecological hysterectomies were performed in women under 40 years. Close to one-half of hysterectomies included oophorectomy, in the 20 audits where information was reported; analysis suggested less than 1 in 5 oophorectomy cases during hysterectomy for benign conditions had clear medical justification. Common use of hysterectomy for benign indications likely reflects the peak occurrence of symptomatic benign conditions during these years and the perception that the reproductive role of the uterus has already been fulfilled. 20 – 22 Findings from other settings indicate that hysterectomy in younger populations not only terminates fertility but also predisposes women to early oestrogen deficiency, with long-term implications for bone, cardiovascular, and metabolic health. 6 , 7 , 23 , 24 The predominance of fibroids, including medical audits with cases of small fibroid and nonspecific symptoms like vaginal discharge and pelvic pain, suggests that conservative alternatives such as myomectomy, hormonal therapy, or minimally invasive approaches may be underutilised in India. The lack of clear justification of oophorectomies in the reviewed medical audits resonates with trends were noted in an American audit, where nearly three-fourths of oophorectomies were performed in women with benign diagnoses. 25 While oophorectomy is warranted in specific situations such for suspicious adnexal pathology or a high genetic risk for malignancy, unwarranted removal can lead to premature oestrogen deficiency, increasing the risk of osteoporosis, cardiovascular disease, and reduced quality of life. 6 , 23 , 24 This review has certain limitations. Heterogeneity in study design, outcome definitions, and reporting styles precluded meta-analysis. Most audits were of moderate methodological quality and lacked uniform audit standards. The available medical audits did not indicate clear regional or public–private sector variation in the profile of women undergoing hysterectomy; this observation should be interpreted cautiously given gaps and inconsistencies in reporting across medical audits. Socioeconomic and psychosocial aspects such as patient counselling, informed consent, and postoperative quality of life were rarely documented. A major gap was the lack of standardised reporting, with sociodemographic details reported in only two to three public hospital audits and largely absent in private settings. Clinicopathological correlations were available in only 20 of 64 medical audits, key variables such as parity, comorbidities, and prior treatment history were inconsistently documented, histopathological confirmation was reported in only 29 of 64 medical audits, and perioperative outcomes were systematically presented in just over half of the medical audits. The findings of this review have several implications for clinical practice and policy, particularly the need for careful preoperative evaluation, documentation of indications, and consideration of conservative or minimally invasive options where feasible. Integrating hysterectomy audits into hospital reporting systems and national health registries could strengthen accountability and quality. Capacity-building initiatives including MIGS modules in postgraduate curricula and hands-on training should strengthen competencies in minimally invasive gynaecological surgery and evidence-based decision-making. Hospitals, particularly in the public sector, must be equipped with infrastructure to support non-surgical alternatives, advanced diagnostics, and safe surgical care. And finally, transparency and accountability must be improved through mandated public reporting of hysterectomy data in line with the National Guidelines, integrated into ongoing maternal and reproductive health surveillance systems.