In Reply

David and Kentenich are correct in their criticism of the fact that the hysterectomy rates reported in the first sentences of the results and discussion sections (1) are contradictory. The reason for this is as follows: in the first sentence of the results section, we reported the hysterectomy rates for any indication (362/100 000 person-years) for the entire age range. In the first sentence of the discussion section, we reported international comparisons of hysterectomy rates for benign diseases of the female genital organs (Sweden, US, Australia). These rates were reported for women aged 20 years or older (2).

David and Kentenich further criticize that we included girls younger than 10 years and women older than 80 years in our calculations. This criticism is not justified. Excluding persons from rate calculations makes sense only if persons are not “at risk” for hysterectomy. In 2005–2006 in Germany, hysterectomies were performed in eight girls younger than 10 and 8180 women older than 80 years (2.7% of all hysterectomies).

David and Kentenich asked for a correction relating to our mention of focused ultrasonographic ablation and uterine artery embolization. This statement related to a recommendation of an S2 guideline for the diagnostic evaluation and therapy of endometriosis (3), which we clarified by citing a reference. David and Kentenich are thus asking for a discussion of the S2 guideline, which obviously cannot take place here.

Klippel mentions the study of Salfelder et al. (4), which we cited in our article, and notes that hysterectomies performed outside the inpatient setting should not be ignored. According to Salfelder et al, a total of 193 laparoscopic hysterectomies were performed in the „Tagesklinik Altonaer Straße“ in 2006. According to DRG data, a total of 2335 hysterectomies were performed among Hamburg’s female population in 2006. If we assumed (which is unlikely) that the patients operated on by Salfelder et al. were Hamburg residents, then the DRG data would include 92% of hysterectomies performed in this population. Since it may safely be assumed that only some of the patients operated on by Salfelder et al were Hamburg residents, we can assume that the proportion is higher than 92%.

Differences in DRG based hysterectomy rates for benign diseases of the female genital organs that are specific to federal states (Hamburg: 213.8; Mecklenburg-Western Pomerania: 361.9 per 100 000 person-years) can obviously not be “debated away” by using the argument of differently high hysterectomy rates outside inpatient settings. Why Klippel has to cast considerable doubt on our findings is not clear, especially when remembering that no better hysterectomy data for Germany are currently available. We have nothing to add to the comments made by Rott.

DOI: 10.3238/arztebl.2012.0159b

Prof. Dr. med. Andreas Stang

Institut für Klinische Epidemiologie

Medizinische Fakultät

Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)

andreas.stang@medizin.uni-halle.de

Prof. Dr. Ray M. Merrill, PhD

Department of Health Science, College of Life Sciences,

Brigham Young University, Provo, UT 84602, U.S.A.

PD Dr. sc. hum. Oliver Kuss

Institut für Medizinische Epidemiologie, Biometrie und Informatik

Universitätsklinikum Halle und Medizinische Fakultät

Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)

Conflict of interest statement
The authors declare that no conflict of interest exists.