EDITORIAL Hysterectomy Trends: A Canadian Perspective on the Past, Present, and Future I. Chen Innie Chen, MD, MPH; 1,2 Abdul Jamil Choudhry, MBBS, MSc; 2 Togas Tulandi, MD, MHCM 3 1 Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON 2 The Ottawa Hospital Research Institute, Ottawa, ON 3 Department of Obstetrics and Gynecology, McGill University, Montr eal, QC W ith more than 41 000 hysterectomies performed annually in Canada, surgical removal of the uterus is a cornerstone of gynaecologic surgery. 1 Soranus of Ephesus is credited with performing the first hysterectomy in the second century CE. He removed a gangrenous pro- lapsed uterus vaginally; however, the bladder and ureters were also transected. 2 Another notable case is that of Faith Howard, who in 1670 performed an auto-amputation for a completely prolapsed uterus. Although she survived the surgery, she experienced “water passing from her insensi- ble day and night.” 3 The first elective vaginal hysterectomy was performed suc- cessfully in 1813 by Conrad Lagenbeck of Gottingen, and the first successful abdominal hysterectomy was performed in 1853 by Ellis Burnham of Massachusetts. 3 In the 1920s, Johanns Pfannenstiel introduced the transverse incision for abdominal surgery, and in the 1930s, Richardson intro- duced removal of the cervix as part of total abdominal hys- terectomy to avoid cervical discharge and cervical cancer. Aside from these two innovations, in the most recent cen- tury, there was little advance in hysterectomy techniques until the advent of laparoscopic hysterectomy, pioneered by Harry Reich. 3 By comparison, the current generation of practising gynae- cologists have witnessed unprecedented changes in gynae- cologic surgical care for women in the past few decades, with the advent of new medications, technologies, and approaches to inpatient care. One of the most striking changes in gynaecology practice is the global decline in hysterectomy rates in recent decades. In the United States, the number of hysterectomies declined consistently each year, from 681 234 procedures in 2002 to 433 621 in 2010. 4 Similarly, hysterectomy rates in Canada fell from 484 per 100 000 women in 1997 to 303 per 100 000 women in 2017. 5,6 Given that 90% of hys- terectomies are performed for benign indications, 7 the decline in the hysterectomy rate reflects the availability of alternatives, including hysteroscopic surgery, endometrial ablation systems, progesterone-containing intrauterine devices, and hormonal suppressive options. 8 The introduc- tion of long-term medical treatments (e.g., selective proges- terone receptor modulators) for fibroids—a condition that has traditionally been managed surgically—has further obviated the need for surgery for many women. 9 Finally, with advances in assisted reproductive techniques and soci- etal trends of advancing maternal age, women with uterine disorders are increasingly choosing treatment options that preserve future fertility. 10 In addition to the declining numbers of hysterectomies performed, the current generation of practising gynaecolo- gists has witnessed a dramatic shift towards minimally invasive endoscopic surgery. Because of its faster recovery period and lower number of complications compared with conventional abdominal approaches, it has become the default mode of hysterectomy for many gynaecologists across Canada. 11,12 Surgeon uptake of laparoscopic hyster- ectomy appears to be multifactorial, and self-reports of J Obstet Gynaecol Can 2019;41(S2):S340-S342 https://doi.org/10.1016/j.jogc.2019.09.002 © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved. S340  DECEMBER JOGC D  ECEMBRE 2019