Understanding the Value of the Uterus: A Nationwide Cross-sectional Survey on Women's Preferences

INTRODUCTION: Understanding the value placed on the uterus and its impact on decisions regarding uterine removal versus preservation is critical. Current research is limited by small, regional populations that restrict generalizability. This study addresses these gaps by utilizing a large, diverse population to explore factors influencing women’s valuation of the uterus. OBJECTIVE: To determine clinical and demographic predictors for placing high value on the uterus among women in the United States (U.S.). METHODS: A multicenter cross-sectional survey was distributed to 11 medical centers across the U.S. from 12/2023 to 06/2024. Adult patients with a uterus who were assigned female at birth and not considering future pregnancies participated. The survey included questions on demographics, clinical history, the validated Value of the Uterus (VALUS) instrument, and a visual analog scale (VAS) with the question “How important is it to you to keep your uterus when you have a gynecologic condition?” with 0 as no value and 100 as highest value. Preferences regarding hysterectomy vs uterine-sparing procedures were also collected. Using the median summative VALUS score, patients were categorized into low (score <16) and high-value VALUS groups (score ≥16). Univariate analyses assessed differences in demographic and clinical variables between the two groups, while multivariable logistic regression (MVR) examined the effect of combined predictors for high value on the uterus. RESULTS: 749 surveys were completed (83% response). Most participants identified as White (75%), aged 45–60 years old (36%), and postmenopausal (57%). Regional distribution included 318 from the South (43%), 290 from the West (39%), 123 from the Northeast (17%), and 7 from the Midwest (1%). For the value of the uterus, 369 (49%) placed low value and 378 (51%) placed high value, with a mean VAS of 40.8 (SD: 32.4). Univariate analysis revealed significant differences in race (p=0.01), income (p=0.02), and history of urinary incontinence (UI) (p=0.02) between high and low VALUS groups. Other factors, including region, age, religion, and personal history of cancer, were not significant. In our hypothetical scenarios, those with low value of the uterus more often chose hysterectomy if it offered any cancer reduction benefits (48% vs. 24%, p<0.01) compared to those with high value. On MVR, individuals identifying as Asian American and Pacific Islander (AAPI) had higher odds of high VALUS scores compared to White individuals (OR=2.17; 95% CI 1.18–4.11; p=0.01), adjusting for income and UI. Those with an annual income of $20,000 to $49,000 had higher odds of a high value of the uterus compared to the highest income bracket (OR=2.41; 95% CI 1.47–4.02; p<0.01). Patients with self-reported UI had lower odds of placing high value on the uterus (OR=0.70; 95% CI 0.52–0.96; p=0.02). CONCLUSIONS: In this nationwide cross-sectional study, we identified AAPI racial identity, middle income, and absence of UI as predictors for placing high value on the uterus. Clinicians should consider these factors when counseling patients for decisions regarding hysterectomy versus uterine-preserving procedures (Tables 1 and 2).