Uterine leiomyomas, more commonly known as fibroids, are among the most common neoplasms in reproductive-aged women [1-3]. These neoplasms are benign tumors that originate from the myometrium, the outer muscular layer of the uterus, and are composed of smooth muscle cells and extracellular matrix ranging in size from less than 1 cm to more than 20 cm [1]. Symptomology including abnormal uterine bleeding, heavy menstrual bleeding, pain, recurrent pregnancy loss, and infertility. Symptoms can be severe enough to cause up to 30% of women to seek treatment [2].

Management includes medical (hormonal or nonhormonal) and surgical options. Surgical management options include laparoscopic radiofrequency volumetric thermal ablation (LRVTA), endometrial ablation, myomectomies, and hysterectomies. LRVTA induces coagulative necrosis in targeted uterine fibroids and is a minimally invasive procedure recommended for patients who desire uterine preservation. As of 2021, there is insufficient data on endometrial ablation to make a clinical recommendation [4]. For women who desire future pregnancy or uterine preservation, myomectomy is the recommended surgical option. Myomectomy can be performed by laparoscopic, robotic, or abdominal techniques. It can provide symptom improvement in up to 80% of women, but it is associated with a 27% risk of recurrence [5]. Hysterectomy is the only definitive surgical management treatment for fibroids and is not an option for patients who want to retain their uterus for future childbearing or any other reason. It can be performed by laparoscopic, vaginal, abdominal, or robotic-assisted techniques. Age should be considered when deciding on total abdominal hysterectomy as it is associated with increased mortality risk among young women [6]. When comparing myomectomy and hysterectomy, there is not a statistically significant difference in the rate of major complications, including life-threatening events and hospital readmission. Both interventions are associated with substantial improvements in health-related quality-of-life measures and short and long-term symptom severity [5].

Race, along with age, are risk factors that are predictive of the presence of uterine fibroids. Black women are more likely to develop fibroids at younger ages, more frequently, have larger fibroids, and experience more severe symptoms compared to White women [1]. When it comes to surgical treatment, black women are 6.8 times more likely to have a myomectomy and 2.4 times more likely to have a hysterectomy than White women [3]. Access alone cannot create health equity because these disparities are still observed in enhanced access systems like the Veterans Health Administration [7]. Regardless of surgical route, Black women undergoing surgery for uterine fibroids have higher rates of surgical complications, longer surgery times, and greater likelihood of hospital readmission compared with White women [8]. Although there has been some literature that alludes to environmental factors, limited access to quality healthcare, and distrust in the healthcare system by Black women as a reason for the racial disparities seen in the management of uterine fibroids, the exact reasons are poorly understood [1,7,8]. To our knowledge there has been no previous attempt to systematically review the reported racial disparities in the surgical management of uterine fibroids. Since race is a key risk factor for uterine fibroids, is it crucial to identify the underlying factors contributing to these disparities and provide recommendations for healthcare policy and practice changes to reduce these disparities and improve outcomes for all women. This research not only fills a gap in the current understanding of fibroid management but also serves as a call to action for healthcare providers, policymakers, and researchers to work towards achieving health equity. By highlighting and addressing the disparities in surgical outcomes, this study aims to identify and address racial disparities in surgical outcomes for uterine fibroids.

Search strategy and study selection 

A systematic review of the literature was performed in PubMed, Embase, and Scopus (see Methods in the Supplement). The goal of the literature search was to systematically review existing studies focusing on the surgical management of uterine fibroids in black women. The search aimed to identify and evaluate the efficacy of various surgical treatments, including laparoscopic radiofrequency ablation, hysterectomy, and other minimally invasive approaches, and to assess the impact of these treatments on surgical outcomes, patient satisfaction, and psychosocial outcomes for black women. The review also sought to highlight any discrepancies or gaps in the literature, considering socioeconomic factors, geographic location, and fibroid characteristics. 

Study assessment 

All eligible studies were independently assessed by two reviewers based on predetermined inclusion/exclusion criteria. Any disagreements about whether a study should be included or not were resolved by a designated third reviewer. Studies were included if they were randomized trials, nonrandomized trials, controlled before-after studies, cross-sectional studies, qualitative studies, interrupted time-series studies, or prospective and retrospective observational studies (e.g., cohort studies, case-control studies) focusing on black women, undergoing surgical management of uterine fibroids. Studies were excluded if they were (1) descriptive studies without outcomes data, (2) modeling studies using simulated data, (3) non-clinical studies such as editorials, nonsystematic reviews, or letters to the editor, (4) biological studies, (5) case reports or case studies, (6) measurement or validation studies, or (7) self-described pilot studies lacking adequate power to assess the impact of interventions on outcomes. In terms of population, exclusions applied to studies that focused on (8) children or (9) solely on Caucasian or non-ethnic populations. For interventions, studies were excluded if they involved (10) non-surgical treatments for uterine fibroids. Regarding comparator/context criteria, exclusions were made if the studies (11) did not focus on racial and ethnic disparities in the surgical management of uterine fibroids. Finally, outcomes were excluded if they (12) were non-clinical and not directly related to the surgical management of uterine fibroids. Additionally, studies were excluded if they were (13) meeting abstracts, protocols without results, or gray literature. 

Assessing study quality 

The assessment utilized the Methodological Index for Nonrandomized Studies (MINORS) scale, which evaluates various criteria: a clearly stated aim, inclusion of consecutive patients to prevent selection bias, and prospective data collection according to a pre-established protocol. Studies must have appropriate endpoints, unbiased assessment of these endpoints, and a sufficient follow-up period to observe outcomes and side effects. Additionally, the dropout rate should be ≤ 5%, and the study size must be prospectively calculated to ensure adequate power. Comparative studies require an adequate control group, contemporaneous study groups, baseline equivalence between groups, and appropriate statistical analyses. Each criterion is scored from 0 to 2, with higher scores indicating better adherence to methodological standards. The maximum score for non-comparative studies is 16, while the maximum score for comparative studies is 24 due to additional criteria. The total MINORS score was used as a quality score, classifying studies as low quality (total score < 7 points), medium quality (total score 7-14 points), or high quality (total score ≥ 15 points). Studies deemed low quality were excluded from further analysis. 

Data extraction 

The primary outcomes measured in the included studies were the effectiveness of the interventions, the incidence of side effects, and overall complication rates. Baseline characteristics noted across the studies included patient demographics such as age, gender, and comorbidities, as well as specific clinical parameters relevant to the intervention.
 

Literature search and study selection 

Our database search identified a total of 1,063 potentially relevant articles, of which 505 duplicates were removed. Following, another 457 articles were excluded based on title and abstract alone. 101 full-text articles were assessed for eligibility using the previously stated inclusion and exclusion criteria, resulting in 19 studies included in our qualitative synthesis.

Study assessment 

We used the MINORS scale to assess the methodological quality of the 19 studies included in our original analysis. Scores ranged from 2 to 19 points with an average score of 17.8 and a median score of 14. Based on this classification, the quality of 5 studies was deemed low, the quality of 5 studies was deemed moderate, and the quality of 9 studies assessed to be high. All studies deemed low quality were excluded from analysis. 

Study characteristics 

Of the 14 studies included in our analysis, 1 was an experimental study, 5 were cohort studies, 3 were cross-sectional studies, 1 was a subgroup analysis, 1 was a chart review, 1 was a case control study, 1 was a medical record review, and 1 was a qualitative study. The total number of patients included from the 14 studies was 2,348,547. Outcomes evaluated were uterine size and fibroid burden; invasive surgical treatment including open abdominal hysterectomies and myomectomies; complications pre-, peri-, and post-op; as well as psychosocial outcomes.

Study outcome 

Studies from Becker et al., Weiss et al., and Zaritsky et al. found that Black women were younger (baseline age 41.8 vs. 45.3; 45.2 vs. 46.7, p=0.003; 36.4 ± 5.6 vs 37.4 ± 5.8 years, p<0.001) and had higher BMI at presentation for treatment (33.1 vs. 26.8, p<0.0001; 30.8 ± 7.3 vs 26.6 ± 5.9 kg/m², p<0.001) [10-12]. Kim et al. found that Black women had higher uterine weight preoperatively (p=0.0035) [13]. Berman et al. found that Black women had a higher fibroid burden (7.3 fibroids vs. 3.7 fibroids, p<0.001) and symptom severity (p<0.001), and lower quality of life score (p<0.001) than White women at baseline; however, the difference in QoL disappeared at follow-up periods assessed [14]. Machtinger et al. found that Black women had a lower volume of treated fibroids (p=0.0001) but higher number of treated fibroids (p=0.01) [15]. Black women were less likely to undergo a minimally invasive surgery; Callegari et al. found a relative risk ratio (RRR) of 0.52 (95% CI, 0.38–0.72) for laparoscopic versus abdominal hysterectomy, and a RRR of 0.58 (95% CI, 0.43–0.73) for vaginal versus abdominal hysterectomy [7]; Carey et al. found that while no significant difference exists between Black and White veterans with postoperative weight >250 g, Black women with postoperative weight ≤ 250 g were less likely to have gotten a minimally invasive hysterectomy [16]; Frost et al. found that Black women had a lower odds ratio (OR) of undergoing minimally invasive myomectomy (OR 0.57, 95% CI 0.50—0.64) [17]; Ko et al. found that minority women were more likely to undergo abdominal hysterectomy [18]; Sanei-Moghaddam et al. found that, even when controlling for income level, non-European Americans had an increased likelihood of undergoing a total abdominal hysterectomy when compared to European Americans [19]; Stentz et al. found that Black women were more likely to undergo abdominal vs. laparoscopic myomectomy compared to White women (62.1% vs 43.8%, p<0.001) [20]; Zaritsky et al. found that Black women were less likely to undergo minimally invasive myomectomy when compared to non-Black women (aRR, 0.65; 95% CI, 0.52-0.82, p<0.001) [12]. Studies from Becker et al., Zaritsky et al., Kim et al., Stentz et al., and Kjerulff et al. found that Black women had longer lengths of stay following surgery (3.02 vs. 2.56 days; 2.0 vs. 1.0 day, p=.009; >10 days (OR 2.7, 95% CI 2.5-3.1); 2 (1-2) vs. 2 (2-3) days, p<0.05; 23.6 ± 29.0 vs 15.4 ± 20.7 hours, p<0.001) [10,12,13,20,21]. Zaritsky et al. and Stentz et al. found that Black women had longer mean operation times (177.0 ± 75.2 vs 154.4 ± 67.4 minutes, p<0.001) [12,20]. Zaritsky et al.  also found that Black women had higher volume of blood loss during surgery (331.7 ± 500.9 vs 213.6 ± 388.0 mL, p<0.001) [12]. Sengoba et al. found that Black women experienced more difficulty before, throughout, and after treatment: they had more financial challenges such as lack of sufficient insurance coverage or no insurance (73%) and a more difficult recovery [22]. Black women have higher risk of mortality and/or complications related to treatment; Kim et al. found they were more likely to have increased overall risk of mortality (65% v.34%, p=.007) [13]; Kjerulff et al. found that Black women who underwent a hysterectomy had increased risk of medical or surgical complications (OR 1.4, 95% CI 1.3-1.5) [21]; Ko et al. found Black women had significantly higher odds of experiencing any complication for abdominal hysterectomy (17.3% vs 11.1%, aOR, 1.54; 95% CI, 1.31−1.80), vaginal hysterectomy (10.8% vs 7.1%; aOR, 1.65; 95% CI, 1.02−2.68), and laparoscopic hysterectomy (8.7% vs 6.1%; aOR, 1.37; 95% CI, 1.13−1.66) when compared to White women [18]; Stentz et al. found that Black women were more likely to experience a thromboembolic event (OR 9.2, 95% CI 1.2–69.2) [20]; Zaritsky et al. found that a higher proportion of Black women had a perioperative complication (6.3% vs 4.8%, p=0.049) [12]. 
 

Multiple studies found that Black women had a hysterectomy at a younger age than White women aligning with the current literature [23-26]. Weiss et al. found Black women had hysterectomies at a younger age than White women (48yo vs 50yo; p=0.0008) and also found that Black women compared to White women were younger (baseline age 45.2 vs. 46.7; p=0.003) [11]. Becker et al. and Zaritsky et al. also found that Black women underwent myomectomy at a younger age [10,12]. This could be attributed to higher fibroid burden that Black women face [27,28]. Weiss et al. found that Black women uteri weighted more than that of White women (448 g vs. 240 g; p=0.0005) [11]. Berman et al. found that Black women had a higher fibroid burden (7.3 fibroids vs. 3.7 fibroids, p<0.001) and symptom severity (p<0.001), and lower quality of life score (p<0.001) than White women at baseline [14]. This supports the observation that Black women have more severe symptoms prompting them to undergo hysterectomies at a younger age [29-31]. 

Uterine fibroid symptom severity does not completely explain Black women having hysterectomies instead of minimally invasive myomectomies at a younger age. Multiple studies have reported that Black women were less likely to undergo minimally invasive techniques to treat their uterine fibroids [17]. Becker et al. found that white women had the highest rate of laparoscopically assisted vaginal hysterectomies, which is a less invasive technique, than all other races [10]. Ko et al. found that Black women were more likely to undergo abdominal hysterectomies [18]. One explanation for this racial disparity is disparity in insurance coverage. Multiple papers have reported that individuals covered by Medicaid have worse treatment options. Medicaid expansion has not leveled out the racial health disparities in medicine [32-34]. Becker et al. found that White women are less likely to use Medicaid, while Hispanic and Black women were the first and the second most likely to use Medicaid [10]. This follows the trend that minority racial and ethnic groups are covered under Medicaid at a higher rate [35]. Becker et al. also found that patients covered by Medicaid were more likely to be treated for their uterine fibroids with a hysterectomy than with myomectomy compared to patients covered by HMO/private insurance [10]. Sanei-Moghaddam et al. supports this through their finding that traditional Medicaid patients had a higher likelihood of undergoing total abdominal hysterectomy ([OR], 3.66; 95% [CI], 2.62-5.1; P<0.006) [19]. This conveys that socioeconomic status renders women of color to procedure types that are more invasive with worse outcomes [19]. Interestingly, Sanei-Moghaddam et al. found that non-White women had a higher rate of total abdominal hysterectomy with no significant differences between income levels compared to White women [19]. Therefore, income alone is not enough to overcome racial disparities in treatment options.

Multiple studies confirmed that Black women were more likely to have more postoperative complications than White women. Specifically, Kjerulff et al. found that Black women had worst postoperative outcomes compared to White women undergoing hysterectomy [21]. They found that Black women undergoing hysterectomies had an increased length of hospital stay defined as greater than ten days (Odds ratio (OR) 2.7, 95% Confidence Interval (CI) 2.5-3.1), risk of one or more complications of surgical or medical care (OR 1.4, 95% CI 1.3-1.5), and hospital mortality (OR 3.1, 95% CI 2.0-4.8) compared to White women [21]. Kim et al. found that Black women had a higher rate of complications despite the different surgical methodologies, abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy [13]. These findings convey that there are systematic disparities that increasing the amount of minimally invasive surgical techniques in Black women would not fix.

Machtinger et al. researched Magnetic Resonance-guided focused ultrasound surgery (MRgFUS) for treatment of uterine fibroids, found that there was no statistically significant postoperative difference between African American women and non-African American women [15]. They found that, regardless of race, the mean volume of treated fibroids decreased significantly over twelve months postoperatively (p=0.002) [15]. Another study found that mean symptom severity score decreased post MRgFUS throughout a two-year follow-up period [36]. This makes MRgFUS potentially one of the few surgical options that close the gap between postoperative outcomes between African American women and non-African American women. Therefore, Black women should consider undergoing this type of minimally invasive procedure rather than other types of myomectomies and hysterectomies. MRgFUS was recently approved by the Food and Drug Administration (FDA) in 2004 and many interventional radiologists are not commonly trained in its usage [37]. MRgFUS has multiple requirements to be approved for treatment, however other studies have suggested the potential to broaden the inclusion criteria [38-40]. This would allow more people, including more Black women, to undergo this procedure [40]. There are few studies comparing the effectiveness of MRgFUS to more invasive surgical treatments [41]. There are few studies on MRgFUS on uterine fibroids and Machtinger et al. may potentially have had the only study that focuses on Black women [15]. Therefore, there needs to be more studies on this technique and its effects on Black women. 
 

The inherent constraints of the included studies, reflects the broader context of the limited literature on the disparity in treatment for uterine fibroids in Black women. Many studies used large databases like NSQIP and HCUP-NIS, which lack detailed clinical information such as fibroid size, surgeon experience, and patient preferences. For example, Carey et al. noted the absence of data on surgeon volume and years of experience, which could influence surgery choices and outcomes [16]. The studies varied in inclusion criteria and designs. Katon et al. focused on Black and White women, excluding other racial groups, limiting broader applicability [8]. Similarly, Zaritsky et al. faced generalizability issues due to the single-payer system at Kaiser Permanente, which may not reflect other healthcare settings [12]. 

Many studies did not account for socioeconomic factors that impact health outcomes. Sengoba et al. did not evaluate the severity of illness or secondary illnesses [22], while Weiss et al. did not control for comorbidities, complicating direct outcome comparisons between racial groups [11]. Methodological limitations included retrospective designs and reliance on ICD-9 and ICD-10 codes, which can introduce biases and misclassification (Stentz et al. [20], Frost et al. [17]). Small sample sizes in subgroup analyses limited the power to detect significant differences. Sengoba et al. and Dallas et al. both noted limitations in generalizability due to small sample sizes and exclusion of certain populations like Hispanic and Asian women. 

Carey et al. found significant disparities in outcomes, with Black women experiencing more complications, but these findings might not be applicable to other populations [16]. Katon et al. confirmed worse outcomes and higher complications for Black women, but the inclusion of only two articles with relevant data limits robustness [8]. Zaritsky et al.  highlighted persistent disparities in access to minimally invasive procedures [12]. Sengoba et al. noted that Black women reported more difficult recoveries compared to other racial groups, but the small sample size limits generalizability [22]. 

The systematic review reveals significant disparities in the surgical treatment of uterine fibroids between Black women and their non-Black counterparts. Black women are more likely to undergo open hysterectomy and experience higher rates of postoperative complications. These disparities persist even after adjusting for various health and socioeconomic factors, indicating systemic issues in the healthcare system. The review highlights the need for more equitable care practices and suggests that improvements in access to minimally invasive surgical techniques and addressing socioeconomic barriers are essential for reducing these disparities. Furthermore, the review underscores the importance of future research focused on understanding and mitigating the barriers faced by Black women in accessing quality care for uterine fibroids, ultimately aiming to achieve health equity. 

None.

None relevant.