Unearthing Inequalities in Minimally Invasive OB-GYN Surgery

Kelly N. Wright, MD

Uneven Access to Advanced OB-GYN Surgery

Black women are three times more likely than white women to develop uterine fibroids, often suffering larger and more numerous growths. Yet, Black patients are offered advanced fibroid surgeries at a much lower rate than their white counterparts.

Wright and colleagues, including Matthew Siedhoff, MD, vice chair of Gynecology, and Rebecca Schneyer, MD, a fellow in Cedars-Sinai's Minimally Invasive Gynecologic Surgery (MIGS) Fellowship program, performed an institutional review of uterine fibroid patients at Cedars-Sinai. The paper, published in the Journal of Minimally Invasive Gynecology, found that nearly 60% of white patients were treated by a subspecialist surgeon, compared to less than 50% of patients of color. While 81% of white women underwent minimally invasive myomectomies and hysterectomies, just 57% of Black women and 65% of Latina patients had access to the techniques.

As a result of these inequities, Black and Latina women are exposed to more extensive gynecologic surgeries, particularly traditional abdominal hysterectomies. Black women also experienced the highest rates of blood loss and anemia and the longest surgeries.

"For Black women and other patients of color, I want to validate their mistrust in healthcare, because these are real, systemic issues," Wright said. "I can completely understand why someone would be afraid to undergo surgery."

Read: Racial Disparities in Minimally Invasive Surgery for Fibroids

Matthew T. Siedhoff, MD

Life-Altering Complications

Other Cedars-Sinairesearch suggests that patients of color undergoing surgical care for endometriosis likely face similar disparities as those who are receiving surgical care for fibroids. Black and Latina women experience the highest rates of significant postoperative problems for both conditions. Such adverse effects can lead to worse pelvic pain and bleeding and potentially result in long-term damage.

In a far-reaching retrospective cohort study, investigators examined more than 66,000 patients who underwent both minimally invasive and traditional abdominal myomectomies, which remove fibroids but keep the uterus intact. The study found that Black women faced the highest rates of subsequent surgeries and serious infections across surgical routes, health insurance types and other health conditions.

"The consequences are really dire," Schneyer said.

Rebecca J. Schneyer, MD

Another observational study of minimally invasive endometriosis surgeries across 700 medical centers found that Black women experienced the highest proportional share of severe surgical complications among any race or ethnicity. The risks persisted in both simple and advanced cases that required bowel involvement or a full hysterectomy.

"There has been a longstanding misconception that endometriosis is a disease of white, wealthy patients," Schneyer said. "With so little known about endometriosis in communities of color, these findings that define the disparities are at least the first step."

Read: Endometriosis Awareness Month: Answers to Frequently Asked Questions

Advancing the Field to Close Gaps

Although MIGS is a growing field, just 2% of OB-GYNs are subspecialized in techniques such as laparoscopic or robotic assistance.

"For every patient we see, there are so many others who never find their way to a minimally invasive surgeon," Schneyer said.

In 2022, Cedars-Sinailaunched its three-year MIGS Fellowship program, one of only two programs of this duration in the U.S. The program's leaders hope that the robust training opportunity will act as a springboard to build the MIGS workforce and that the enhanced education will deepen our understanding of chronic gynecologic conditions.

"There's such a huge need," Wright said. "We're trying to train up the next generation of minimally invasive surgeons to get to the root of these diseases and change the tide."

Read: Equitable, Personalized Care for Women and Children of Color