India’s least educated women are at enhanced risk of premature menopause from hysterectomies, new research has shown, bolstering evidence for long-standing suspicions that vulnerable women are exposed to unnecessary hysterectomies.

A study that used data from a nationwide health survey has found the prevalence rates of premature menopause among women aged 30 to 39 years to be 6.8 per cent among the least educated but 0.9 per cent among those with the highest education.

Social science researchers who conducted the study have also determined that hysterectomies alone account for 73 per cent of the seven-fold higher prevalence rate of premature menopause among the least educated women.

Their findings imply that the less educated a woman the more likely she will have a hysterectomy, indicating excessive dependence on surgery and low priority to alternative, conservative treatment options.

“Menopause is primarily influenced by biological factors, but we were surprised to see significant differences in the prevalence rates of premature menopause across states,” said Vanita Singh, a public policy researcher and faculty member at the Management Development Institute, Gurgaon. “Our study was aimed at understanding the reasons for these geographic differences,” Singh said.

The study, based on over 1,80,740 women covered by the Union health ministry’s National Family Health Survey 2019-21, has found that nationwide 15 per cent of women in the 30 to 49 years age group are in menopause. But prevalence rates vary from 24 per cent in Andhra Pradesh and Telangana, and 22 per cent in Bihar, 15 per cent in Bengal, Ladakh, Uttar Pradesh, to 12 per cent in Karnataka, Maharashtra, Tamil Nadu, and 10 per cent in Manipur and Meghalaya.

The researchers discovered stark patterns when they analysed the premature menopause levels with socio-demographic factors such as education, household income, and place of stay. Besides the seven-fold increase in the least educated women, the study also found that the premature menopause prevalence rates were 1.8 times higher in the women from the poorest and rural households compared with the women from the wealthiest and urban households.

“We find that education and hysterectomy are the most important determinants of who will experience premature menopause,” said Karan Babbar, an assistant professor with the department of social sciences and humanities at the Jindal Global University in Sonipat, Haryana, and the study’s first author.

The analysis, just published in the journal Scientific Reports, has shown a graded decrease in prevalence rates of premature menopause in women between 30 and 39 years with increasing education — 6.8 per cent in women with no education, 4.4 per cent with primary education, 2.9 per cent with secondary education, and 0.9 per cent with higher education.

The researchers used statistical tools to measure what among several possible factors might explain these changes associated with education and found a common answer — “had undergone hysterectomy” — accounted for 73 per cent of the seven-fold difference.

“We will need more studies and deeper research to understand why low education levels translate into hysterectomy,” Singh said. “But one possible explanation is a lack of awareness among poorly educated women about alternative treatment options.”

Studies in the past have suggested that women covered by government health insurance schemes are more likely to be prescribed hysterectomies by private doctors in hospitals empanelled and therefore incentivised by the insurance schemes. “Given that surgery is a big contributor to premature menopause in India, our results underline the need for greater emphasis on conservative treatment,” Babbar said.

Earlier studies indicated that the most common reasons for hysterectomy are excessive menstrual bleeding or pain and uterine fibroids or cysts. But experts caution against hysterectomy as the first treatment option because the surgery is associated with an enhanced risk of bone and joint disorders, diabetes and high cholesterol.