A hysterectomy

Why have a hysterectomy?
Hysterectomy, in which a woman’s womb is removed, is one of the most common surgical operations in the West. By age 60, about one-third of American women and one-fifth of British women will have had this operation - mainly for non-emergency motives. Apart from localised cancer, the principal reasons for hysterectomies are for:

* Serious menstrual bleeding or pain: this is the reason for half the hysterectomies performed in the UK. However, most women with heavy bleeding have no detectable disease in the pelvic area, and their symptoms may be caused by hormonal imbalances, thyroid problems or fibroids. Sometimes, there is no obvious cause at all.

* Fibroids: these are non-cancerous fibrous, muscular growths inside or around the womb. Around 20 per cent of women over 30 have at least one fibroid, but may be totally unaware of it. The problem fibroids are those that start to grow under the lining of the womb, causing excessive menstrual bleeding, continuous cramping pain or urinary problems.

* Prolapsed womb: this is where the womb or parts of the vaginal wall drop down through the vagina.

* Endometriosis: the reason for 30 per cent of hysterectomies, in this mysterious disorder, bits of the same tissue as in the womb lining are found elsewhere in the pelvis, but behave as if they are still in the womb.

What does the operation involve?
There are three main types of hysterectomy:

* Radical: the womb, upper vagina, fallopian tubes and ovaries are removed, triggering an immediate menopause; ovaries may be left in place to avoid this happening

* Total: only the womb and cervix are removed; this is the most common type of operation

* Sub-total: only the womb is removed; keeping the cervix is believed to maintain sexual sensation.
These operations are performed either through an incision in the abdomen or via the vagina.

What are the downsides of hysterectomy?
The most obvious major disadvantage is irreversible infertility: childbearing becomes impossible.

In addition, there are problems with the operation itself. Despite being an ‘everyday’ operation, it is not risk-free - one in 1000 women die from it. It also has a 'high risk' of infections, affecting one in every three operations (Minerva Ginecol, 1991; 43: 435-41). Nearly 40 per cent of women lose so much blood that they require transfusions, and 16 per cent end up with damage to other organs, such as the bladder, and intestinal disorders, severe bruising or pneumonia. This adds up to more than half the women having 'major complications' after hysterectomy (Obstet Gynecol, 1993; 81: 206-10).

The operation can also be done using a laparoscope inserted through the abdomen or the vagina. However, such ‘keyhole surgery’ can result in more complications, particularly when done via the abdomen (BMJ, 2004; 328: 129).

Radical hysterectomy has even more problems, including fistula formation (an abnormal connection between organs or through the skin to outside the body), sepsis, and damage to the nerves supplying the bladder and colon. Other complications include a ‘dropped bladder’ (prolapse), urinary leakage, chronic pain and fatigue, depression and pain during sex. Longer term, hysterectomy also increases the risk of heart attack, heart disease and osteoporosis.

Moreover, hysterectomy doesn’t guarantee a cure - in 63 per cent of hysterectomies for endometriosis, the problem recurs. When women with heavy periods are operated upon, about half turn out to have had a normal uterus (Royal College of Obstetricians and Gynaecologists, The Initial Management of Menorrhagia: Evidence-Based Guidelines, No 1, London: RCOG, 1998).

Is hysterectomy really necessary?
In his groundbreaking 1979 book Confessions of a Medical Heretic, Illinois physician Dr Robert Mendelsohn was the first to question the routine use of the operation. Analysing the data from US hospitals, he contended that nearly 60 per cent of hysterectomies were unjustified. Hysterectomy was recommended as a solution to virtually any major gynaecological problem and routinely performed after the menopause to remove a body part that supposedly no longer had a function.

More recently, gynaecologists at the University of California at Los Angeles, one of the premier US medical research establishments, found that 70 per cent of hysterectomies are 'inappropriate' due to 'lack of adequate diagnostic evaluation' - in other words, surgery was the only route offered rather than an exploration of less invasive alternatives (see boxes, below and on p 11) (Obstet Gynecol, 2000; 95: 199-205).

Part of the problem is that doctors seem to disagree as to when a hysterectomy is truly warranted: some actively persuade their female patients to submit to one while others believe it should only be used as a last resort (Am Fam Physician, 1997; 55: 827-34).