Hysterectomy

Womb snatching

Besides cesarean, hysterectomy is the most likely operation you'll face if you're a women, even though up to 90 per cent could be unnecessary. Here's how to avoid one.There is a joke among medical practitioners confronted with a woman suffering from gynecological problems. The diagnosis: she is suffering from CPU or Chronic Persistent Uterus. The solution: Hysterectomy.

In fact, hysterectomy, or more correctly female castration, is now one of the most widely applied surgeries for women, second in some countries only to the cesarean. In the US, a woman has a one in three chance of having her uterus removed by the age of 60. In Britain, her chances are only slightly better at one in five.

The majority of hysterectomies, nearly 75 per cent, are performed on pre menopausal women between the ages of 20 and 49. On the whole, endometrial cancer, invasive cervical cancer and uncontrollable post partum hemorrhage are the only medical indications for hysterectomy, but according to a recent survey these account for only around 10 per cent of hysterectomies (Hospital Episodes Statistics 1993-94, HMSO, London). This throws into question the appropriateness of the remaining 90 per cent, though within the medical profession this question has yet to be widely addressed.

Although hysterectomy has been practised for 100 years, virtually no strict criteria has been established to identify when it is appropriate and when it is not (Soc Sci Med, 1982; 16:811-24) The most often applied criteria is that the woman should have no desire to have any (or any more) children fuelling the idea that the uterus serves no useful purpose beyond its reproductive function. In fact, the uterus has hardly been studied separately from its role in childbirth, leading to the widely held belief that it is only good for two things growing babies and growing cancer.

It appears also that medical and social mindsets not disease determine who ends up on the operating table. For instance, male gynecologists do more hysterectomies than females (N E Jr Med, 1985, 313:1482). Black women are more likely to end up having a hysterectomy than white women 65 per cent as opposed to 28 per cent (Ob Gyn, 1993; 82:757-64).

Rates can vary between individual doctors in the same hospital. Within the US, rates vary enormously, according to geographical region, with women in the poorer areas of the South often public clinic patients claiming the highest hysterectomy rates in the country (see The Hysterectomy Hoax, Doubleday, New York, 1994).

Mistakes and money also play a part. In one study of hysterectomies for cervical cancer, an amazing 31 per cent were performed in spite of normal Pap smears and negative cervical examinations, and 5 per cent were due to a misreading of the pathology report (Ob Gyn, 1992, 79:485-9). A recent survey of American healthcare plans revealed that some 16 per cent of hysterectomies carried out under these plans were performed for inappropriate reasons (JAMA, 1993; 269: 2398-402).

This is because private health plans do not endorse, and consequently do not pay for, alternative treatments. Perhaps this is why one American doctor was moved to write, "more often the indications [for a hysterectomy] are a cooperative patient with a uterus and good health insurance" (New Eng J Med, 1993, 399: 276).

The most common stated reasons for performing an hysterectomy are: fibroids (30 per cent), endometriosis (20 per cent), vaginal prolapse (15 per cent) and endometrial hyperplasia, or abnormal growth of cells (6 per cent). Various other causes, such as excessive bleeding, pelvic pain, pelvic inflammatory disease (PID) and ovarian cysts account for the remaining 30 per cent (New Eng J Med, 1993, 328:856-60). But it is the contagious and largely unfounded fear of cancer which can lead surgeons to perform (and women to agree to) hysterectomies when they are simply not appropriate or on a just in case basis.

However a recent review of the subject concluded that "cancer prevention alone does not justify hysterectomy" (New Eng J Med, 1993, 856-60). For instance, less than 2 in 1000 fibroids turn into uterine cancer. Since the mortality rate for hysterectomy is 1 in 1000, the risk of dying from the operation is actually greater than the risk of cancer.

The best advice is to watch and wait (Ob Gyn, 1992, 79:481-4). Some doctors say that large fibroids make it impossible for them to detect ovarian cancer during pelvic examinations. But this goes against reported experience in 75 per cent of cases, the disease is only detected after it has spread beyond the confines of the ovary (New Eng J Med, 1985, 312: 415-9). At any rate, ultrasound has proved to be an effective means of evaluation of the ovary (Br J Ob Gyn, 1990, 97:304-11). And removal of one organ to detect the possible, eventual cancer of another is simply not justified.

Endometrial hyperplasia can progress to cancer, though only in around 1-3 per cent of cases (Cancer, 1985; 56: 403-12). Even using the questionable tools offered by conventional medicine, treatment with progestins is highly effective, usually eliminating the risk within six months (although exposing you to the other cancer risks of HRT). Only after this, if hyperplasia is persistent should hysterectomy be considered. Endometrial cancer is most prevalent in women between the ages of 50 and 70, hardly a justification for the widespread hysterectomy rate in younger women.

It has also been shown that "just in case" removal of the cervix does not eliminate the risk of cancer it merely shifts the risk to the vaginal epithelium (its outer layer). Since the cervix plays a major role in sexual stimulation and orgasm, it should not be removed without proper indication (Jr Rep Med, 1993, 38:781-90). A newer surgical technique sub total hysterectomy preserves the cervix and some part of the uterus.

The short and long term complications and side effect of hysterectomy are becoming more well known, though there has yet to be any widely accepted definition of what constitutes "major" or "serious" complaints after hysterectomy (Am J Ob Gyn, 1992, 144:841-8). These can vary according to the route of the operation from 24 per cent for vaginal hysterectomy to 43 per cent for abdominal hysterectomy (Am Jr Ob Gyn, 1982; 144: 841-8). Infection, fever, and urinary retention are the most common post operative problems. The risk of a fatal blood clot in the lung rises after hysterectomy 1 in 5,700 particularly in women over 50 (Br Jr Ob Gyn, 1994; 101:468-70). Women who have had a hysterectomy are more likely to suffer from constipation and bowel problems such as IBS (Pulse, Aug 14, 1993). Figures from the American Association of Gynecological Laparoscopists estimate that as many as 3 out of every 10,000 women die as a result of surgery, and serious complications can arise in as many as 15 out of every 100 operations (WDDTY vol 4 no 12).

The vaginal route can fail if the size of the uterus is not properly diagnosed. If the uterus is 300-999 g the failure rate is 16 per cent; but only 5 per cent if is 100-299g (Ob Gyn, 1995, 86: 60-4). In these cases the surgeon will need to switch, mid surgery, to an abdominal route, increasing the probability of post surgical complications. The vaginal route also more than doubles the need for further unexpected surgery usually to repair trauma to bladder or bowel or to control hemorrhage (Am J Ob Gyn, 1982; 144: 841-8). Injury to the ureter is more common with the abdominal route (Am Jr Ob Gyn, 1992; 167: 756-7).

Urinary problems, such as incontinence, are well documented and can be the result of nerve damage to the bladder during the operation, due to that organ's close proximity to the uterus (Br Jr Urol, 1989; 64: 594-9).

Between 33 and 46 per cent of women experience a decrease in sexual response after a hysterectomy and oopherectomy (ovaries removed) (Am Jr Ob Gyn, 1981; 140: 725-29). If the surgeon is not skilled in the technique of "worrelling" where the vagina is peeled carefully off the cervix and then restored to its original length, the vagina can end up substantially shortened, making intercourse almost impossible. Surgical skill can also influence morbidity for better or worse, for up to three months post operatively in relation to blood loss, length of hospital stay, the incidence of blood transfusion, and bladder dysfunction (Gyn Onc, 1993; 51:39-45).