Hysterectomy
Question: My doctor recently told me that I need a hysterectomy. I have heard in the news lately that women are undergoing hysterectomy surgery when it is not medically necessary for them to do so. I was wondering if you could tell me why doctors would recommend this surgery if it is unnecessary? And also how I can know if a hysterectomy is the right treatment option for me?
Answer:
Hysterectomies
The United States has the highest rate of hysterectomy in the industrialized world and according to the Center's for Disease Control and Prevention (CDC), hysterectomy is the second most frequently performed surgical procedure (after caesarean section) for U.S. women. Approximately 600,000 hysterectomies are performed annually in the United States, and approximately 20 million American women have had a hysterectomy. Studies show that anywhere from 10 to 90 percent of hysterectomies performed in the United States are not medically necessary, evidenced by the fact that today, approximately 90 percent of hysterectomies are performed electively. The National Women's Health Network (NWHN) believes that unnecessary hysterectomies have put women at risk needlessly, and that health care providers should recognize the value of a woman's reproductive organs beyond their reproductive capacity and search for hysterectomy alternatives before resorting to life-changing operations.
Quoted in the Los Angeles Times, NWHN Executive Director Cindy Pearson says, "I advise any woman who is not in a life-threatening situation to see someone else besides a surgeon to explore nonsurgical options first."
If your physician is pressuring you towards a particular treatment option, it is important to educate yourself on your other options and seek a second opinion. The number of hysterectomies performed has been declining as newer approaches to gynecological problems are developed. Diagnostic tests can be used to help determine the need for a hysterectomy, and other treatment options may be similarly effective in treating a gynecological problem.
The most common purpose of a hysterectomy is for the treatment of conditions involving pain and abnormal bleeding. These conditions include:
- Uterine fibroids
- Pelvic inflammatory disease
- Endometriosis
- Pelvic relaxation
- Uterine prolapse
- Cancer
Very rarely, hysterectomy is recommended when a condition has the potential to become life-threatening. Only 8-12% of hysterectomies are performed as a treatment for cancer, including cancer of the uterus, cervix, vagina, fallopian tubes, and/or ovaries. Other serious conditions for which hysterectomies are recommended include:
- Severe uncontrollable infection (such as severe cases of PID, or pelvic inflammatory disease)
- Severe uncontrollable bleeding (rare, often associated with childbirth)
- Rare but serious complications during birth (such as the rupture of the uterus)
Many times, in fact most often, hysterectomies are performed as treatment for conditions not considered life-threatening. These treatments are usually elective and it is important to discuss all of your options and the possible risks with your physician before making your decision. More specifically, the following conditions are sometimes treated for hysterectomy:
- Severe pelvic infections unresponsive to antibiotics
- Pre-cancerous changes of the endometrium (the lining of the uterus)
- Excessive endometriosis causing debilitating pain and/or involving other organs (though less invasive surgery and medications can also work)
- Fibroid tumors that are large, extensive, involve other organs, or cause debilitating bleeding (myomectomy, which leaves the uterus intact, is another option)
- Pelvic relaxation (such as uterine prolapse) that is causing severe symptoms (another option is uterine suspension surgery)
There are cases in which a hysterectomy should not be performed. These are:
- Mild abnormal uterine bleeding
- Fibroids without symptoms
- Pelvic congestion (menstrual irregularities and lower back pain)
As always, it is important to discuss your options and symptoms with your physician before making a decision. Because the necessity for hysterectomies has become controversial in recent years, many insurance companies require a second opinion before covering the cost of the procedure. Diagnostic techniques such as sonography, Pap smears, hysteroscopy (using a flexible telescope inserted through the vagina to view the uterus), and laparoscopy may be performed to assess the need for a hysterectomy.
When a Hysterectomy Seems Necessary
If a hysterectomy seems necessary, It is important to initiate open communication with your health care provider regarding the specifics of your situation. Here are some important questions (adapted from The Woman's Guide to Hysterectomy by Adelaide Haas and Susan L. Puretz) that you may want to ask your health care provider before you decide on a hysterectomy:
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What are the risks involved with this type of hysterectomy, and what is the success rate?
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How long will I be in the hospital? Can this procedure be performed on an outpatient basis? What type of surgery will be needed? [See below for more information about surgical options]
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How much will the operation and the follow-up care cost? Will these be covered by my insurance? Will the care of any medical complications resulting from this operation be covered by my insurance?
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When can I expect to be fully recovered from the surgery?
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How will this surgery affect my sexual functioning?
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What might happen if I choose not to have surgery, or wait awhile to decide?
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How many of these surgeries have you performed? When was the most recent one?
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What type of anesthesia will be needed?
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Can someone (my partner/friend) stay with me while the surgery is being performed?
Types of Hysterectomy
There are several types of hysterectomies, as well as several different methods of performing the procedure. The hysterectomy procedure itself is classified into four types:
- Total hysterectomy (also called complete): the uterus and cervix are removed, leaving the fallopian tubes and the ovaries. Ovulation still occurs but menstruation does not - the egg is simply absorbed into the pelvic cavity.
- Total hysterectomy with bilateral salpingo-oophorectomy: the uterus, cervix, fallopian tubes, and ovaries are removed (if not diseased, one ovary may not be removed).
- Radical hysterectomy: the uterus, cervix, fallopian tubes, and ovaries are removed. In addition, the upper part of the vagina and the lymph nodes in the pelvic area are also removed.
- Supra-cervical (subtotal) hysterectomy: the cervix is not removed so as to limit the effect of surgery on the function and anatomy of the vagina. This is less likely to interfere with nerves and arteries. However, Pap tests will still be needed after surgery to ensure proper cervical health.
In addition to the different types of procedure, there are several methods for performing a hysterectomy:
Abdominal hysterectomies allow the surgeon to see the pelvic cavity more completely. A horizontal incision is made across the pubic hairline, leaving only a barely visible scar after recovery. Alternately, a vertical incision between the navel and the pubic hairline may be made. Abdominal hysterectomies are usually more invasive and include longer recovery periods.
Vaginal hysterectomies have a shorter recovery period and the healing process is often faster. There is no visible scar, as the incision is made inside the vagina. Laparoscopically assisted vaginal hysterectomy (LAVH), is when carbon dioxide is pumped into the abdomen, and allows the surgeon to see an image of the pelvic cavity. Vaginal hysterectomy and LAVH are performed less frequently and require greater skill, so it is important to find a surgeon who performs the procedure regularly. Mistakes can lead to permanent urinary tract infection. Additionally, the vagina may be shortened, causing painful intercourse and possible temporary, but severe, lower back pain. As a precaution, many surgeons routinely order antibiotics before performing the procedure.
Surgical and Post-Surgical Risks
Although the death rate from hysterectomy is low (less than 1 percent) surgical complications are very real and can result in any of the following: infection, hemorrhage during or following surgery and/or damage to internal organs such as the urinary tract or bowel. Patients have a 30% chance of complication (typically infection or fever) while in the hospital and a significantly lower risk of more serious complications such as hemorrhage or bladder and bowel damage depending on the individual's condition and the surgical approach taken.
Long-term Risks
Removal of the uterus and ovaries at a young age (early forties and younger) may increase risk of heart attack, and (even when ovaries are not removed) chances of experiencing an earlier menopause. Hysterectomy has also been associated with urinary problems, such as increased frequency of urination, incontinence, fistula, and urinary tract infections; sexual function problems, such as decrease in sexual sensations and lack of lubrication; depression or psychological stress (stemming from feelings associated with losing reproductive organs); hormone deficiencies, which may be caused by removal of the ovaries, or a decrease in blood supply to the ovaries.
In summary, NWHN is very critical of physicians who do not explore other treatment options before resorting to a hysterectomy. It turns out that there are many effective and less drastic measures for controlling problematic gynecological symptoms other than hysterectomy. However, being brought up trusting our health care providers, fearing cancer, and being ashamed of our bodies; many women are feeling pressure to undergo this procedure.
Unnecessary hysterectomies put women at risk needlessly and it is important that health care providers recognize the value of a woman’s reproductive organs beyond their reproductive capacity and search for hysterectomy alternatives before resorting to life-changing operations. For some women having a hysterectomy may be the right choice; many women may benefit from the procedure. Ultimately, when faced with a decision, each woman must do what she feels is right for her and what makes her comfortable.
Additional Resources
Here are more links to websites with useful hysterectomy information:
http://medicalconsumers.org/2009/05/05/healthy-ovaries-should-not-be-removed/- Article explaining why healthy ovaries do not need to be removed
http://nwhn.org/hysterectomy - NWHN’s Hysterectomy Fact Sheet
http://www.ourbodiesourselves.org/book/chapter.asp?id=26 – Our Bodies, Ourselves website on Menopause
http://www.hystersisters.com – online support group and forum information for women considering hysterectomy
http://www.hersfoundation.com/ - Hysterectomy Alternatives & After Effects website
