There seems to be plenty of blame to go around, but the statement itself is faultless: Too many women are undergoing hysterectomies.
An estimated 600,000 American women have the procedure each year, a much higher rate than in any other nation and not much different from the rate in 1970 - although the number peaked near 750,000 in 1980. Only a Caesarean section is a more common surgery.
Roughly half of all hysterectomies result in removal of the ovaries along with the uterus, adding an “oophorectomy” to the surgical log. According to the federal Centers for Disease Control and Prevention, only about 10 percent of hysterectomies in the United States are done to avoid life-threatening conditions such as cancer.
“There are unnecessary hysterectomies getting done in this country every day,” said Dr. Lane Mercer, chief of gynecology and gynecological surgery at Northwestern Medical Center, in Chicago. “There are two reasons for it: One is doctors, one is patients.
“Doctors see a problem, and they figure removing the uterus is the most expeditious way of solving it. Many patients end up thinking the same thing.”
The problems include uterine fibroids, endometriosis, abnormal uterine bleeding, chronic pelvic pain, defects in pelvic support and, most rarely, cancer.
One expert said understanding the symptoms is the first step to making an informed decision about a hysterectomy.
“These women frequently don’t know what their medical problem is,” said Nora Coffey, founder of Hysterectomy Educational Resources and Services, a suburban Philadelphia operation that has counseled more than 78,000 women since 1982. “When they call us, we ask about the diagnosis. They say, `The doctor said I need it.”’
Coffey learned her hysterectomy lessons the hard way at the age of 36. She “saw five different doctors, read the popular books, asked questions” but still elected the surgery performed on one-third of all women in the United States by the time they reach 60.
“I had a normal uterus and ovaries removed,” she said. “I didn’t know it for a year.”
She was diagnosed with a very large ovarian mass that turned out to be benign. Instead of removing only the cyst, her surgeon took all of her reproductive parts. Coffey has been dedicated to educating women about the disadvantages of hysterectomies ever since.
There is not much hard data describing the long-term physical or psychological effects of hysterectomies. A wide range of problems have been reported, including fatigue, urinary difficulty, constipation and change in sex drive. Losing the uterus and ovaries can be devastating to some women, though others are happy to be relieved of what was unbearable pain.
“Americans like a quick fix,” said Dr. Kirtly Parker Jones, chief of reproductive endocrinology at University of Utah Hospital in Salt Lake City. “There is no quicker fix than taking the uterus and ovaries out. But there is also such a finality to it.”
About 75 percent of hysterectomy candidates go to their gynecologists with pelvic pain and bleeding problems. There are four basic diagnoses that present such symptoms:
Uterine fibroids: These are benign tumors that can enlarge to such proportions that a woman looks three months’ pregnant. A woman may have one or several tumors (one translates to a much lower rate of recurrence, about 10 percent, compared with 50 percent for multiple fibroids). Excessive bleeding and anemia may result; fibroids lead to about 30 percent of all hysterectomies.
This rankles Dr. Stanley West, a New York gynecologist and author of a new book, “The Hysterectomy Hoax” (Doubleday, $12.95).
“Fibroids can always be removed in a surgery called a myomectomy,” he said. “We take out only the fibroids, leaving the uterus and ovaries intact.”
West said there is a bit more risk to the procedure because the surgeon is snipping certain blood vessels feeding the fibroid while not harming those bringing blood to other parts of the reproductive system. It runs two to five hours compared to one to two hours for a typical hysterectomy. But in the hands of an experienced surgeon, this is the preferred alternative for women who still want to bear children.
Endometriosis: This condition makes life miserable, with pelvic soreness, extremely painful menstrual periods, irritable urination and irregular bleeding, all caused by a wild overgrowth of the uterinelining tissue in other parts of the reproductive system. It accounts for 20 percent of hysterectomies, though this procedure should be considered a last resort after trying drug treatments intended to alleviate symptoms by suppressing natural estrogen.
Some physicians will make a case for more conservative surgery to remove abnormal tissue. In addition, new laser techniques to remove only diseased tissue are helping women avoid hysterectomies.
Abnormal uterine bleeding: There are other possible treatments for this symptom, which eventually prompts 20 percent of hysterectomies. Options include hormone therapy, non-steroidal antiinflammatory drugs and endometrial ablation, a relatively new outpatient surgical procedure in which the uterine lining is burned out electrically or with lasers (this eliminates possibility of bleeding).
Mercer, for one, would like to see more research before widely recommending ablation. “The technology is coming rapidly, but we really have not done any studies over a length of time that are appropriate,” he said.
Chronic pelvic pain: Ten percent of hysterectomies are attributable to such pain, and that appears to be about 10 percent too many. Most hysterectomies performed to relieve chronic pelvic pain do no such thing. A better bet might be psychotherapy; there is evidence that about 40 to 60 percent of all women reporting pelvic pain were sexually abused as children.
Another 15 percent of hysterectomies are done because of genital prolapse, or sagging caused by weakened pelvic muscles. Progressive doctors recommend first trying a passary (a diaphragmlike device) to provide support, along with estrogen cream and special pelvic exercises.
No one wants to stop the appropriate hysterectomies. West said it is simply a matter of women making sure they are counted.
Mercer suggested that women always search out a second opinion, making sure to not tip the follow-up doctor to the original recommendation. “Look out for someone who wants an immediate answer from you, scheduling surgery before you even have time to think about it,” he said. “Plus, you don’t want a doctor who doesn’t explain the various treatments and why they can or cannot be done.”
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