Hysterectomy Still Overdone: How to Avoid One

Healthfacts, March, 2000 by Maryann Napoli

Though the U.S. hysterectomy rate has declined slowly over the last two decades, it remains one of the highest in the world. A new study suggests that in about 70% of cases, this operation continues to be inappropriate (Obstetrics & Gynecology, 2/00). Dr. Michael S. Broder of the University of California in Los Angeles, and colleagues assessed the medical records of 500 women who underwent hysterectomy--surgical removal of the uterus--for reasons unrelated to cancer or an emergency. Benign uterine growths (fibroids), pelvic pain, and excessive menstrual bleeding (menorrhagia) are the most common reasons for hysterectomy.

Dr. Broder and colleagues found that many of the women had not been properly evaluated by their physicians prior to surgery; a laparoscopy, for example, was not ordered to investigate the cause of pelvic pain. This finding wouldn't surprise Nora Coffey of HERS (Hysterectomy Education and Resource Services), whose independent non-profit organization has been counseling women on the telephone for 18 years.

"We give women guidance about how to determine whether they had an appropriate evaluation," she said in a telephone interview, using menorrhagia as an example. When Ms. Coffey asks the reason for a hysterectomy, she said that women usually answer by saying that they are bleeding. "But bleeding is just a symptom, not a disease, and you need to know the cause," she cautioned, "We tell women how to get the most basic evaluation, for example, an ultrasound." She explained that bleeding due to hyperplasia is identified on a ultrasound as a thickened endometrium (lining of the uterus). "You don't need an endometrial biopsy, which is what most doctors do; instead, the bleeding can be treated with a D & C [dilation of the cervix and curettement of the endometrium]." On the other hand, bleeding due to a submucosal fibroid, the only location that Ms. Coffey said would cause menorrhagia, can be treated by a procedure called hysteroscopic resection of the tumor--if it is smaller than 4 cm on an ultrasound. "We also tell women why they should never let a gynecologist or a technician in the gynecologists office do an ultrasound," said Ms. Coffey, who believes that neither has the expertise of a radiologist. "You need to get a detailed written report of what exactly is going on."

Hysterectomy has serious short- and long-term complications, such as sexual dysfunction and displacement of the bladder and bowel, and a small risk of death. The risks increase with the removal of ovaries, adding such problems as abrupt onset of menopause in women of reproductive age. All are reasons enough to be cautious about the decision to undergo the operation whose complications usually go unmentioned by most gynecologists.

The new study, which identified a 70% rate of unnecessary hysterectomies, also found that women did not try alternative treatment before having a hysterectomy. But many of the alternatives are themselves drastic. Drugs called GnRH agonists are prescribed to shrink fibroids by blocking the hormones that encourage growth. They have formidable side effects and work only as long as a woman stays on the regimen. Fibroids can be removed while leaving the uterus intact in an operation called a myomectomy, but the operation requires a special skill most gynecologists do not have.

Ms. Coffey is particularly concerned about a currently popular technique called uterine artery embolism, which she says is a treatment for fibroids and menorrhagia secondary to fibroids. "It is performed by a radiologist who puts a catheter into the groin on each side, spreading down through the uterine artery and occluding it permanently with polyvinyl alcohol particles." The idea is to cut off the blood flow to the fibroid causing it to shrink. Polyvinyl alcohol is listed as a carcinogenic substance, according to Ms. Coffey. "The question I have for doctors is: How do you know that you are not giving women cancer? You are permanently putting this substance into womens bodies."

Sometimes the excessive bleeding that plagues women in mid-life can be treated with such low-tech advice as using an ice pack on the pelvis, elevating the feet, eating iron-rich food, and drinking an herbal tea combination, said Ms. Coffey. "If a woman has heavy bleeding and is close to menopause, often she can get through it [following this advice]," she said. "Women can slow the bleeding down by drinking tea made of one teaspoon each of raspberry, black cohosh, and shepherd's purse; steeped for five minutes in a cup of hot water. Drink it three times a day starting with the day of the menstruation. Its very bitter. I dont think you could get it down without honey."

Resource

Call HERS, Hysterectomy Education and Resource Service, (610) 667-7757 to make an appointment for a phone counseling session. HERS charges a $15 fee, which is waived for those who cannot afford it. HERS refers to physicians for treatment options and will send relevant articles ($3.50 each) from medical journals. Visit the Web site (www.ccon.com/hers).