Pro & Con: is supracervical hysterectomy a reasonable option for most women?

OB/GYN News, Nov 15, 2001

YES

The amount of scientific data supporting this opinion are relatively limited. There is an inherent bias toward doing a total hysterectomy because of historical concerns about the development of cervical cancer. If you want to answer this question using evidence-based data, it's hard to do.

For individuals who don't have a history of cervical precancers or cancers and who have access to health care, the available data and science would support leaving the cervix in for three main reasons:

The first reason is the surgery itself. When you leave the cervix in, the surgery can be done in less time, and data support that it can be done with few complications. If it's done laparoscopically, it can be an outpatient procedure. If it's done through a small incision, it can still be an outpatient procedure or possibly a simple overnight stay.

The second issue is about not disrupting anatomy that doesn't need to be disrupted. If the disease is in the corpus of the uterus, just remove the place where the disease is. If you also remove the cervix, it could have a negative effect on the pelvic anatomy. There's the issue of support and also the possible disruption of nerve pathways that go to the bladder, urethra, and G-spot. Potential bladder control problems due to removal of the cervix are well addressed (Obstet. Gynecol. 89[1]:133-39, 1997).

The third issue that has been discussed--which varies among different communities--is the emotional distinction between removing something that needs to be removed and removing something that's normal. Particularly when I practiced in Southern California, a common feeling was that if it's not involved in the disease process, why are you removing it? For some people who want to maintain a view of normalcy, leaving something that's normal is what you should do.

Cervical cancer is not as great a risk for American women as it was in the past because more people are being screened.

At my institution, we offer supracervical hysterectomy to patients who are having surgery for nonmalignant processes, have a normal cervix with normal cervical support, and do not have a history of cervical dysplasia or precancerous changes.

Even in women who don't have access to regular health care, if they have never had an abnormal Pap smear and are at low risk for having cervical cancer or a precancerous change, I think you could argue for leaving in the cervix.

Dr. F.J. Montz is professor and director of the division of gynecologic oncology at Johns Hopkins University, Baltimore.

NO

Supracervical hysterectomy was the norm in this country in the 1940s and 1950s, but we moved away from it for a variety of reasons. During that time, there were problems with the retained cervical stump that led doctors to abandon supracervical hysterectomy.

We don't know what fraction of women had such problems, but the most serious concern was cervical cancer. Pap smears came into use in the 1950s and 1960s, and with adequate screening we've seen a decline in cases of invasive cervical cancer, but we have not eradicated the problem completely.

In the past, one of the major concerns with total abdominal hysterectomy was bleeding--a life-threatening consideration in the pretransfusion era--but that argument has been lost with advances in surgical practice and the safety and availability of transfusion.

If total hysterectomy can now be performed safely and the woman restored to excellent health with or without the cervix, then it seems to make sense to remove that significant health risk--the cervix--at the time of hysterectomy

In my opinion, the proponents of supracervical hysterectomy have not shown that it's safer or results in improved health.

People have tried to measure whether it makes a difference in sexual satisfaction, but I don't think there are good studies to suggest it is affected by the retention or removal of the cervix. We know as gynecologists that the best predictor of healthy sexuality after hysterectomy is healthy sexuality before hysterectomy Even in retrospective studies that have been published, there's no credible evidence that there is improved sexual function when the cervix remains in place.

Postmenopausal bleeding may become a problem if the cervix is present after hysterectomy because of endometrial tissue remaining after supracervical hysterectomy In doing supracervical hysterectomy it's tempting not to go too low. But if you don't go low enough, there's a chance of leaving endometrial tissue, which complicates the issue of hormone replacement therapy If patients have endometrial tissue left, there's an endometrial cancer risk if they get estrogenonly treatment.

Finally when supracervical hysterectomies were done more often, about half the surgeries to later remove the cervix were due to prolapse and pelvic relaxation problems. That's important because some people argue that one reason to keep the cervix is to keep pelvic support.

Dr. Bobbie S. Gostout is with the division of gynecologic surgery in the department of ob.gyn. at the Mayo Clinic in Rochester, Minn.