Removal of Uterus Still Common

The charge that too many women have hysterectomies was first leveled at the medical profession 50 years ago. It appears little has changed.

A new report from the federal government shows that the rates have remained stubbornly steady since the 1980s, when criticism caused a moderate decline. The surgery to remove a woman’s uterus is the second-most common surgery in the United States, following only caesarean section.

The numbers frustrate many health experts and consumer watchdogs because several alternatives to hysterectomy became available in the last decade.

“Education about hysterectomy and the alternatives is a huge issue,” said Carla Dionne, executive director of the National Uterine Fibroids Foundation, a consumer group. “Women don’t know which option is best for them, and the problem is compounded by gynecologists not knowing what the options are.”

According to the new analysis by the Agency for Healthcare Research and Quality, or AHRQ, 5.6 women per 1,000 had hysterectomies in 1997, the most recent year for which statistics are available, compared with 5.5 per 1,000 in 1990. The study examined only hysterectomies for noncancerous conditions, such as fibroids, menstrual disorders, endometriosis and uterine prolapse, which occurs when the uterus drops into the vaginal canal due to weakening of supporting tissue.

Using these figures, about 600,000 U.S. women have a hysterectomy each year. One in three American women will have a hysterectomy by age 60, a rate that is three to four times higher than Australia, New Zealand and most European countries, according to the AHRQ. Hysterectomy rates even vary widely within the United States, with rates almost twice as high in the South as in the Northeast.

“There is a lot of data out there on appropriate and inappropriate uses of hysterectomy and on alternative treatments,” said Dr. Claudia Steiner, a coauthor of the study at the AHRQ. “When should those things start impacting hysterectomy rates? I don’t think anyone knows that--or even knows what is the right rate.”

The difference in hysterectomy practices between the United States and similarly modernized countries suggests that the operation may not be necessary in vast numbers of cases. But American doctors and patients appear satisfied with hysterectomy despite the fact that the surgery usually entails several days in the hospital, a 2% to 10% chance of a serious complication (including a death rate of 1 per 1,000 women), a long recuperation, possible long-term side effects including sexual dysfunction and bladder and bowel problems, and the sudden onset of menopause when the ovaries are removed along with the uterus.

Hysterectomy costs from $6,800 to $9,300 depending on which technique is used, according to the AHRQ.

“Hysterectomy works very well to treat the problem it’s used for,” said Dr. Michael Broder, an assistant professor of obstetrics and gynecology at UCLA. “So what is the impetus to do something different? Medicine is a very conservative field and tends not to move unless it’s shoved.”

In a study published in 2000 of 497 women undergoing hysterectomy in Southern California HMOs, Broder found that--in 70% of the surgeries--either the causes of women’s symptoms were not fully explored or less-severe alternatives were not tried first. He estimates that in about 30% of hysterectomies, the patient’s symptoms were minimal and surgery was unnecessary.

Medications such as birth control pills, hormones or pain relievers could have been tried for some patients, Broder said.

Even in cases of fibroids--noncancerous growths in the uterus that can cause pain and bleeding--many doctors favor hysterectomy over an established, less radical surgery called myomectomy, said Dr. William Parker, a Santa Monica gynecologist and author of “A Gynecologist’s Second Opinion.” Myomectomy is surgery to cut away the fibroids without removing the uterus. At least one-third of hysterectomies are performed to treat fibroids.

“It’s a matter of comfort for the doctor,” Parker said. “Hysterectomy is easier. Myomectomy takes a little longer. But the data show there is not a higher complication rate. Often there is no good reason not to do a myomectomy.”

Even fewer doctors appear interested in the newer, less invasive alternatives to hysterectomy. These include uterine artery embolization for fibroids and endometrial ablation for bleeding disorders. In the embolization procedure, the arteries that carry blood to the fibroids are blocked; in ablation, the lining of the uterus is removed.

With hysterectomy so entrenched, doctors may not have the opportunities or willingness to learn the new procedures, Dionne said.

“I think it will take a long time for the new technology to trickle down to all the gynecologists practicing in isolation,” she said. “The gynecologists are comfortable with what they’re doing, and there is little to make them offer anything that is outside their comfort zone until it becomes so widespread.”

Women are most likely to hear about alternatives to hysterectomy if they live in large urban areas or seek care through an academic hospital, Dionne said.

“We tell patients you have to get to a teaching institute to have the greatest chance to hear about one of the newer techniques. But there aren’t that many teaching institutes.”

Endometrial ablation was introduced more than 15 years ago to help women with heavy menstrual bleeding, but Parker said it wasn’t simple enough to attract much support.

However, the U.S. Food and Drug Administration in 1997 approved a simpler ablation device, and three similar devices were approved last year. With the new technology, the lining of the uterus can be removed using freezing, heat or electrical current and with minimal doctor involvement and training.

Another alternative to emerge in the 1990s, uterine artery embolization for the treatment of fibroids, has also been slow to catch on. The minimally invasive procedure is performed by interventional radiologists, and some women may never hear about it from their gynecologists.

Some gynecologists may simply be unfamiliar with the procedure; others may opt for a treatment they can perform themselves. According to a new survey by the Society of Cardiovascular and Interventional Radiology, only 1% of women ages 35 to 50 have heard of uterine artery embolization to treat fibroids.

Another problem with many of the alternatives is that it’s hard to predict who will be helped in the long term and who will still end up needing a hysterectomy, Steiner notes. More studies are needed on the alternative methods to examine their long-term benefits.

“Emotionally, what drives women to hysterectomy is the possibility of facing another surgery if the alternative doesn’t work,” Dionne said. “With a hysterectomy it’s a done deal. The problem is taken care of.”

But most experts agree that too many women aren’t offered a choice between hysterectomy and alternatives. Dionne’s organization, which has a Web site at www.nuff.org, is working on a project to refer women to doctors who agree to explain all the options.

“I don’t think the numbers on hysterectomy are going to change unless patients band together and drive it,” she said. “The whole mind-set has to change. Somewhere between patient demand and physician training, it’s got to change.”

The study, published last month in the journal Obstetrics & Gynecology, did find that more doctors are using a less severe method to perform hysterectomy. Laparoscopically assisted vaginal hysterectomy, in which the uterus is removed through the vagina with the aid of viewing instruments inserted in the abdomen, now accounts for 9.9% of all hysterectomies--up from 0.3% in 1990.

Still, 63% of hysterectomies are still performed using a large abdominal incision, while the number of surgeries performed through the vagina, called vaginal hysterectomy, remained unchanged at about 23%. Any type of vaginal hysterectomy usually involves a shorter hospital stay, lower complication rate and faster recovery time than abdominal hysterectomy, Steiner said.

“Vaginal hysterectomy clearly has been shown to have advantages to women,” she said. “It’s good we did see more vaginal hysterectomy overall. But we still don’t do it as much as other countries.”

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Treatment Options

Here are the primary treatment options for women considering hysterectomy, the conditions for which each is used, and the associated risks and considerations.

Hysterectomy (surgery to remove uterus through abdominal incision): Used to treat uterine cancer, fibroids, menstrual disorders, endometriosis, uterine prolapse; resolves problem in most cases, but has the risks associated with major surgery; eliminates childbearing potential and can cause long-term problems with bladder, bowel and sexual function.

Vaginal hysterectomy (surgery to remove uterus through vagina): Used to treat same conditions as above, except for endometriosis and when fibroids are large; resolves problem in most cases, but eliminates childbearing potential; can cause long-term problems with bladder, bowel and sexual function.

Laparoscopically assisted vaginal hysterectomy (surgery to remove uterus through vagina with laparoscope): Treats same conditions as traditional hysterectomy, except when tumors are large or pelvic adhesions are present; resolves problem in most cases, but eliminates childbearing potential; can cause long-term problems with bladder, bowel and sexual function.

Myomectomy (surgery to remove fibroid tumors): Can be done with abdominal incisions or laparoscopy or through cervix; preserves fertility; can be major surgery depending on method, and fibroids can recur. Only for selected patients.

Endometrial ablation (procedure to remove lining of uterus): Treats abnormal bleeding with freezing, heat or electrical current that destroys tissue; is minimally invasive but may not resolve problems. Only for selected patients, including those who have not reached menopause and whose childbearing is completed.

Uterine artery embolization (procedure to cut off blood supply to fibroids): Is minimally invasive and preserves childbearing potential, but may not resolve problem; risks include infection and other complications. Only for selected patients.

Medication (depending on the condition--hormones, oral contraceptives, nonsteroidal anti-inflammatory drugs and gonadotropin-releasing hormone agonists): Treats fibroids, menstrual disorders, endometriosis; is the most conservative treatment option and preserves childbearing potential; may take time, and side effects possible; may not resolve problem. Only for selected patients.

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Sources: Mayo Clinic; FDA Consumer magazine (Nov.-Dec. 2001)