When does hysterectomy go too far?
Even as doctors and women’s advocates increasingly question the need for many of the nation’s hysterectomies, researchers have found that the procedure may be more dangerous than was thought.
Not only does the routine removal of the ovaries during a hysterectomy have no clear health benefit, they say, it actually raises the risk of death from heart disease and hip fracture.
“There never was any good evidence that taking out ovaries was a good idea, yet doctors did it anyway,” said Judy Norsigian, director of Our Bodies, Ourselves, a nonprofit women’s health advocacy group in Boston.
Healthy ovaries are removed in more than half of all uterus-removal surgeries, or hysterectomies, in the U.S. The step is taken to prevent ovarian cancer, despite the fact that ovarian cancer, though often deadly, is rare.
A woman is 25 times more likely to die of heart disease, said Dr. William H. Parker, a clinical professor of gynecology at UCLA and lead author of the study, published in the August issue of the journal Obstetrics & Gynecology.
Ovaries are important. Even well past menopause, they pump out some estrogen and lots of testosterone and androstenedione, from which muscle and fat cells make estrogen. Without these hormones, the risk of heart disease and bone thinning that leads to osteoporosis and hip fracture go up.
But there’s something even more alarming here: Many, perhaps even most, of the 615,000 hysterectomies performed every year may be unnecessary.
Obviously, if a woman has uterine cancer, it makes sense to remove the uterus. Yet more than 90% of hysterectomies in the U.S. are not done because of cancer, but because a woman has fibroids, endometriosis, abnormal bleeding or a prolapsed or fallen uterus -- all conditions for which less drastic surgery or nonsurgical treatments are available.
“Women are not told enough about the downsides of hysterectomy and the alternatives so they can make a truly informed decision,” said Dr. Mitchell Levine, a Cambridge, Mass., gynecologist.
The rate of hysterectomies in the U.S. dipped in 2003, to 41.7 per 10,000 women, down from 45.7 the year before, according to the American College of Obstetricians and Gynecologists. But American women are twice as likely as British women to have a hysterectomy, Parker said, and four times as likely as Swedish women. Why? It’s probably not money, he said, because alternative procedures are reimbursed at roughly the same rate.
“It’s cultural,” Parker said. “It’s the way doctors have been taught and what women expect.”
“We certainly do more hysterectomies than other countries -- it’s the way we’ve been trained,” said Dr. Jonathan Niloff, a gynecologic surgeon at Beth Israel Deaconess Medical Center in Boston. But a hysterectomy may make sense, he said, if, for example, a woman has a suspicious mass on an ovary and is past childbearing years. Taking out both ovaries and the uterus all at once may be better than removing only the suspicious mass, finding out that it’s cancerous and then having to go back for a second operation.
Although many women report no decrease in sexual satisfaction after a hysterectomy, others do, because uterine contractions can be part of orgasm, said Nora W. Coffey, founder and president of the Hysterectomy Educational Resources and Services, or HERS, Foundation.
In addition to removing healthy ovaries, American surgeons also routinely remove a healthy cervix during a hysterectomy, though cervical cancer is even more rare than ovarian cancer and can be detected easily with regular Pap smears.
One recent study found no difference in sexual sensation whether the cervix was removed or not, but loss of sensation is a potential risk, given that during cervix removal, nerves to the external genitalia, including the clitoris and labia, are sometimes cut. (A Dartmouth Medical School study last year showed that millions of women are still being screened with Pap tests even though their cervices were removed during hysterectomy, and there’s no way they could have the disease the Pap detects.)
So, what should you do if you’ve been told you need a hysterectomy? Get a second opinion, preferably from a doctor open to alternatives.
“I advise any woman who is not in a life-threatening situation to see someone else besides a surgeon to explore nonsurgical options first,” said Cindy Pearson, executive director of the Washington, D.C.-based National Women’s Health Network, a health advocacy group.
If fibroids, benign growths in the uterus, are the problem, a woman can try managing the pain and waiting until menopause, when they may disappear on their own.
“Although many of my colleagues would disagree, I believe it is almost never necessary to do a hysterectomy for fibroids,” said Levine.
If fibroid surgery is necessary, consider a myomectomy, surgical removal of just the fibroids, not the uterus. Not everyone is a good candidate, though, because if a woman has many fibroids it can be difficult to get them all, said Dr. John Griffith, director of the Fibroid Center at Johns Hopkins.
Uterine artery embolization, in which tiny plastic pellets are inserted into the blood vessels that supply the uterus, to cut off blood supply, is also an option -- though if uterine tissue itself is destroyed, not just the fibroids, a woman might lose fertility.
Laparoscopic surgery done through a keyhole incision in the abdomen is an option if there is a mass on an ovary that may or may not be cancer. This minimally invasive procedure can also be used to treat endometriosis, a growth of uterine-like tissue outside the womb that can be extremely painful.
For heavy bleeding due to problems other than fibroids, doctors can use ablation to destroy the uterine lining with hot water, radio frequency waves or electric current.
For a prolapsed uterus, surgeons can put in stitches to secure the uterus in the pelvis.
Finally, in conversations with doctors, ask them to be explicit, and careful, with their language. Removal of the ovaries is called “oophorectomy,” but an equally valid word is “castration,” which packs more emotional punch and may tip the decision in a different direction. When a doctor calls a fibroid a “tumor,” remember that “tumor” can mean benign or cancerous.
And, if the doctor wants to remove the ovaries, ask about the personal risks and benefits.
