More than 600,000 American women this year will undergo a hysterectomy, or removal of the uterus. That rate is among the highest in the industrialized world. By age 60, one in three women in the U.S. will have had the surgery, and in more cases than not, they will also have had their ovaries and fallopian tubes removed during the procedure. Doctors have long turned to hysterectomy as a treatment for conditions that range from heavy periods to ovarian cancer, but its widespread use concerns some critics, who say it's tantamount to female castration.
So, what are women to do? The truth about the health effects of hysterectomy lies somewhere in between the extremes, and experts say the key is to educate patients on the alternatives to surgery.
In the U.S., some 10% of patients who undergo hysterectomy do so to treat cancer of the ovaries, uterus or cervix. In such cases, doctors agree that the procedure is necessary. And these patients undergo hysterectomy in its most radical form, which involves removal of the uterus, cervix, the upper part of the vagina and the lymph nodes.
But the other 90% of hysterectomy patients opt for the surgery for noncancerous, non-life-threateningand some would say unnecessaryreasons: 35% of women use it to remove fibroids (benign tumors in the uterus); another 30%, to do away with abnormally heavy bleeding during menstruation. Other common reasons for hysterectomy include endometriosis, or growth of tissue outside the uterus, and pelvic pain. Today, twice as many women in their 20s and 30s undergo hysterectomy as do women in their 50s and 60s.
Aside from cancer, "there's nothing in gynecology that has one treatment," says Dr. William Parker, chair of the obstetrics and gynecology department at Saint John's Hospital and Health Center in Santa Monica, Calif., and author of A Gynecologist's Second Opinion. "If you're only getting one option, it's likely that your doctor doesn't know how to do the others."
Take fibroids, for instance. Parker challenges the common misconception that fibroids can often become cancerous; the actual incidence of cancer cases in women with fibroids is very rare, less than 1 in 1,000. According to Parker, patients should treat fibroids by communicating with their doctor and monitoring how the fibroids make them feelwhether they cause pain, bloating or heavy menstrual bleeding and whether they affect mood and energy levels. For patients who choose to remove fibroids, there are alternatives to hysterectomy: laparoscopic myomectomy eliminates fibroids through half-inch incisions made in the abdominal wall. In fibroid embolization, an interventional radiologist injects tiny polyvinyl alcohol particles, like miniature Stryofoam balls, into the uterine arteries to stop the flow of blood to the uterus and keep fibroids from growing.
To treat heavy menstrual bleeding, patients can use an interuterine device (IUD) coated with the hormone levonorgestrel, a type of progesterone. One study of Finnish women showed that two-thirds of those who used IUDs canceled their hysterectomy due to significantly reduced or stopped bleeding. The IUD has also helped hysterectomy rates fall in the U.K. to one-third of what they were a decade ago.
And for most cases of endometriosis, Parker says, women can be treated with medication or laparoscopic procedures. Given these alternatives, hysterectomy should be the last resort, Parker says, not the first option.
Rick Schweikert, program director of the HERS Foundation, a nonprofit organization that educates women about hysterectomy, says he would like to see the surgery go the way of tonsillectomyeffectively phasing it out. HERS compares the procedure to castration and says its many adverse health effects far outweigh any benefits. A recent Foundation survey of women found that those with hysterectomy reported irritability, diminished sexual desire, fatigue and lost genital sensation. Other risks of the surgery include damage to the bladder and bowels. HERS says there are also economic reasons to curb the use of hysterectomy and estimates that $17 billion would be saved annually if doctors stopped performing the procedure unnecessarily.
In an August 2005 study in Obstetrics & Gynecology, Parker found that hysterectomy with removal of the ovaries increased women's risk of dying from heart disease. More recent studies also support the idea that leaving the ovaries intact benefits women's long-term health because ovaries continue to release significant amounts of the necessary hormones estrogen and progesterone after menopause. Still, physicians have not seen the expected decrease in the number of hysterectomies, and rates of oophorectomy are climbing. The reasons: Parker says that doctors have not learned many of the new alternative techniques, which can be difficult to master, and insurance companies continue to pay out more for hysterectomies than for alternative operations that preserve the uterus and ovaries.
Dr. Mary Jane Minkin, an OB/GYN and clinical professor of obstetrics and gynecology at Yale University School of Medicine, thinks that describing hysterectomy as a form of castration is as alarmist as it is inaccurate. Many patients benefit from hysterectomy. But she says the issue isn't black and white: "It all boils down to individualization of care." Minkin says women need to understand their particular condition, the risks they face in choosing hysterectomy and the treatment options available to them. Parker agrees. "It's really hard to change doctors' behavior," he says. "I'm trying to change women. They have a vested interest."