October 4, 2019 Jonathan 0Comment

Till 1978, hysterectomy – the surgical removal of the womb – was the commonest major operation performed on women (Today, it is the second most common, after caesarean section).

Not only are the statistics alarming, but the reasons for them, too. Hysterectomies are being performed for perfectly frivolous reasons such as stopping menstrual periods, or for problems that lend themselves to far easier and safer solutions.

So, before you consider a hysterectomy, be aware of all its implications, and then explore other options before you say ‘yes’.

Last year when I found that most of my friends were wombless and period-free, I asked my long-standing gynaec, “Why don’t you operate on me to stop my tiresome periods?” after a pelvic examination, Dr. sat me down and explained how ridiculous it was to have a major operation with all its attendant risks to remove perfectly normal organs for totally frivolous reasons. Suitably chastened, I now have all my “innards” intact. And when one of my friends developed renal failure due to anaesthetic complications in a hysterectomy – which now requires dialysis tri-weekly – I thank my stars for my doctor.

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Why was I, who pride myself on my enlightenment and literacy, so native? Perhaps because, while the number of hysterectomies has burgeoned, the discussion of its implications has not. The whole subject is still shrouded in a haze of prudery and misapprehensions, or even positive euphoria that birth control, child-bearing and menstruation will be things of the past.

Hysterectomy is the surgical removal of the womb or uterus, following which a woman will no longer be able to become pregnant and bear a child, or have menstrual periods. However, unless both ovaries are also removed, menopause will not occur until such time as would happen naturally – even though menstrual periods will stop, the ovaries will continue to release estrogen in a cyclic fashion.

What are the reasons for the high rate of hysterectomies being performed? While a hysterectomy is a life-saving measure in certain diseases or obstetrical complications, a general survey reveal that far too many hysterectomies are being carried out for flippant reasons – such as stopping the ‘nuisance’ of periods; several more are being carried out in cases where other, less drastic treatment options are available – e.g. in vaginal infections. Gynaecologist says, “Considerable concern has been expressed in reputed medical circles that hysterectomies are over-used and are quite often done without proper indications. Studies suggest that the increase in the number of hysterectomies is due to its liberal use as a prophylaxis (preventive measure) against uterine cancer, as a method of sterilization and as a means of treating mild symptoms of pelvic relaxation and menopausal bleeding.”

The womb is a very important organ. In addition to child-bearing it plays a role in hormone production, is supported by surrounding structures and helps a woman achieve orgasm. Can you get rid of it without possible risks and consequences to your future health – both bodily and emotional?

The surgical approach is appealing to both, the patient and the physician. The problem is attacked definitely. There will be a quick answer, and most probably a highly effective solution.

Also, the relief that many women experience after hysterectomy can be so immense that it literally gives them a new lease on life. After being anxious about their bodies, exhausted from constant pain and apprehensive of sudden, flooding periods, they graduate to new activities and pleasures. New studies in the American Journal of Psychiatry show that women who are depressed before a hysterectomy tend to recover from both anxiety and depression afterwards, provided the operation was unrelated to cancer.

However, these kind of positive results do not mean that a hysterectomy is altogether harmless – any surgical procedure carries its risks and complications. And the bottomline where any surgery is concerned is that if you can do without it, you’re better off without it.

Which brings us back to the question: Do you really need that hysterectomy? Let’s look at the problems. You have a condition that can be properly and ethically handled either surgically or non-surgically. In the second case, you may be made nervous and anxious by such non-definite care. The problem will not be solved immediately and demands patience from both you and your doctor. But it could be a safer, less costly – and therefore better – alternative. The percentage of cases in which needless surgery is performed is impossible to pin down. But it is not small.

We have Mrs. D, 42, who went to her gynaecologist for a routine pelvic check-up. She had no complaints. After examining her, the doctor informed her that the small fibroid tumour that he had been watching for the past few years had grown considerably and there was now a cyst in her left ovary. He recommended a radical hysterectomy. Frightened, Mrs. D sought another opinion. The consultant found a minimally-enlarged fibroid and no ovarian cyst. She recommended against surgery.

Mrs. E, 39, had vague lower abdominal pains. Her doctor ordered a battery of tests to examine her gall bladder, stomach, intestines and pelvis, which uncovered no abnormality. But he informed her that a physical pelvic exam had revealed an ovarian cyst and that she should have a hysterectomy because, once the ovaries were removed, the uterus was useless. The second-opinion consultant found nothing whatsoever amiss.

Both Mrs. D and Mrs. E did not opt for surgery.

On the other hand, Mrs. A, 33, was being treated for recurrent vaginal infections. She wanted no more children and had been on the pill for four years. She had been advised that a hysterectomy was the correct way to eliminate the infections and end her fertility. She had the operation. Her symptoms disappeared and she was delighted that her periods had stopped.

What could have been done instead in the last case? The doctor could have cleared up the infection by a simple cauterization carried out in his clinic. He could have obtained vaginal smears and treated her with appropriate medication. He could have stopped the birth control pills which sometimes causes vaginal infections and advised alternative mechanical devices, or tubal ligation.

Medical attitudes towards hysterectomy rage between startling extremes. There are physicians who feel that a uterus is useless once a woman has had all the children she wants, and that its removal has no adverse health consequences. There are those who consider it butchering (the word for the removal of the ovaries is ‘castration’), although it is warranted for cancer or a life-threatening disorder.

Again, medical attitudes differ dramatically depending on the age of the woman undergoing hysterectomy. Everyone feels sorry for the young, perhaps childless woman who’s had her womb removed; her doctors rally round to counsel and advise. For middle-aged women, beyond child-bearing age or those who’ve already had their families, there’s not much consideration. They’re fobbed off with statements like, “You’re better off without it,” “Nothing but trouble and no real use, is it?”

The uterus is also a favourite target for a small number of unscrupulous doctors, perhaps driven by ignorance, impatience or indifference, who use terror tactics to persuade women to have high-priced, unnecessary surgery, saying, “It looks bad… who knows what it will cause in the future… we can’t tell when it will become malignant.”

Most of women think of cancer when they hear the word, ‘hysterectomy’. Would you have the courage to walk away from that? However, in reality, the incidence of cancer of the womb is relatively low – 1 in 1000 post-menopausal women a year in the general population. Researchers at Stanford University have also found that, when performed on healthy women, the risks of the operation outweigh the possible gain in cancer prevention, when one considers non-fatal complications.

According to a Gynaecologist, “Many gynaecologists remove the ovaries because of the risk of ovarian cancer. But the ovaries are hidden in the pelvis and it is difficult to make a critical assessment on pelvic examination. Ovarian cancer is accompanied by few warning signs and, in 60 per cent cases, so well disguised that it has spread beyond a reasonably curable stage at the time of detection. In pre-menopausal women, the hormonal function of the ovaries is more important than the 0.1 per cent risk of subsequent cancer; it is up to the gynaecologists to assure the patient of this. However, in menopausal women, it is considered better to remove the ovaries as the physical and psychological traumas are less acute than the risk of cancer.”

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THE AFTERMATH

Gynaecologist continues: “We gynaecologists must remind ourselves that what, for us, is an ordinary daily event is, for the patient, a unique ordeal that challenges the core of her identity because of the removal of a part that is emotionally synonymous with her fertility.”

The most dramatic consequences occur when the ovaries are removed, especially when unindicated, depriving a woman of her natural supply of estrogen. They include:

  • Instant menopause, including hot flashes and vaginal dryness.
  • A feeling of nothingness inside.
  • A vastly increased risk of bone-mass loss, often leading to osteoporosis (brittle bones)
  • Depression, rage, bitterness tinged with anxiety about ageing.
  • Prolapse or falling of the supporting organs, leading to increasing blabber and bowel complaints.
  • An increased risk of heart disease.
  • Fatigue, insomnia, urinary tract problems, joint pain, headaches and dizziness.
  • A lack of sexual arousal, interest and desire, leading to the termination of sexual identity and, possibly, the break-up of a relationship.
  • Post-operative fever, infection, bleeding, continuous pelvic pain and even death. One in ten may need a blood transfusion, a disturbing prospect in this age of Hepatitis B and AIDS.
  • A painful scar or granulations which require scraping or cauterization.

Estrogen replacement curbs many of the after-effects of a hysterectomy. But not all women can tolerate it and it is reported to increase the risk of breast cancer and gall bladder disease.

So, when is a hysterectomy imperative/advisable?

“The indications for any surgical procedure fall into three broad categories – to save life, to relieve suffering, to correct significant deformity,” explains Gynaecologist.

A hysterectomy should be performed when the preservation of the uterus continues to be a greater threat to the patient’s life than the risks of the operation, or when there are disabling symptoms for which there are not equally successful treatments.

The indications would include:

  • Cancer of the cervix, uterus, ovaries or fallopian tubes.
  • Diseases of the tubes and ovaries, where the uterus is not primarily involved but must be removed because of the closeness to the diseased area. Instances of such diseases include chronic infection of the tubes or severe pelvic inflammatory disease.
  • Involvement of the uterus in non-gynaecological diseases like cancer of the colon or a severe abscess in the uterine wall.
  • An obstetrical catastrophe such as uncontrollable bleeding after delivery, uterine rupture or massive infection.

Since most hysterectomies are recommended for conditions that are not life-threatening, you almost always have time to explore alternatives. Also, check if your ovaries can be saved.

YOU HAVE A CHOICE IN

Abnormal bleeding, that is, persistent vaginal bleeding not related to normal menstruation or any known disease. You can opt for a hysterectomy (if you are elderly), or a D and C, or a course of the hormone progesterone.

There’s also Hysteroscopic Re-section, a type of surgery that strips away the top layer of the uterine lining using a resectoscope vaginally without damaging healthy tissue underneath. It’s done under anaesthesia, but there’s no incision and it can be performed as an out-patient procedure. However, it causes sterility. And still its risks haven’t been fully assessed.

Sterilization. Hysterectomy is only indicated for severely retarded girls, after they have reached puberty. Otherwise, tubal ligation is cheaper and safer.

Endometriosis. This is a non-cancerous condition in which the lining of the womb attaches itself to other areas, across the ovaries and inside the abdominal cavity. There it undergoes the same changes as the womb lining, cued in by hormonal changes. But this means that your menstrual blood cannot escape from the ovaries – it is trapped and forms blood cysts. Endometriosis can cause painful sexual intercourse, and affects women who have postponed or foregone childbearing.

You can opt for a hysterectomy which will not always eliminate the symptoms, or for hormone therapy or drugs like Danazol. Unfortunately these drugs may trigger off hot flashes and other menopausal symptoms. The effects are temporary and will disappear when treatment is discontinued. The disease can be reduced or eliminated and may or may not recur.

Laser surgery to remove patches of endometrial tissue can be done through a laparoscope – an instrument inserted through a small incision in the abdomen – and can relieve symptoms. This is done in a very few cancer hospitals.

Prolapse of the womb. This condition stems from a loss of muscular support for the womb and occurs commonly among women who have had many children – two-thirds of these women are under 55. In mild cases, the cervix extends part way down the vagina. In more severe cases, the womb can reach the vaginal opening or even protrude outside it. Although most women have their wombs located considerably lower after childbirth, very few have resulting symptoms. Others suffer from considerable discomfort in the form of urinary incontinence, feeling of pressure or heaviness.

A symptomless, prolapsed womb does not require surgery. Quite often, further descent would not occur.

If you have a constant urge to urinate, you can be treated with medication. Exercising the vaginal and pelvic muscles at the first signs of prolapse may prevent worsening of the condition. One of the best exercises for these muscles is to stop your urine mid-flow and hold it for 10 seconds before releasing.

If you have severe discomfort from the prolapse or major stress incontinence – in which urine leaks out when you cough, sneeze, laugh hard, strain in the toilet, lift a heavy weight, exercise or even just walk, you may need a hysterectomy.

Or, a vaginal pessary (usually a ring-shaped device) can be inserted to hold the fallen womb in place. You have to return every few months to the doctor to have it cleaned and re-inserted. The disadvantage of the pessary is that it can interfere with intercourse and may cause an irritating discharge with an unpleasant odour.

If you are post-menopausal, estrogen replacement may help build up the genital muscle strength and slow down the rate of prolapse.

Fibroids. These are masses of tissue growing on or in the walls of the womb. About one-third of women develop fibroids and the vast majority are symptomless. They are almost always non-cancerous.

When no symptoms exist and fibroids are discovered during a pelvic exam, current medical practice is to leave them alone unless they cause profuse bleeding, large enough to cause bowel or urinary problems, are excessively painful or are growing rapidly (confirm this with sonography – your womb should be about the size of a 12-week pregnancy).

If profuse bleeding is the problem, have an iron-rich diet and check for anaemia. An endometrial biopsy or D and C should be done.

If there is no malignancy and you are approaching menopause, the fibroids may be shrunk by a hormonal treatment which indices a temporary menopause, including hot flashes. This is short-term treatment and the fibroids may grow again when it is discontinued.

If you still want to have children, you can undergo an operation called myomectomy which removes the fibroids but leaves the uterus, ovaries and tubes intact. However, this is a more complicated operation than a hysterectomy and is not a fool-proof solution – there’s a 50 per cent chance that new crop of fibroids will develop, although they may not be large enough to warrant fresh surgery.

Laparoscopy, is another option.

Hysteroscopic re-section done vaginally with a resectoscope can be used for removing one fibroid.

Many fibroids shrink after menopause, so the problem may eventually solve itself without treatment.

HYSTERECTOMY IS TOTALLY UNNECESSARY FOR

  • Simple sterilization
  • Chronic pelvic pain in the absence of organic pelvic pathology, i.e. any indication of pelvic disease.
  • Menopausal women as an estrogen replacement therapy
  • Chronic cervicitis or inflammation of the cervix
  • White discharge
  • Painful periods
  • Pre-menstrual tension
  • A single episode of post-menopausal bleeding (this requires careful examination and curettage)
  • Abnormal vaginal or cervical pap smear
  • Mild to moderate change in pattern of cells, showing no malignancy

THE SECOND OPINION

If you wish to avoid an unnecessary hysterectomy, become medically sophisticated. Make use of a second opinion especially if you are under forty. This should be sought in an area where there is no mutual relationship between the first and second consultants.

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