Hysterectomy is dead!
Of course this is an overstatement, but even though an exaggeration, it makes a firm point. I have been a gynaecologist for over 30 years and in that time-span, the practice of gynaecology has been transformed. It is now a great rarity to need to remove a uterus other than for malignant disease, severe endometriosis, prolapse, or enormous size. There are simply less risky, less painful ways of dealing with period problems and pelvic pain.
The statistics bear this out. In 2002, around 33,000 women per annum had total abdominal hysterectomies in the UK and by 2011 that number had fallen to 26,000. The same rate of fall has been noted in all other Western Countries, including the USA. The falling rate in total abdominal hysterectomies (with the rate of subtotal abdominal, probably for endometriosis, and vaginal, probably for prolapse, hysterectomy remaining relatively constant) has plateaued since 2009. This suggests that the remaining operations are for indications which could not be dealt with by hormonal treatments, the Mirena or equivalent IUS, endometrial ablation using one technique or another, or fibroid embolization. Hysterectomy rates in countries such as India remain controversially high.
It is not just the immediate peri- and post-operative risks, pain and time spent recovering that concern me, although experiencing a woman die of a postoperative pulmonary embolus at the age of 42 years, leaving a young family, certainly focuses the mind. The only comfort in that case was that both a Mirena and a thermal ablation had been tried and failed.
No, it is the impact on the pelvic floor which really concerns me, and which I feel gets far too little attention. I have coined an expression which is that ‘Women embark upon their surgical prolapse (and this is the important word) career’. It is a career. So when women come to see me with a prolapse of their vagina, with bladder or bowel problems, I tell them that they started their surgical prolapse career when they had their uterus out in their 40s. Of course if there was no alternative and they were chronically anaemic, then all well and good. But nowadays there are so many alternatives, and they should all be discussed according to the specific circumstances of the woman.
- Is her family complete?
- Does she need contraception?
- Is the uterus a normal size or are there significant fibroids?
- If there are fibroids can they be resected from inside the uterus or perhaps killed by embolization?
- Is pain a major part of the story?
And so on and so on.
Information and choice is what it is all about. Having said that, it is near enough impossible for non-medical people to understand ‘risk’.
“I’ve been referred for my hysterectomy” remains a not infrequent statement when a woman enters my gynaecology outpatient clinic. I feel it would be like me taking my car to the garage and saying,
“I’ve come for my new gearbox” when I have absolutely no understanding of cars.
These consultations are very difficult and not infrequently lead to a complaint that I didn’t listen to the woman, when in fact nothing could be further from the truth. I was doing my best to make her better, but minimising risk of every kind.
I often say “I am a surgeon. I like being a surgeon. I like the actual process of being in the operating theatre and doing the operation. Making the wound look nice and seeing the lady get better afterwards, and being pleased with the result. But I would never have an operation unless I absolutely had to.”
So…. hysterectomy is not dead, but (for period problems) it should certainly be a last resort.
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Dr Karen Morton is founder of Dr Morton’s – the medical helpline© – a service for busy people wanting speedy access to an experienced doctor for confidential reassurance or advice by phone or email. When needed, Dr Morton’s doctors are able to prescribe for a wide variety of medical issues and arrange for medication to be sent to the customer’s door. For more information call 012 123 123 123 www.drmortons.co.uk