Too many hysterectomies?

A new report from Canada has suggested that too many women, especially those living outside big centres, are having hysterectomies when often another, less invasive treatment would solve their medical problems.

Too often, those hysterectomies involve unnecessary removal of ovaries – a move which precipitates menopause if a woman has not yet gone through it. Too often, the hysterectomies are performed via an abdominal incision, even though vaginal hysterectomies are less risky, are easier on the patient and allow for a shorter hospital stay, the report says.

The head of the expert panel which wrote the report suggested the adherence to an old-style approach to uterine problems in the face of modern, less drastic alternatives makes her think of the old days, when doctors automatically took out the appendix – just to be on the safe side – if they were doing any abdominal surgery.

“For many of those conditions, apart from endometriosis, it’s hard to think why anybody would take out ovaries in women under 40,” said Dr. Donna Stewart, chair of women’s health issues at the University Health Network and the University of Toronto.  “And when you ask the gynecologists why they’re doing it, they say: ‘Well, you know, they’re getting on to the age when they’re not going to need them anyway.'”  But “getting on to the age” may be taking some liberties with the interpretation

of menopause, which for the average Canadian woman begins around age 52. Yet Stewart says significant numbers of women under age 40 have their ovaries removed as a matter of course when they have a hysterectomy.

“It’s pretty amazing that in women under 40 having discretionary hysterectomies that 72 per cent of them lose their ovaries,” she said.  Losing her ovaries plunges a woman into premature menopause and all that that entails – the increased risk of osteoporosis, possible heart-health problems as well as the insomnia and hot flushes that often accompany menopause.  “I think that they (doctors) partly do it because they’re worried about ovarian cancer,” Stewart said.

The figures are for Ontario only. But Stewart is doubtful practice would be much different in other parts of the country.   However, Dr. Richard Johnston is doubtful for another reason. An obstetrician-gynecologist in Orillia, Ontario, Johnston doesn’t believe the 72 per cent figure.  Doctors are trained not to remove ovaries in women under 50, unless the ovaries are involved in the underlying disease, he said.  “That just sticks out like a red light in there,” said Johnston, a past chairman of the Ontario Society of Obstetricians and Gynecologists.

Johnston also challenged the idea that too many hysterectomies are being performed, saying there is no guideline on how many women should have them. Furthermore, he insisted there is a high satisfaction level among women who undergo the operation.  “Women do check out their options with their friends and the Internet and everything else,” Johnston said. “It’s an old cliche that patients will say two years after a hysterectomy: ‘I wish I’d done that sooner.’  “So then they tell that to their friends and that has a huge impact. If Canadian women are telling their friends ‘Whatever you do, don’t do that,’ then that patient never ends up in my office. I don’t even have to talk them into or out of it. It’s a non-issue.”

The report, which was prepared for the Ontario Women’s Health Council, deals primarily with practices in Ontario. But it lists hysterectomy rates for women over 35 for the entire country.

That chart shows that Ontario’s hysterectomy rate is topped by six other provinces – Newfoundland and Labrador, New Brunswick, Saskatchewan, Prince Edward Island, Nova Scotia, Manitoba, in that order.  Quebec, Alberta and British Columbia perform fewer hysterectomies than Ontario.

The report notes that while there has been a significant decline in hysterectomy rates since 1981, the Canadian rate remains double that of countries like Britain, Sweden, the Netherlands and Norway.  In fact, 22 per cent of Canadian women aged 35 and older have had a hysterectomy – and for the majority of cases, the operation is performed for a discretionary reason. The figures suggest women with more education are less likely to undergo a hysterectomy than those without and that women living in rural or remote communities are more likely to have a hysterectomy than city-dwellers.  That may be because the shortage of doctors and specialists is more acute in non-urban settings. If women know they will have to wait an additional six months or more to see a doctor if a less invasive treatment fails, they may be more inclined to simply opt to have their uterus removed, Stewart said.  “Certainly some places we went in Northern Ontario the women said: ‘My mother had it, my sister had it, it’s time,'” she explained.  “There are some women who think that, and one of the recommendations (in the report) was that we try to promote education to dispel that idea.”

The report recommends that the Canadian Government mount an educational campaign to let women know a hysterectomy is not always the desirable option, and to also let them know that if they do opt for a hysterectomy, they should talk with their doctor about keeping their ovaries and about the method he or she plans to use.  It also suggests the fees paid to doctors for performing hysterectomies should be tiered, so that compensation for vaginal hysterectomies – which can take longer than abdominal hysterectomies to perform – is higher as an incentive.

Investigate the alternatives by talking to a homeopathic doctor or acupuncturist.

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