Hysterectomies—Frequently Performed But Often Unnecessary

Hysterectomy, the second most frequent major operation performed on women in the United States, has long been criticized as being over performed, especially for benign conditions. In the late sixties, the women's health movement tried to bring national focus to this issue, but still today, some experts say, most of the 600,000 hysterectomies performed annually in this country may be unnecessary.

Some hysterectomies are performed to treat cancers, but benign conditions are the indications for 90% of the procedures each year. And uterine fibroids account for up to 50% of these.

Hysterectomy rates had declined in the eighties, according to the CDC. But a greater use of ultrasound in identifying fibroids—the most common diagnosis for the procedure—led to a significant rise in rates from 1994 to 1998. A very recently published study gives some reason for optimism. Published online in the American Journal of Obstetrics and Gynecology (November 5), the study looked at hysterectomies performed in hospitals as inpatient procedures from 2000 to 2004. It found that rates have been decreasing slightly, to 5.1 per 1000 in 2004 from 5.4 in 2000, with a corresponding decline in fibroids as an indication.

According to Dr. Mitchell Levine, a Cambridge, Massachusetts, ob/gyn, “it is never necessary to have a hysterectomy for fibroids.” Other doctors, also concerned about the high rate, are less categorical. Dr. Michael S. Broder, an ob/gyn who teaches at UCLA’s school of medicine, says hysterectomy would be an appropriate recommendation for fibroids “after other treatments have been tried and failed.” Many women who consult Levine for a second opinion after being advised to have the procedure don’t need surgery at all, he says. Or if the fibroids are causing problems such as bleeding, pain and/or pressure on the kidneys, the fibroids can be removed but the uterus can be preserved. For abnormal bleeding not caused by fibroids, another common indication to have this procedure, Levine says that it would depend on the source of the bleeding. He would recommend birth control pills if there were a hormonal imbalance, or possibly an endometrial ablation, in which the lining of the uterus is removed.

Although “tradition has it that the classic treatment for fibroids is hysterectomy,” Levine boldly estimates that "for probably well over 90% of hysterectomies there would be another alternative." Amy Allina, program director of the National Women's Health Network (NWHN), adds that there is a "lack of respect for women's bodies." Often practitioners claim that it is a "breeding ground for disease." Broder points out that "medicine is a conservative field . Change happens slowly." That "hysterectomy works very well is well established, and for fibroids it is a guarantee that it won't recur," he adds.

“The problem is that doctors often don't recognize the importance in keeping the uterus,” says Levine. Its removal can diminish orgasm and affect hormonal functions. As a result, hysterectomy can have repercussions for the woman's personality and energy level.

Also, the removal of the uterus compromises the blood supply to the ovaries, causing them sometimes to fail, even if they are not removed. Removal of the ovaries, performed concomitantly about half the time to prevent ovarian cancer, often “causes a profound change for women, more than a normal menopause,” says Levine. “For even post-menopausally, ovaries can produce hormones.” Dr. Broder is currently working on a study, to be completed by the end of 2007, which takes 30 years of data from the Nurses Health Study, begun in the mid seventies to 2004, examining the effects of removing the ovaries vs. keeping them. Broder said that women whose ovaries are removed are more prone to heart disease and osteoporosis, and these risks are greater than that of contracting ovarian cancer in women who retain them.

Among other consequences of hysterectomy, Allina mentions that women can experience urinary problems. Also, if the cervix is removed at the same time, she adds, there can be a loss in sexual sensation. Another effect often cited is difficulty in having bowel movements. Some studies have indicated that there are heart problems associated with hysterectomy, but both Levine and Broder agree that this is an area that needs more research.

Dr. Ernst Bartsich, an ob/gyn affiliated with New York Presbyterian/Weill Cornell Medical Center in New York City, worries that women often never hear about alternatives to hysterectomy. He hears women say that their mothers and other relatives got theirs at specific ages, as if it is a rite of passage. As one who teaches myomectomy techniques—removing the fibroids while leaving the uterus intact—he is emphatic that it need not be the case.

According to Allina, alternative procedures are not offered because "health care providers are less likely to recommend them if not trained in those procedures." One technique, uterine fibroid embolization, is performed by interventional radiologists, only sometimes in concert with gynecologists. The procedure is usually not covered by insurance. Broder says coverage of myomectomies varies from place to place but the procedure is generally reimbursed at rates lower than hysterectomies.

Responding to such obvious needs for further research and education, Senator Barbara Mikulski (D-MD) and Congresswoman Stephanie Tubbs Jones (D-OH) reintroduced a bill in May that would double the current allocation for fibroid research to 30 million a year for five years. Originally introduced in 2001, the bill currently has been referred to committee in both the Senate and the House. Tubbs Jones spokeswoman Nicole Y. Williams says that in order to bring the bill to the floor for a vote, it would need 218 co-sponsors. Presently, there are 12. "Most of the members are men and we have to appeal to them in a way that hits home,” says Williams. “It affects their mothers, and daughters, and, disproportionately, minority women.” African American women are more likely to have fibroids. Williams cites other immediate priorities this year and expects to "pick up the pace in 2008." The environment in Congress is “highly politicized and polarized,” agrees Amy Allina. "It's not a great time to get a small bill through."

In the meanwhile, Allina stresses that women who are facing these problems should become informed and active decision-makers in the process. They need to use the resources available, such as NWHN fact sheets on fibroids and hysterectomy posted on its website. Regarding hysterectomy for fibroids, she says, "there is no reason not to try to avoid it."

Removing the Fibroid, Preserving the Uterus

Getting advice on alternative treatments for fibroids can be difficult. It can also be hard to find a doctor who will go along with a treatment option once a woman has decided not to have a hysterectomy. Just a few months ago, it took a relative of mine four attempts to find a doctor who would offer a myomectomy, and this was in New York—the state with the lowest reported rate of hysterectomies.

In addition to myomectomy, alternative treatment options for fibroids include wait and watch (since fibroids tend to shrink in menopause), hormones (to reduce heavy bleeding), and shrinking methods using drugs such as Lupron, although it can bring on menopausal symptoms, which subside after the medication is stopped. Sometimes used in combination with surgery, Lupron can alter the consistency of the fibroids, making them soft and more difficult to remove. Studies of mifepristone (RU-486) suggest that it may be a useful substitute for Lupron for shrinking fibroids, but the government, intent on restricting the drug’s use for abortion, has set strict limits so far on researching its potential.

Additional techniques include uterine fibroid embolization, myolysis, and MRI guided focused ultrasound surgery (a procedure in very early stages of development, and therefore not recommended by Dr. Broder).

If the symptoms significantly affect the women's quality of life, myomectomy is an option that can preserve a woman’s fertility. It has an 80 to 90% rate of relief of symptoms, according to Broder. In 10% of the patients the fibroids will recur. A frequent criticism of the abdominal myomectomy, in which an incision is made across the abdomen, is that it has the potential for excessive bleeding. Dr. Bartsich says that his method minimizes bleeding. He uses a machine to retrieve any blood lost and retransfuse it to the patient, eliminating the need for blood transfusions. The size and location of the fibroids determine whether abdominal myomectomy is required, or whether other, less invasive procedures will work.

Uterine fibroid embolization is a less invasive technique in which the artery feeding the fibroid is filled with pellets, thus depriving it of a blood supply and causing it to wither. According to Broder, it has a higher recurrence rate and there’s an added risk of ovary failure, as the artery feeding the fibroid can also be a blood supply to the ovary. The uterus itself might be affected, causing impairment to sexual functioning, as well as possible conception problems or uterine rupture during a term pregnancy. Under investigation, says Broder, is a blood flow mapping technique that may protect the ovaries.

In myolysis, used for small fibroids but performed by few doctors in this country, an electrical current, laser, or cryoprobe (freezing) is used to shrink the fibroids. For larger fibroids, Lupron can be used to bring them down to a size (4 to 8 centimeters) where the technique can be used. Because myolysis can incur adhesions to the uterine wall, it is thus not recommended if a future pregnancy is desired.