Hysterectomy Hype and Reality

October 7, 2011

I have been involved in learning about and helping to develop alternatives to hysterectomy for many years. I have been instrumental in refining the use of the laser in an office setting to treat pre-malignant diseases of the cervix. I have treated thousands of women with the laser, many of whom would have otherwise had a more invasive treatment or hysterectomy.

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Dr. Indman, before reading anything else, I want to know what your bias regarding hysterectomy is?

I have been involved in learning about and helping to develop alternatives to hysterectomy for many years. I have been instrumental in refining the use of the laser in an office setting to treat pre-malignant diseases of the cervix. I have treated thousands of women with the laser, many of whom would have otherwise had a more invasive treatment or hysterectomy.

I introduced Nd:YAG laser endometrial ablation as an alternative to hysterectomy to Northern California in 1985, and have taught techniques of endometrial ablation, hysteroscopy, and laparoscopy, both locally and nation wide. I have also been involved in clinical research involving other alternatives to hysterectomy.

As a gynecologist in private practice, I see many patients referred by other gynecologists for hysterectomy alternatives. I have nothing to gain financially if these women decide to have a hysterectomy, as I send them back to the referring physician for the procedure. So it is to my financial disadvantage if that woman has a hysterectomy. (I also see patients who refer themselves; if a women is not referred by another gynecologist and chooses to have a hysterectomy, I will do the procedure if they would like me to.) Many times however, I am able to find less invasive alternatives for women who are told that they need a hysterectomy.

So what's your point?

It's very simple. I want to help women make the best decision possible - one that is based on knowledge and fact rather than on myth and misinformation.

How can I tell what is fact and what isn't?

That's not easy to do, and may take lots of research! For example, if I pointed out that only 5% (I'm making up a number) of women undergoing hysterectomy could play violin after the surgery, your first question would be how many could play the violin before surgery. Seems simple, but if we compared a group of nurses having hysterectomies with a group of music teachers not having surgery, it would be easy to conclude that hysterectomy impairs violin playing. Does this example sound absurd? If you were to review studies about hysterectomy, you would find that this very type of mistake was frequently made. Although you will often see results of these studies quoted, you would only realize that they are meaningless if you were go back to the original studies, or read a review paper discussing it. (I will list several excellent reviews in the "references" section.)

The best type of study is a randomized prospective study, in which subjects are matched before treatment, and then randomly selected to undergo hysterectomy or some other treatment. Obviously, this is a difficult type of study to do, but studies that evaluate subjects before as well as after treatment are still better than retrospective studies.

In addition, statements that sound logical may or may not be correct. Such statements need to be tested before being accepted as true. I'll present some of these too.

Well, are you for or against hysterectomy?

Hysterectomy is not a religion that one believes in. It is not a political position that I am for or against. It is a surgical procedure that like any other surgical procedure has both advantages and disadvantages. There are many situations in which less extensive surgery may be preferable. There also are times when a hysterectomy may be the best alternative. Each situation is unique.

Some myths, realities, questions, and interesting thoughts...

Why not have a hysterectomy?

Although improvements in medical care have shortened the time required to recover from a hysterectomy, it is still a major operation. There is a small risk of serious complications and even death. These risks need to be compared to the risks of other treatments or no treatment at all, and should be compared to other risks we take in everyday living.

There is also pain associated with major surgery. I have found that newer techniques of pain control have greatly reduced this, so most women who are otherwise in good health are able to go home the next day after a vaginal hysterectomy, and two days after an uncomplicated abdominal hysterectomy.

What are the types of hysterectomy?

There are many ways to classify hysterectomy. Many terms are used in lay articles differently than by the medical profession. For example, many people think that a "total hysterectomy" means taking out the tubes and ovaries. Wrong! It means taking out the entire uterus, with or without removing the ovaries. In the old days, surgeons couldn't safely take out the entire uterus, so they would leave the cervix. This is called a subtotal hysterectomy. Recently there has been renewed interest in leaving the cervix. A special type of hysterectomy, called a radical hysterectomy is done for certain types of cervical cancer.

In medical terms, anything to do with the ovary uses the term "oopher" and the tube is referred to as the "salpinx" (or snake). Removing both tubes and ovaries is called a bilateral (meaning both sides) salpingo-oophorectomy, or "BSO". A BSO may or may not be done with any type of hysterectomy.

The other major distinction, with multiple variations, describes how the uterus is removed. If it is removed through the vagina, the procedure is called a vaginal hysterectomy. If it is removed through an incision in the abdomen, it is called an abdominal hysterectomy. Removing the uterus with the cervix through the abdomen is called a total abdominal hysterectomy, or TAH. The ovaries may or may not be removed at the same time.

What is a "laparoscopically assisted vaginal hysterectomy" (LAVH)?

There is little debate that recovery is faster if the uterus is removed through the vagina without the need to make an abdominal incision. Some disease processes make the vaginal approach difficult or impossible. Such situations may include large ovarian cysts, extensive endometriosis, large fibroids, or unexplained pelvic pain where the gynecologists needs to get a good look at the pelvic organs. In some situations, the surgeon may be able to insert a laparoscope, (a small telescope) through the belly button and be able to see the entire pelvis. Other instruments are inserted through other tiny incisions in the abdomen. These instruments can be used to perform parts of the hysterectomy, and to allow it to be completed through the vagina. In a laparoscopic hysterectomy (or LH) the entire (or most of the) procedure is done through the laparoscope.

Why not do all hysterectomies this way?

A LAVH or LH is often less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy. If the procedure can be done vaginally, then no incisions are needed in the abdomen. There are no data showing that LAVH is superior to vaginal hysterectomy (if it can be done safely). There are situations in which I cannot tell which is the best approach until I actually can see the uterus and ovaries. It this situation it is often helpful to look with a small laparoscope, and make a decision based on what I see.

Are there still reasons to do an abdominal hysterectomy?

Given enough hours in the day, a skilled laparoscopic surgeon can probably do almost any hysterectomy through the laparoscope. The problem comes in when the time and effort required puts the patient at increased risks for complications. New instruments are aiding in the removal of large tumors, such as fibroids, through the laparoscope. Still, many times the safest route may require an incision.

In some operations, such as the removal of a gallbladder or ovarian cyst, most of the trauma and recovery is from the incision rather than from what is done inside. Recovery is much faster if these operations are done through the laparoscope. With a hysterectomy, however, much of the healing required is in the tissues around the uterus. So although recovery is faster when an incision is avoided, the difference is not as great as it is with some other operations.

Claim: Hysterectomy causes depression.

There is no question that some women are depressed after hysterectomy. Many women are also depressed before hysterectomy. The real question is "does hysterectomy cause depression?" Obviously, asking a group of women who have had a hysterectomy if they are depressed would give us no information about whether the hysterectomy caused the depression. This is a difficult problem to evaluate, and proper study design is crucial if we are to get valid information.

This topic is too large to tackle in depth in this summary, so I will quote several articles (which I will list in references). You are welcome to disagree with the statements, but please review all of the source material first. Also, I am not a psychiatrist, and will not begin to claim to be an expert in depression.

A review of outcomes of hysterectomy by Karen Carlson, M.D. in Clinical Obstetrics and Gynecology in 1997 summarized the studies on depression after hysterectomy:

Early studies claiming that hysterectomy causes depression were of poor design, and seriously flawed.

"In the past decade, however, more methodologically sound studies have established that hysterectomy for benign disorders does not cause depression and may decrease psychiatric symptoms in many women."
This is a well done review, and I highly recommend reading the article. The same physician also co-authored two excellent studies on outcomes of hysterectomy, which I recommend reading as well.

My two cents... Personally, if I knew that I was going to have horrible pain every month, or bleeding keeping me from doing what I want to do, I would be pretty depressed about it. Treatment of the problem would be expected to help the depression. What about depression from the surgery? Certainly some depression after any surgery is not uncommon, especially if the recovery limits activities. But I have found, as is supported by scientific studies, that depression before surgery is the best predictor of depression afterwards. In addition, if someone is convinced that they will be depressed after surgery, it usually is a self-fulfilling prophecy.

Hysterectomy will ruin my sex life. Orgasm will never be the same!

How would a male gynecologist begin to know anything about a woman's orgasm? Easy. In my pre-operative counseling for hysterectomy I discuss sexuality, orgasm, and hysterectomy. And I tell my patient that a year later I'm going to ask her about it. But this is not a controlled scientific study, so before telling you what I am hearing, let's look at some real data. Again, don't take my word for it. Go to the sources listed in the references. And if you like, check out their references.

First, I was amazed when I reviewed some of the early publications. Retrospective studies, with no control groups. Honestly, they proved about as much as did my "violin" example above: absolutely nothing.

Dr. Carlson also reviewed a number of studies on sexual function after hysterectomy in the above referenced article. Most interesting, perhaps, was a well done, prospective study which she co-authored: The Maine Women's Health Study (see references). In Part I a number of health related questions were evaluated before and after hysterectomy. In Part II, a comparable group of women with similar problems treated without hysterectomy were evaluated. The results are interesting. After hysterectomy 7% of woman experienced "lack of interest in sex". Of those treated without hysterectomy 6% of women had the same complaint. This is not a significant difference. "Lack of enjoyment of sex" was reported in 1% of women having hysterectomy and in no women without hysterectomy.

Another study, by L. Helstrum, concluded that the most predictive factor in postoperative sexuality was preoperative sexual activity.

What women tell me after hysterectomy: The most frequent response to the question of how sex and orgasm are a year after hysterectomy is a laugh and a big smile. Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don't have their original problem to interfere with sex. Many others report no change. Some women tell me orgasm is better and more intense after their hysterectomy (don't ask me why). A small number of women tell me they have less interest in sex, but rarely do they consider this a problem. I have heard once that orgasm was different than before. Not "bad," just different. And some women who had sexual dysfunctions before hysterectomy had sexual dysfunctions after hysterectomy.

My impression regarding depression is that infertile women who desired children, and had a hysterectomy because of a problem that caused infertility such as endometriosis, may have a hard time coping with the finality of the realization that they would never carry a child. And certainly women who have a problem with depression before surgery often still have the problem afterwards. At times however, the resolution of a problem that interfered with a woman's health and was a major focus in her life often improved emotional well-being.

Supracervical hysterectomy - should I keep my cervix?

Before surgeons learned how to safely remove the cervix (which is really the lower portion of the uterus), it was left in place during a hysterectomy. In the 1950's improvements in surgical technique and the desire to prevent cervical cancer resulted in the adoption of the routine removal of the cervix with the rest of the uterus at the time of hysterectomy. Currently there is a resurgence of interest in leaving the cervix at the time of hysterectomy. The short version: there are many arguments in favor of leaving the cervix, but very little data to support or to disprove these arguments. What are some of the arguments?

Statement: There is less risk of vaginal vault prolapse with subtotal hysterectomy (the vagina falling out). It is argued that the supports of the vagina are damaged by removal of the cervix.

Counterpoint: Uterine prolapse (the uterus falling out) is a common indication for hysterectomy. The supporting structures are frequently damaged by childbirth, and can be repaired during hysterectomy.

Fact: There are no good studies comparing vaginal prolapse with and without removing the cervix. Lot's of arguing, but no data.

Statement: Orgasm is better with the cervix left in. In 1983 Kilkku published a study showing more frequent orgasms after supracervical hysterectomy than after total hysterectomy. It is argued that the nerves in the cervix are important for orgasm.

Counterpoint: Much of this argument comes from Kilkku's 1983 study (see references). The flaws in this study were numerous. This was a retrospective study in which there was not even a baseline assessment of the subjects. It is impossible to draw any meaningful conclusions from this study.

Fact: In order to study this, it would be necessary to evaluate a group of woman planning hysterectomy, randomly leave the cervix in half of them, and then re-asses orgasm at a given time after surgery. Once again, strong opinions, little information.

Statement: If the cervix is normal then leave it in.

Counterpoint: It is easier to leave in the cervix if the uterus is removed through the abdomen, but the reverse is true for a vaginal hysterectomy. Although we have good screening methods for cervical cancer, adenocarcinoma (cancer of the glands inside of the cervix) is increasing in frequency, and can be fatal. In addition, there are now reports of having to go back and remove the cervix after a supracervical hysterectomy because of bleeding or other problems.

Fact: There is a small but definite risk of cancer in a remaining cervix, and of needing to have surgery to remove the cervix at a later time if it causes problems. The arguments about pelvic support and sexual functions have not been tested, so their validity is unknown. Hopefully there will be good prospective studies to better determine whether or not it is best to remove the cervix.

Sounds like you're for hysterectomy after all...

I'm not for or against hysterectomy. If less invasive alternatives have a reasonable chance of solving a problem, then in most cases that would be preferable. That is why I am so aggressive about promoting hysteroscopy, hysteroscopic procedures, and laparoscopic procedures when they are medically appropriate.

On the other hand, I don't want any woman to be to be afraid of hysterectomy because of myths and misinformation. Most women who have a hysterectomy do very well. On the other hand, if a less invasive alternative is available, give it serious consideration!