Hysterectomies

I recently watched a news report about the number of women who are having hysterectomies. According to the announcers, despite alternative treatments for gynecologic disorders, the number of hysterectomies performed is increasing and most are not necessary. A physician states that hysterectomy causes women’s sex life to "go to hell in a hand basket." The number of hysterectomies has increased slightly (from 42.9-44.8 per thousand women) but is this all unnecessary surgery; are all these women’s sex lives ruined? What is the truth about hysterectomies?

Hysterectomy refers to the surgical removal of the uterus and cervix. Removal of the ovaries and fallopian tubes is a separate procedure (although may be performed at the same time as a hysterectomy).A supracervical hysterectomy refers to removal of the uterus but not the cervix. It is important to understand that the reproductive hormones (estrogen, progesterone and testosterone) are mainly produced in the ovaries and not in the uterus.

Unless performed for life threatening hemorrhage or cancer, hysterectomy is an elective procedure, performed to improve the quality of life. Some indications for elective hysterectomy include uterine prolapse, incapacitating uterine bleeding, symptomatic uterine fibroids, disabling menstrual cramps, severe endometriosis and pelvic pain unresponsive to medical therapy. It is critical that before having a hysterectomy non-uterine causes for pain have been excluded and appropriate testing is done to diagnose the disorder for which hysterectomy is planned. Most importantly the woman and her physician have thoroughly reviewed alternative medical or surgical treatments for the particular condition. For example, abnormal uterine bleeding may be treated with medication or with less invasive surgery such as endometrial ablation (where only the uterine lining is removed). Uterine fibroids (benign tumors of the uterus) are one of the most common reason for hysterectomy, sometimes only the fibroid can be removed (myomectomy). If fibroids are not causing any problems they can be left alone. Gynecologists are justifiably criticized for earlier recommendations that fibroids be removed based on size alone.

Several studies have looked at the effectiveness of hysterectomy on improving quality of life. Researchers from the University of Maryland followed 1300 women for two years after their hysterectomy. They found that the majority of women reported substantial improvement in symptoms, quality of life and psychological function. This confirmed previous findings from the Maine Women’s Health Study. Of interest is that both groups of researchers found that women who were significantly depressed or had other severe emotional problems were less likely to be satisfied. Certainly there were women in both studies who had problems after their surgery or whose symptoms were not significantly improved. Other women developed physical or emotional problems that were unrelated to the surgery. These studies both emphasized the need for a comprehensive preoperative evaluation and trial of non-surgical management before resorting to hysterectomy. However, performed for appropriate medical conditions, hysterectomy will improve quality of life for the majority of women in whom it is necessary.

Sexual function after hysterectomy has also been studied. A decrease in painful intercourse and an increase in libido were noted by the researchers at the University of Maryland in their group of women who required hysterectomy. This is not to imply that removal of a healthy uterus and ovaries will improve sexual function, only that women who need a hysterectomy because of disease can generally expect improvement in sexual function. The woman they interviewed in the news show (who had significant sexual dysfunction after her surgery) had a hysterectomy for cervical cancer. This requires a much more radical surgery than a simple hysterectomy and is associated with more bladder and potentially sexual dysfunction. Her story will not apply to the majority of women who have hysterectomies for benign disease.

All gynecologists will tell you that the majority of their patients are glad they had a hysterectomy; in fact many women will say they should have had it done sooner. I have noted that women I have seen who were unhappy after hysterectomy were either unsure why they had the surgery or did not receive adequate estrogen replacement therapy if their ovaries were removed.

Women considering a hysterectomy should explore other treatment options and ask questions of their physician. However, they should be reassured that overall quality of life is improved when hysterectomy is performed for significant gynecologic pathology.