John Studd, DSc, MD, FRCOG
Consultant Gynaecologist, Chelsea & Westminster Hospital, London
Hysterectomy seems to be an operation welcomed by some women but dreaded by far more. Many contemporary feminists and journalists write against it and Germaine Greer regards it as "devastation" and even blames women because about 20% end up having their womb removed. The worst, she claims, are female doctors, nurses and doctor's wives who convince themselves that they are better after "this particular form of devastation". It is odd that she chooses not to believe the experience and views of these women. Perhaps it is a reaction to the feeling that men have controlled labour positions, hospital confinement and surgery on women and it is about time women had more control over this. No doubt that is why hysterectomy has become a political issue.
It is important to see the truth through the huge amount of prejudice because women have a right to treatment that relieves their symptoms. If hysterectomy produces more problems than it solves, then there is a need for other methods of treating heavy periods or fibroids. If it does dramatically improve women' lives, we need to redress the balance of this prejudice This is what the debate is all about.
There are certainly plenty of drugs, such as anti-prostaglandins, progestogens and Tranexamic acid which are sometimes helpful for heavy periods but the benefits usually only last for a short time. Most patients who complain of heavy periods do not just have excess blood loss. They also have pain. They also have premenstrual tension. They often have menstrual headaches. They often have exhaustion and long- standing cyclical depression. These cannot be helped by pills which merely (sometimes) reduce the amount of menstrual blood loss. When women read anti hysterectomy articles in the press, claiming that this operation causes depression, destruction of their sex life, or broken marriage and exhaustion for six months after the procedure, they are scared. The truth is that every single scientific paper has shown that after hysterectomy, women are less depressed, have better libido, better sexual response, less anxiety and better "general health" scores.(*) With these facts available, why is it that crusading anti-hysterectomy journalists continue scaring women with false information?
A well conducted hysterectomy, whether it is done by the abdominal route through a small scar in the bikini line or through the vagina should, with good pain relief and good surgical technique, have the woman out of bed on the first day, quite well on the second day, bored stiff on the third day and anxious to go home on the fourth day. The usual comments at the six weekly post operative visit were "I never thought it would be so simple", " I feel better than I have felt for many years" and "Why was it not done years ago" and sometimes "other problems that I have had have also improved after the operation". It is very unusual for women to feel worse after the operation than before, even as early as six weeks.
I want to stress this reality of the benefits of surgery because the alternatives which are claimed to be smaller procedures are often neither straightforward nor safe, nor do they always relieve the symptoms.
For example, during the last eight years there has been an enthusiasm for removing the endometrium (womb lining) either by laser or cutting strips with hot wire cautery or diathermy. It is not an easy procedure, has had more than its share of complications of uterine perforation, damage to the bowel, the bladder and even to the artery supplying the leg. There have been some terrible complications that all gynaecologists are aware of but still crusading journalists promote this as a good way of avoiding the dreaded hysterectomy.
Happily there is a very effective non-surgical treatment of heavy periods that has become popular over the last 5 years. This is a Mirena intrauterine device which is a contraceptive coil with progestogen in the reservoir in the stem. This stops the growth of the lining of the womb and reduces menstrual blood loss and in many cases will stop periods altogether. The coil works for at least 5 years and when it works, (and it does in 85% of cases), will remove the need for hysterectomy for the problem of heavy periods. It will not, of course, influence the problems of fibroids, PMS or pain. It is however, a wonderful new advance which has certainly reduced by personal hysterectomy rate by about 50% since I started using this device in July 1995.
Another recent technique has been embolisation of fibroids by cutting off the blood supply to the uterus produces some sort of gangrene in part of the uterus which contains a fibroid or fibroids. Recently the Daily Mail magazine gave an uncritical view of this technique which the modern up to date bright young things will perform the but old dinosaurs in gynaecology will still do a hysterectomy. Nothing could be further from the truth. The pain can be considerable for 10 to 14 days after the procedure and the reduced blood supply to the uterus and ovaries can also produce an early menopause To my mind the technique is illogical, dangerous and recently a woman has died from this "minor procedure".(**) My point of view is that hysterectomy is no longer a big operation, although it may well be an emotional challenge in a few women. It guarantees to stop bleeding, the pain, premenstrual syndrome if the ovaries are also removed and with sufficient HRT, will certainly lead to a much greater well being, less depression and greater sexuality in most cases.
Somewhere in this decision making process should be the information that 4% of women, that is about 7,000 per year in this country will die of cancer of the uterus, the cervix or the ovary. It may be wrong to labour this point but if we really want women to have an informed view about their choices (and mean it), this information should be part of the balance of pros and cons of the procedure. These deaths would be prevented in women who have had hysterectomy, with removal of ovaries and good effective safe hormone replacement therapy for many years. On the other hand, deaths following hysterectomy are now virtually unheard of.
One minor modification of the hysterectomy is to leave the cervix, a so called sub-total hysterectomy because there is some belief but little evidence that leaving the cervix is valuable for sexual function and orgasms with deep penetration. That may or may not be true but most of us are very happy to leave the cervix behind, as long as there has been repeated negative cytology tests.
The choice of whether to have a hysterectomy is the woman's not the doctors. However the medical profession owe it to the patients to ensure that they do have the correct information and do not submit themselves to fashionable less effective procedures because of bias and frankly dishonest reporting in the press. I have tried to set the record straight but perhaps I cannot claim to be totally impartial because the evidence of every study over the last 20 years is so overwhelmingly supportive of the message of the belief that a well performed hysterectomy for distressing menstrual symptoms can greatly change a woman's life for the better.
* The most recent paper, Khastgir and Studd 2001, published in the American Journal of Obstetrics and Gynaecology, Chapter 29 is a study of 200 patients who have had a hysterectomy and bilateral oophorectomy with implants of oestradiol 50 mgs and testosterone 100 mgs inserted into the wound on closure. This was repeated every six months. After 3 years there had been a long-term improvement in wellbeing, patient satisfaction, depression, anxiety, sexual response and general health scores. We have shown that the continuation rate of HRT in the form, usually of implants, after hysterectomy is 95% at 5 years and 88% at 10 years. This long continuation rate of HRT occurs quite simply because the women feel better!
** I have in the last six months received some very hostile correspondence via the internet about my criticism about fibroid embolisation. It has certainly become popular by radiologists and some of them are extremely skilled at the technique. I stand by my view expressed in the article but there is no doubt that it will find favour with women who want to avoid a hysterectomy at any cost. Perhaps the procedure will become safer and less painful in the years to come.