Hysterectomy

Hysterectomy means surgical removal of the uterus. It is the most frequently performed major surgical procedure in gynecology. Hysterectomy came into widespread use about hundred years ago.

Last year, in Palliser Health Region, 159 hysterectomies were done, 50 vaginal and 109 abdominal.

In Canada, in 1998-99, 462 hysterectomies were done per 100,000 women over the age of 20. This rate varies per province from a low of 434 in British Columbia to a high of 750 in Newfoundland. Within each province, the rates fluctuate significantly by region as well, says Health Canada statistics.

The rates also fluctuate among different Western countries. For example, 37 per cent of women in the United States have had hysterectomy by the age of 60, compared to 20 per cent of women in the United Kingdom.

This raises several questions:
-Why are so many hysterectomies performed?
-Why do the rates vary so much?
-What are the outcomes, and do outcomes differ among different types of hysterectomy?

Answers to these questions are discussed in the October 24th editorial in the New England Journal of Medicine (NEJM).

In 1880, death rate due to abdominal hysterectomy was 70 per cent. In 1930, it was three per cent. Now it is less than 0.1 per cent. This has made it safer to operate on women with benign and malignant gynecological conditions. Thus more women benefit from the procedure.

Most common indication for hysterectomy is to improve a woman’s quality of life rather than cure life-threatening conditions, says the NEJM editorial.

The majority (85-90 per cent) of hysterectomies are done for fibroids, endometriosis or uterine prolapse. And their symptoms are:
-Heavy or irregular uterine bleeding
-Pelvic pain
-Pelvic pressure

There are several reasons why rates of hysterectomies vary from country to country, province to province and from region to region. For example, application of drug therapy and minimally invasive surgical techniques are available to treat the conditions for which hysterectomy may be performed, says the editorial.

However, the success of such methods of treatment are not always uniform and without side-effects. Some women are desirous of keeping the uterus and others want relief from hysterectomy. And a treating physician’s preference becomes an important factor in deciding whether hysterectomy should be done or not. All these factors make rates of hysterectomy variable.

The editorial says that there is no universal agreement with respect to strict criteria for hysterectomy, and treatment is currently tailored to individual patients. Studies have shown that 96 per cent of women who had hysterectomy for severe pelvic pain had complete resolution of their symptoms.

Currently there are three ways of doing hysterectomy: vaginal, abdominal and laparoscopic. This may be total (including the cervix), or subtotal (cervix is preserved), and with or without ovaries.

In Canada, in 1999-2000, 32 per cent of hysterectomies were vaginal, the rest were abdominal and laparoscopic.

In U.S., between 1990-97, 65 per cent of hysterectomies were total abdominal, 23 per cent total vaginal, 10 per cent total laparoscopic, and two per cent subtotal abdominal or laparoscopic. The NEJM editorial says that it is not clear whether all types of hysterectomy result in similar outcomes.

However, hysterectomy, whether total or subtotal, has beneficial effects on urinary tract symptoms like stress incontinence, urgency, frequency, and voiding at night. And it does not cause deterioration in sexual function.

Over the last 100 years, hysterectomy has helped many women improve their life style. It will continue to do so until other treatments are developed that provide similar results, says the editorial.

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