It can be a life-saving procedure.
Hysterectomy, or removal of the uterus, is a boon for women who would otherwise suffer excessive uterine bleeding, prolapse – when the uterus slips down into or protrudes from the vagina – or have cancer in the uterus, endometrium, cervix, ovaries and fallopian tubes.
The surgery, performed on women usually close to, or after menopause, does carry the risk of side-effects such as bleeding, infection, blood clots, lung and wound complications.
There’s also the issue of cost, and time taken to recover.
However, the procedure is largely safe and uneventful for most women.
Except when it is not done for the right reasons.
Of late, more Indian women have been getting their uterus removed before they are 40, for treatment of heavy bleeding and fibroids and cysts.
This has emerged as a critical public health issue, given the adverse effects of the surgery on women’s health and well-being.
The latest National Family Health Survey reported that about one in ten women aged 40-49 have undergone a hysterectomy. The median age for surgery was 37.
This is a notably lower age at hysterectomy than other countries, and is a full decade before the age of natural menopause.
Data analysis revealed that women with no formal education and from rural areas were among the most vulnerable, and had higher odds of undergoing hysterectomy.
Social norms around menstruation have played a big role in promoting acceptance of early hysterectomy in rural areas.
Most of these women never have access to a gynaecologist, or an opportunity to learn about their options. This raises the all-important issue of health equity and access to health care.
Higher risk of heart disease
For young women, hysterectomy can be a bane if not done in the right setting and backed up with appropriate care by a qualified provider.
Early hysterectomy, especially when done with removal of ovaries, is associated with a range of long-term effects on women’s health and well-being, including the increased risk of non-communicable diseases such as high blood pressure, high cholesterol, diabetes, and bone and joint disease.
Hysterectomy is one of the most common procedures in gynaecology and results in surgical menopause, meaning a woman will no longer have her periods.
If, however, the ovaries (responsible for the production of estrogen and progesterone hormones) are retained during surgery, she will continue to benefit from the hormones secreted by the ovary.
For many women, this benefit is substantial – estrogen protects against heart disease and bone loss.
However, emerging data suggest that removing only the uterus also results in an earlier decline in the ovarian function.
The decline in hormones is associated with effects on almost all organ systems.
In the short-term, the effects range from vasomotor symptoms such as hot flashes and night sweats, to atrophic effects such as vaginal dryness and urinary symptoms including urinary tract infections and incontinence.
Long-term effects include an increase in the risk of cardiac events, strokes, dementia and fractures.
By the time the serious effects manifest though, a woman may not even correlate her problems with the original surgery.
Other changes seen in menopause include changes in physique as well as relatively minor problems such as effects on digestion, bowel function and dry eyes.
To offset some of these effects, hormone replacement therapy (HRT) can be offered under supervision to women who have lost ovaries or ovarian function, at least until the age of 50, which is the average age of menopause.
It does not increase the risk of estrogen dependent cancers over the baseline risk which is present in all women from the estrogen present naturally in their bodies.
However, HRT might not be affordable for all women, and there’s a risk of side effects which means it may not be suitable for others.
Despite it being safe when given after evaluation by a qualified provider, HRT uptake in India remains low.
New treatments can help
Avoiding surgery is an option in many cases, especially among younger women.
For young women with heavy menstrual bleeding, offering contraceptive choices such as pills, injectables, implants or intrauterine devices can help control bleeding.
The levonorgestrel intrauterine systems have revolutionized treatment for women with heavy menstrual bleeding.
These devices, a form of birth control, are placed in the uterus, where they deliver very low doses of the female hormone, levonorgestrel.
They are safer than birth control pills, and can help avert hysterectomy in a large number of women.
Once inserted, these devices last for up to seven years, leaving women feeling liberated.
For younger women with fibroids and cysts, minimally invasive surgery now offers removal of only these without sacrificing the uterus or ovaries.
For women with persistent discharge, the simple clinical procedure of thermal ablation of the cervix can offer relief.
Thus, technological advancements have changed the landscape globally, reducing hysterectomy rates in high-income countries.
In India, the Federation of Obstetrics & Gynaecological Societies (FOGSI) has been running a “Preserve the Uterus” campaign to enhance the quality and scope of gynaecological care.
To address early hysterectomy in India, the ministry of health and family welfare issued National Guidelines to Prevent Unnecessary Hysterectomy, in 2023.
The guidelines include the formation of national, state and district-level monitoring committees, strategies for raising awareness, audits and treatment protocols for gynaecological ailments.
They include detailed data to track who is undergoing hysterectomy, by whom, and for what conditions.
There has to be a concurrent focus on providing alternative, affordable treatment for gynaecological care, including improving awareness and access to these treatments, as well as offering effective management of the side effects of hysterectomy.
(The author is Vice President, Federation of Obstetrics and Gynaecological Societies of India and Former Professor and Head, Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi. This article was originally published under Creative Commons by 360info)
