California researchers dropped a bombshell when they reported that the routine practice of taking out a woman's ovaries during surgery to remove the uterus not only has no clear health benefit, but actually raises the risk of death from heart disease and hip fracture.
"We've been saying this for a long time," said Judy Norsigian, executive director of Our Bodies, Ourselves, a nonprofit women's health advocacy group in Boston. "There never was any good evidence that taking out ovaries was a good idea, yet doctors did it anyway."
Perfectly healthy ovaries are removed in more than half of all hysterectomies in the U.S. to prevent ovarian cancer, despite the fact that ovarian cancer, though often deadly, is rare. A woman is 25 times more likely to die of heart disease, said Dr. William H. Parker, a clinical professor of gynecology at UCLA and lead author of the new study.
Ovaries are important. Even well past menopause, they pump out some estrogen and lots of testosterone and androstenedione, from which muscle and fat cells make estrogen. Without these hormones, the risk of heart disease and bone thinning that leads to osteoporosis and hip fracture go up.
But there's something even more outrageous here: The fact that many, perhaps even most, of the 615,000 hysterectomies done every year may be unnecessary.
"That's absolutely true --- there are too many hysterectomies in the first place," said Parker. There are many alternatives to hysterectomy with fewer downsides, although many women do not know about them.
Obviously, if a woman has uterine cancer, it makes sense to remove the uterus. Yet more than 90 percent of U.S. hysterectomies are not done because of cancer, but because a woman has fibroids, endometriosis, abnormal bleeding, or a prolapsed or fallen uterus - all conditions for which less drastic surgery or nonsurgical treatments are available.
"The real problem is that women are not told enough about the downsides of hysterectomy and the alternatives so they can make a truly informed decision," said Dr. Mitchell Levine, a Cambridge, Mass., gynecologist.
It is true that the rate of hysterectomies in the U.S. dipped in 2003, to 41.7 per 10,000 women, down from 45.7 the year before, according to the American College of Obstetricians and Gynecologists. But American women are twice as likely as British women to have a hysterectomy, said Parker, and four times as likely as Swedish women.
Why? It's probably not money, he said, because alternative procedures are reimbursed at roughly the same rate. "It's cultural. It's the way doctors have been taught and what women expect."
"We certainly do more hysterectomies than other countries - it's the way we've been trained," said Dr. Jonathan Niloff, a gynecologic surgeon at Boston's Beth Israel Deaconess Medical Center. But, he said, a hysterectomy may make sense if, say, a woman has a suspicious mass on an ovary and is past childbearing years. Taking out both ovaries and the uterus all at once may be better than just taking out the suspicious mass, finding out that it's cancerous and then having a second operation.
While many women report no decrease in sexual satisfaction after a hysterectomy, others say they do, because uterine contractions can be part of orgasm, said Nora W. Coffey, founder and president of the Hysterectomy Educational Resources and Services, or HERS, Foundation.
In addition to removing healthy ovaries, American surgeons also routinely remove a healthy cervix during a hysterectomy, though cervical cancer is even rarer than ovarian cancer and can be detected easily with regular Pap smears. One recent study found no difference in sexuality whether the cervix was removed or not. But sexuality loss is a potential risk, given that during cervix removal, nerves to the external genitalia, including the clitoris and labia, are sometimes cut.
(A Dartmouth Medical School study last year, by the way, showed that millions of women are still being screened with Pap tests even though their cervices were removed during hysterectomy, and there's no way they could have the disease the Pap detects.)
So, what should you do if you've been told you need a hysterectomy? Get a second opinion, preferably from a doctor open to other alternatives.
"I advise any woman who is not in a life-threatening situation to see someone else besides a surgeon to explore nonsurgical options first," said Cindy Pearson, executive director of the National Women's Health Network in Washington, D.C.
If fibroids, benign growths in the uterus, are the problem, you can try managing the pain and waiting until menopause, when they may disappear on their own.
"Although many of my colleagues would disagree, I believe it is almost never necessary to do a hysterectomy for fibroids," said Levine, adding that 90 percent of the women who go to him for a second opinion don't need surgery or could have a less invasive operation.
If fibroid surgery is necessary, consider a myomectomy, surgical removal of just the fibroids, not the uterus. Not everyone is a good candidate, though, because if a woman has many fibroids, it can be difficult to get them all, said Dr. John Griffith, director of the Fibroid Center at Johns Hopkins Hospital.
Uterine artery embolization, in which tiny plastic pellets are inserted into the blood vessels supplying the uterus to cut off blood supply, is also an option . However, if uterine tissue itself, not just the fibroids, is destroyed, you might lose fertility.
Laparoscopic surgery done through a keyhole incision in the abdomen is an option if you have a mass on an ovary that might or might not be cancer. This minimally invasive procedure can also be used to treat endometriosis, a growth of uterinelike tissue outside the womb that can be extremely painful.
For heavy bleeding due to problems other than fibroids, doctors can use ablation to destroy the uterine lining with hot water, radio frequency waves or electric current. For a prolapsed uterus, surgeons can put in stitches to suspend the uterus more securely in the pelvis.
In your conversations with doctors, ask them to be explicit - and careful - with their language.
Removal of the ovaries is called "oophorectomy," but an equally valid word is "castration," which packs more emotional punch and may tip your decision in a different direction. When a doctor calls your fibroid a "tumor," remember that "tumor" can mean benign or cancerous. And, if the doctor wants to remove your ovaries, ask about the risks and benefits for you personally.
Judy Foreman's column appears every other week. Past columns are available at www.myhealthsense.com.