Why Would a Woman Resist Hysterectomy?

MICHAEL E. TOAFF, MD, MSc

In the United States 550,000 hysterectomies are performed each year. In the vast majority of these cases the indications for surgery are benign, non life-threatening conditions. Only 10% of hysterectomies are performed for cancer.

The common rationale for advising hysterectomy and oophorectomy (removal of the uterus and the ovaries) is as follows: the role of the uterus is that of an "incubator," to carry babies into this world. Once the incubator role is over, be it because of a woman's age or her lack of desire for more children, the uterus is a nuisance. The uterus may bleed, cause pain, prolapse, and/or develop cancer. At this point, hysterectomy would be considered an advantage to a woman's well being and longevity. Regarding the ovaries, it is commonly felt that after age 40, ovarian function (hormone production) is approaching its end, and since the ovaries can develop cancer it is only logical to remove the ovaries as well during hysterectomy. The resulting absence of ovarian estrogen, it is proposed, can be easily overcome with estrogen replacement therapy.

Is this attitude supported by scientific evidence and recent research? An increasing number of women, as well as many physicians, believe strongly that it is not. The uterus has many roles, not just that of an incubator. Consequently, hysterectomy may be followed by negative consequences, which may significantly impact the quality of a woman's life. First, let us consider the old rationale that hysterectomy and oophorectomy can prolong a woman's life by preventing uterine and/or ovarian cancer. The lifetime probability that a 50 year-old woman will die of uterine cancer (including cervical cancer) is 0.5%, for ovarian cancer this probability is 0.8%. (Interestingly the risk of ovarian cancer after hysterectomy is 40% lower than expected compared to the general population). In contrast, the same woman's risk of dying of cardiovascular (heart and blood vessels) disease is 50%. It has been shown that hysterectomy (even without oophorectomy) during a woman's reproductive years increases the risk (triple the risk according to some studies) of heart attack during the remaining reproductive years. If the ovaries are removed as well, the risk of developing heart disease and osteoporosis is further increased. The risk of coronary heart disease decreases by 6% for each year oophorectomy is delayed after menopause.

It has been shown that after hysterectomy, even without oophorectomy, women tend to enter menopause earlier, by as much as four years on the average according to one study. During menopause there is a sharp increase in the risk of coronary heart disease. We may conclude then that hysterectomy and oophorectomy are not likely to prolong average life span, rather they may actually shorten it, due to an increase in heart and vascular disease.

Estrogen produced by the ovaries reduces the risk of osteoporosis and possibly the risk of heart disease. Estrogen may also help to maintain cognitive and sexual function. Theoretically then, hormone replacement therapy after hysterectomy and oophorectomy could counter the negative effects of estrogen deficiency. However, a recent study (Women's Health Initiative) reports a slight increase in the risk of heart disease, thromboembolic disease, and breast cancer in women on combined estrogen-progesterone (Prempro) replacement therapy. This has led medical authorities to recommend restriction of hormone replacement therapy to be used only for short-term relief of vasomotor symptoms or vaginal dryness. Even prior to this latest study it had been shown that only about 50% of women for whom hormone replacement therapy was prescribed were still taking the medication after 12 months. Overall, only 10% of menopausal women in the U.S. are taking hormone replacement therapy and this percentage is dropping rapidly. Given these facts, there is a compelling argument for avoiding unnecessary hysterectomy whenever possible. It is clear that optimal health is maintained by uterine and ovarian preservation, except when cancer is already present or there is a family predilection for cancer.

Recent studies show that the symptoms of surgical menopause (sudden onset of menopause after removal of the ovaries) are more severe and prolonged compared to symptoms during natural menopause (when ovarian function gradually diminishes). The aging ovaries continue to produce certain amounts of estrogen for at least ten years after the start of menopause and of androgens until at least age 80. The androgens are converted to estrogens by the fatty tissue and muscle to estrogens. Women who had their ovaries removed after menopause had 54% more osteoporotic fractures than women with intact ovaries. Androgen deficiency affects bone loss, libido, muscular and fat distribution, the sense of well being, energy, and appetite. Preservation of the ovarian production of estrogen and androgen, albeit reduced compared to the reproductive years, may contribute significantly to a woman's health. This is another rationale for preserving the genital organs even after menses have ceased.

In a recent long term observational study, hysterectomy was shown to double the risk of fracture in perimenopausal women. Hysterectomy also increased the risk of osteoporotic fractures by 20% regardless of whether the ovaries were removed or preserved.

A recent study reports that women who underwent oophorectomy had an increased risk of developing dementia and cognitive impairment, especially if surgery occurred before age 38. The risk of dementia and cognitive impairment increased 70% in women who underwent bilateral oophorectomy before age 46 and 260% in women who had unilateral oophorectomy before age 38. It is also significant that surgical menopause is abrupt and can cause intensified symptoms. The health risks associated with bilateral salpingo oophreectomy appear to outweigh any health benefits it might confer.

Other long-term adverse effects of hysterectomy have been reported. Some studies, although not all, report that new urinary symptoms such as frequency, urgency, and incontinence occur in 30% of woman after hysterectomy. This may be the inevitable result of bladder denervation (surgically cutting off the nerve supply to the bladder) during hysterectomy. Also, slow propulsion constipation develops in about a third of women after hysterectomy, even without the presence of rectocele. Frequently, hysterectomy leads to sagging of some internal genital organs such as the anterior vaginal wall (dropped bladder or cystocele) and posterior vaginal wall (rectocele). These conditions may cause symptoms such as difficulties in urination, stress urinary incontinence or constipation, difficulty in penetration during intercourse, and vaginal infection. These conditions may be severe enough to require surgical correction.

Emotional health may also be affected by hysterectomy. The uterus has great psychological significance for some women, more so in certain cultures. Although many women have no emotional difficulties after surgery, hysterectomy may be followed by problems such as depression, anxiety, and sexual dysfunction. The issue of sexual function after hysterectomy is complex. Some women feel that by losing their uterus they have lost their womanhood. They may feel that their partner no longer desires them leading to loss of libido. One physical consequence which may result from hysterectomy, and may directly affect sexual function, is shortening of the vagina resulting in pain during deep penetration. The most important effect of hysterectomy on sexual function may be on orgasm. For some women, "deep" orgasm involves rhythmic uterine contractions. Following hysterectomy this important component is lacking and such women complain of a dramatic decline in the quality of their orgasm. For women whose orgasmic pleasure does not depend on uterine contractions, hysterectomy may not lead to a decline in the quality of their sexual response. In fact, many women report that hysterectomy led to an improved sexual life, especially when hysterectomy eliminated major medical problems such as bleeding, pain, and/or prolapse of the uterus. In other women, fear of an unwanted pregnancy always had a negative effect on sexual function and elimination of this fear by hysterectomy has enhanced pleasure.

Finally, many women are strongly opposed, in principle, to the removal of any organ, genital or otherwise, unless absolutely necessary.

In this discussion the drawbacks of hysterectomy have been summarized. As women have informed themselves regarding these issues many have resisted hysterectomy until they are convinced that it is absolutely necessary for their well-being. After 30+ years in the practice of obstetrics and gynecology it remains my firm belief that a woman has the right to decide the fate of her own organs. She should not be made to feel inadequate or disturbed for questioning the necessity of hysterectomy. In fact, I believe that it is the obligation of the physician to present to each woman all of her treatment options in detail, giving her the pros and cons of each option. I believe a physician should do so honestly, even if that particular physician is not capable of providing some of the treatment options. If the patient elects not to have an hysterectomy, it is the obligation of the physician to support her in her decision, even when it means referral to another expert.

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