Is your hysterectomy really necessary ?

A school friend came to me for advise yesterday. She is now 48 years old and was having heavy period which were also painful , for the last two years . She been advised to have a hysterectomy , and wanted to know whether it was better to do a vaginal hysterectomy or a laparoscopic hysterectomy.

While chatting to her, I pointed out that hysterectomies are often performed needlessly. Many studies have shown that lots of them are done even though they are not required; and that the most important determinant of the hysterectomy rate in a given town is the number of gynecologists who practice in that town ! There is no question that hysterectomies are one of the most overused surgical procedures; and that even though there are now many better many nonsurgical alternatives to treating heavy periods and pelvic pain, this remains one of the most commonly performed surgical procedures.

There are many reasons for this. The most common is the fact that gynecologists are trained to be surgeons ! They like operating , and are quite happy to propose a surgical solution for a woman who has a problem , even though it could be treated by less aggressive measures.
A lot of this boils down to their worldview; and it’s interesting that exactly the same problem of heavy painful periods in a 48-year-old woman would be handled completely differently by a homeopath , for example , who would treat her with medical therapy.

It's not that there is a conspiracy against patients; or that gynecologists are out to do unnecessary surgery. Most doctors want what's best for our patients , and will not deliberately set out to harm them. However, if you have a hammer in your hand , you do tend to see nails all the time !

I was talking to her about alternative nonsurgical methods for dealing with her problem, because I told her that she was quite likely to become menopausal very soon , at which time her problems would naturally disappear . However, she became agitated and upset. She had pretty much made up her mind she wanted a hysterectomy and she didn't really want to hear about nonsurgical alternatives - she just wanted to know which route was the best option for her ! However, as a friend , I didn't think it was fair on my part not to explain the downsides of doing unnecessary surgery to her.

Part of the reason she was so confused was she said she had already been to over four different gynecologists ( one of whom was an uncle) ; and all of them had uniformly told her that she needed a hysterectomy. Why I was I being a contrarian ? When I asked her whether any of them had advised medical therapy, she said - I tried this for two months , and this helped, but when I stopped , the bleeding and the pain came back , so I decided to go in for a surgical solution. She had obviously not being given an adequate therapeutic trial with medical therapy, which is why she felt that surgery was her best solution - something which was a result of a flawed perception on her part.

She had had a MRI scan done and requested me to see it. “ My MRI scan shows I have a 3 cm chocolate cyst; and a 4 cm fibroid. After seeing these images , all the gynecologists agreed that I needed to have my uterus removed. “ It's become an increasing problem that doctors no longer seem to treat patients anymore. Rather than talk to the patient, they are more interested in treating the images which the radiologists and sonographers produce for them. Now these are gorgeous images , which give us great insight into the disease and the distortions which they create in the anatomy , but there's very little correlation between what the MRI or ultrasound scan picks up , and what the patient perceives. Thus it's well known that a patient could have a very large endometriotic cysts , which may not cause any symptoms at all. She may remain blissfully unaware she has such a large cyst, because she has enough sense not to go to a doctor !

The bottom line is that it's very unlikely that an asymptomatic patient will be benefited from a surgical intervention . If there are nonsurgical alternatives, it’s best to pursue these aggressively , before considering a surgical option. I told her that her surgery was an elective procedure ; and it would be best if she tried aggressive medical therapy , before making a final decision.
Unfortunately she wasn't very happy , because she had mentally geared herself up for going through the surgical procedure . After hearing me , she was completely confused. However, it’s better for patients to be confused , because they know they have alternative options, rather than end up doing surgery which was never required in the first place , and then regretting this later on.