Routine Pelvic Exams Lead to Unnecessary Hysterectomies, Experts Say

It's been quite a while since I've written anything about the ongoing scandal of unnecessary hysterectomies. I've been spending my time working locally in my home town of Huntington, NY to create community gardens and grow-to-give gardens via my organization LICAN. This is my way of fighting giant agri-businesses in a way that will eventually mean their demise as people realize that communities can become self-sufficient and supply their own vegetables and eggs.

But a Jane Brody article in the April 30 NY Times has brought me back to the subject. Brody, a vastly experienced and reliable reporter, quotes experts who say that those annual, invasive pelvic exams that gynos have told us forever that we need to have--well, we don't need them unless we have troubling symptoms, or it's been more than 3 years since we've had a Pap smear to test for cervical cancer. (And, by the way, if your cervix has been removed, no need for the Pap smear either.)

According to an article quoted by Brody, "frequent routine (pelvic) bimanual examinations may partly explain why U.S. rates of ovarian cystectomy (removal) and hysterectomy are more than twice as high as rates in European countries where the use of the pelvic examination is limited to symptomatic women."

The scenario is that if a woman with no symptoms undergoes a pelvic exam,  the doctor may find something suspicious that can lead to unnecessary surgery and other procedures, not to mention high anxiety and costs.

Indeed, there is no good medical evidence to justify routine pelvic exams in the absence of troubling symptoms, the experts told Brody.

But this, of course, doesn't mean that most of the gynecologists we see will stop recommending them any time soon. The doctors' trade group, the American College of Obstetricians and Gynecologists. endorses them even though they acknowledge the lack of medical evidence.

And, when 250 doctors were asked about doing routine pelvic exams, nearly all said they would do them routinely on women without symptoms, whether they were 18, 35, 55 or 70. This included a 55-year old who had no ovaries, uterus or cervix.

Yes, women's treatment by this branch of medicine is a scandal, and it's all about the money. Since these doctors get paid for an estimated 63.4 million pelvic exams and about 600,000 hysterectomies a year, I surely don't expect them to stop voluntarily.

Tell your friends!

Love Your Body/Love Your Uterus

Say what?  Love your uterus? You'd better. We need to love our bodies, inside and out.

This post is part of the 2011 Love Your Body Day Blog Carnival sponsored by the NOW Foundation.  The focus of this campaign is fighting self-hatred because we’re too fat, too old, too flat, too wrinkled, too unfashionable. But we need to look inside our bodies as well and love the "sacred" organs, as one enlightened doctor described them, that make us female.

The fact is that there is an ongoing epidemic of unnecessary hysterectomies in the U.S. In no other country in the world, developed or otherwise, do one out of three women end up without their uterus by the time they are 60, a toll of about 600,000 women a year. And about half lose their healthy ovaries at the same time.

The unnecessary loss of one's sexual/reproductive organs can cause a profound loss of self-esteem tied to real physical and sexual changes that can't be fixed with a diet, cosmetic surgery, a change in attitude or replacement hormones.

For far too long, American women, including myself,  have been agreeing to let doctors cut out our organs because we didn't know the consequences and because the doctors told us we really didn't need them any more if we'd already had our babies. This attitude by doctors was born of ignorance but reinforced by sexism. Why would women past 40 need to worry about sex anyway? With replacement estrogen, after all, they could still have intercourse!

Sadly, this attitude is still prevalent, even among women gynecologists trained by a male-dominated medical establishment. Women with bleeding or pain problems too seldom learn about alternatives to hysterectomy, and even less often about the importance of our organ to our lifelong health and our view of ourselves.

I first realized this when I heard a gynecologist speaking reverently about the uterus and ovaries. He actually called them “sacred!” I had never understood that the uterus is a powerful muscle even though it has to be. That’s how women push their babies out. Nor did I understand that the uterus is central to the structural integrity of a woman’s body, like the keystone in an arch that keeps everything together.  Here’s a structural description, taken from the text of an informative video on the HERS Foundation website:

     The uterus is attached to broad bands of ligaments, bundles of nerves, and networks of arteries and veins…The severing of the ligaments (done for hysterectomy) permits the pelvic bones to move and widen, affecting the hips, lower back, and skeletal structure.

    The displacement of the pelvic bones results in compression of the spine. 

Women report that as the spine compresses, the rib cage gradually drifts down until it sits directly on the hip bones.  This compression is the reason why hysterectomized women have protruding bellies and little or no waist.

   The bladder sits in front of the uterus, and the bowel sits behind it.  The uterus separates them and helps keep the bladder in its natural position above the pubic bone and the bowel in its natural configuration behind the uterus.

Recent research shows that significant numbers of women are alarmingly ignorant about their reproductive/sex organs. A survey of 1,273 adult women this year found that 30% didn’t even know that removing the uterus would stop menstrual activity, and 13% didn’t know they couldn’t get pregnant without a uterus.

Dr. Oz Harmanli, the Springfield, Massachusetts urogynecologist who led the study, said in an interview that “younger women are almost clueless” about the functions of the uterus, cervix and ovaries. The purpose of the study, he said, was to highlight the need to give women more information so that they can make a well-informed choice about having a hysterectomy. 


Dr. Harmanli, who is director of urogynecology and pelvic surgery at Baystate Medical Center and an Associate Professor of Obstetrics and Gynecology at Tufts University School of Medicine, is refreshingly candid about the penchant of American gynecologists to cut out women’s organs. 

“I come from Turkey, been here over 20 years, trained here, started practicing here,” he told me. “When I go back to Turkey (for meetings), when I suggest hysterectomy for certain conditions, they look at me like I came from Mars.”

           

He continued: “The climate here created by practitioners, and by tradition in families (successive generations having hysterectomies) is that loss of the uterus has not been considered such a major loss compared to other cultures and countries.” He added that there are many complex factors behind the uniquely high rate of hysterectomies in the U.S. I believe that money is one of them: hysterectomies bring in enormous income to both doctors and hospitals; hysterectomies are the second most common women's surgery, behind only Caesarians.

Elsewhere on this blog I have described the serious health problems, shortened life span and sexual problems that result from hysterectomy and removal of the ovaries. There is simply no good medical reason why one-third of American women end up without a uterus compared to, for example, one-fifth of British women. The situation is outrageous, full of long-term implications for the general health of American women and the price women pay for health care via insurance premiums and out-of-pocket.

We’ve allowed gynecologists to define our organs as reproductive and therefore unnecessary once we’ve had all the children we want. But our organs are as central to our identity, our energy, our joy in life,  as surely as men’s testicles are to theirs.

So learn more about these vital organs. Love your uterus and your ovaries even though you can’t see them in the mirror!

Doctors' Group Ignores Hysterectomy as a Cause of Incontinence; Urinary Problems Cost U.S. Women $13 Billion/Year

They call themselves Urogynecologists, women's doctors who do not deal with pregnancies or infertility or  hysterectomies, only what they refer to as "pelvic floor disorders" including urinary incontinence. So you'd like to think they'd be upfront about the fact that hysterectomy is one of the major reasons why 40% of all U.S. women find themselves leaking urine by the time they hit the age of 60. (Interesting coincidence: that's the same percentage of women who undergo a hysterectomy by the time they are 60.)

In fact,  a very large and long study of Swedish women found that a woman's chance of incontinence at least doubled after a hysterectomy.

This group of doctors has even put a price tag on what it costs women to deal with incontinence: an average of $15 a week for pads, laundry and dry cleaning. If you multiply that by the 17 million women--a low estimate--who have this embarrassing problem, and then by 52 weeks, you find out that incontinence is costing American women at least $13 billion a year. This calculation does not include the cost of the various prescription medications now being promoted by drug companies to relieve incontinence.

Yet, you can search the website of the American Urogynecologic Society (AUG) or their new information website, Voices for PFD, and you won't find a mention of hysterectomy. The closest you get is this statement with its vague reference to surgery: "Sometimes, very clear-cut events such as pregnancy, vaginal delivery, surgery, radiation or accidental injury can lead to these kinds of problems..." Notice that all of these causes of incontinence are essentially unavoidable--except surgery for hysterectomy, which is avoidable with other treatments in 70 to 90% of cases.

But wait, these doctors have a solution to incontinence, once you've got it:  More surgery! Last year, the AUG released results of a study showing that two years after women had surgery to try to cure stress urinary incontinence, their cost per week had dropped to $4 from $15 while their episodes of incontinence dropped from 23 per week to 3. Hooray.

The final irony is that just a few days ago, the AUG released its own study of information about incontinence on various web sites and found them "inadequate." Two physician reviewers evaluated more than 50 websites and found them "not comprehensive, relevant or accurate."

I tried to reach Dr. Steven Minaglia, a Hawaii-based physician whose team reviewed the websites, but he had left for a trip to China. Perhaps when he gets back he can ask them to review why AUG's own website doesn't bother to tell women about the connection between hysterectomy and incontinence.

Perhaps he could start by having them review the Swedish study.

Hysterectomy is a Feminist Issue: 1 in 3

The Ms. Magazine Blog now features an article I wrote that gives some of the shocking information about the epidemic of hysterectomy. I have been amazed for a long time that this most feminist of issues is not on the radar of feminist organizations despite the huge impact of these surgeries on women's health, well-being and relationships.  I've struggled to understand why. Partly, I think, it's because the surgery is simply so common. Breast cancer advocates have made women very aware that their life-time risk is 1 in 8. But consider: 1 in 3 women 60 and older no longer has a uterus!

That's right, 1 in 3. It's just about a right of passage for older women.

But as I say in the Ms. blog, we who are the 1 in 3 have got to speak up. We can't let this continue. Keeping our condition a secret because we're embarrassed, afraid of being regarded as less of a woman, or as being too unaware to prevent our doctors from doing this to us--well, we've just got to get over that the same way women who've lost a breast have done so bravely.

Summarizing the Risks of Hysterectomy

When a women has surgery to remove her uterus, and way too often her healthy ovaries at the same time, she increases her risk of dying prematurely, diminishing her sex life, and suffering from a host of other health problems.

Here's a quick summary of the Risk Increase shown by some of the research, with sources:

Hysterectomy Alone

• Incontinence: 60% greater risk by age 60 than an intact woman ("Vital Signs: Consequences; Hysterectomy and Risk of Incontinence." The New York Times, Aug. 22, 2000. By Eric Nagourney
• Coronary Heart Disease: 3 times grater risk if hysterectomy done before menopause (American Journal of Obstetrics & Gynecology, Jan. 1981; 139 (1):58-61)

Oophorectomy (removal of ovaries)

• Early Death: twice the risk if ovaries removed before age 45 and no estrogen replacement given ("Survival patterns after oophorectomy in premenopausal women: a population-based cohort study." Lancet Oncology Volume 7, Issue 10, 2006, pp.821-828; by W.A. Rocca, MD, and others.)
• Dementia: 33% higher over all than women who keep their ovaries through menopause; 74% higher if her ovaries are removed on or before age 43 ("Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause." Neurology 2007; 69:1074-1083; by W.A. Rocca, MD, and others)
• Heart Attack: double the risk if a woman loses her ovaries between the ages of 40 and 44; 40% higher if ovaries removed after age 50 ("Ovarian Conservation at the Time of Hysterectomy for Benign Disease." Obstetrics & Gynecology, Vol. 106, No.2, Aug. 2005
• Bone fractures from osteoporosis: 54% more fractures when ovaries removed after menopause (same study, Ovarian Conservation, etc., cited above)

This is not a list you will find in any of the literature given out by gynecologists. Nor, when they try to talk women into letting them take out their ovaries while doing the hysterectomy, will they reveal that the average woman's risk of ovarian cancer is 1 in 72 (or 1.39% over her lifetime). By comparison, the lifetime risk of breast cancer is 1 in 8 (or 12.15% over her lifetime).

Of course, some women have genetic and family risk factors for ovarian cancer that make their decision much more difficult. I feel for them. But for other women, a gynecologist who uses the fear of ovarian cancer to convince her to consent to ovary removal is nothing less than unethical. Such a doctor should do women the favor of finding some other line of work.

Encouraging News About UAE, An Alternative to Hysterectomy

Recently published research on Uterine Artery Embolization has shown that it is a good alternative to hysterectomy for women suffering heavy menstrual bleeding or pain from uterine fibroid--benign--tumors.

A 5-year follow-up study of women who agreed to be randomly picked for either a hysterectomy or Uterine Artery Embolization (UAE) showed that 7 of 10 women who underwent the organ-sparing procedure had relief of their symptoms that was good enough to have been able to avoid further surgery after five years.

This is important news because 40% of all hysterectomies--275,000 of them--are done each year because of symptoms caused by fibroids. According to best estimates, another 250,000 women a year undergo myomectomies, in which the fibroids are cut out of the uterus but the uterus is spared. Both surgeries usually involve a stay in the hospital and, depending on the technique used for the hysterectomy, recovery periods of up to six weeks. With UAE, women report returning to normal activity, including sex, within two weeks.

In addition, a UAE poses much less risk to a woman's ovaries if she is under 45. Dr. Bruce McLucas, a Los Angeles gynecologist who performed the first UAE in the United States in the early 90s, said in an interview that the incidence of ovarian failure "in my hands is 3%" in women in that age group and about 5% when done by other surgeons. McLucas recently performed his thousandth UAE. However, ovarian failure occurs in about half of all women older than 45 who undergo UAE.

About half of all women who undergo hysterectomies end up without their ovaries--often healthy ovaries-- because gynecologists continue to scare them into consenting to their removal (or yank them out even with no consent) with talk of ovarian cancer. They minimize the adverse impact on women's health that will result from the loss of their ovaries. Most gynecologists still view the low risk of developing ovarian cancer as outweighing the much greater risks of developing heart disease, osteoporosis, loss of sexual pleasure, etc. from castration (the proper word for amputation of women's sex/reproductive organs.)

 McLucas, who practices at the Ronald Reagan UCLA Medical Center and is Clinical Professor in the medical school there, is now engaged in a campaign to publicize the benefits of the procedure. He will be appearing December 1 on the TV show, The Doctors.

I've long wondered why so many women in their early 40s experience such heavy bleeding. McLucas explained that, "In the years running up to the menopause, we have a domination of estrogen in the menstrual cycle," and estrogen fuels the growth of fibroids, which are present in 40% of women over 40. Many women, however, do not experience heavy bleeding or pain from them; only 10 to 20% of women who have fibroids need treatment.

But those who do must deal with monthly hemorrhaging that can last two weeks and require frequent changing of even the most absorbent tampons. Many become anemic.

"The first major myth about fibroids is that waiting for menopause is necessarily a good option," said McLucas. He explained that because fatty tissue produces a substance that mimics estrogen, fibroids in some women will not shrink after menopause. And, if a woman is taking replacement hormones, the fibroids also tend to grow. Waiting for menopause therefore, may or may not be a good idea depending on the individual woman.

So what is UAE? It's an outpatient procedure done under local anesthetic in which a small cut is made in the upper thigh and then in the femoral artery. From there, guided by X-rays, the surgeon plugs the uterine artery with inert particles.

Starved of blood, the fibroids usually--but not always--shrivel to about half their size, calcify and cause no further problems.

But doesn't the uterus then die as well?

Fortunately, the uterus is fed blood by the ovarian artery as well, and will "resupply the uterus within an hour of surgery," according to Dr. McLucas.

He has also published research showing that among women who still wanted to have children after the procedure, about 1/3 had successful pregnancies.

I had a hysterectomy in my early 40s because of heavy menstrual bleeding, and after viewing this new research, I would have tried a UAE if it had been available to me. Maybe it would not have worked, as is the case with a friend of mine, but given the information I now have, it would have been worth a try to keep my uterus.

Even now, many years later, women who want to try this alternative will very likely need to look beyond their usual gynecologist. McLucas thinks he is the only gynecologist doing UAE in the United States. But interventional radiologists--the same doctors who insert cardiac stents--do them, and so do, oddly enough, some cardiologists.

Ideally, women should find a gynecologist who can refer them to a radiologist who will perform the procedure. After that,  the gynecologist will oversee their recovery.

Dr. McLucas predicts that within 10 years there will be at least one gynecologist in each major city who performs UAEs. Until then, women are still on their own in their efforts to keep their precious organs. A good starting place for information is the Fibroid Treatment Collective website, which features Dr. McLucas.

Websites Exploit Women Worried About Hysterectomy

There they are on the home page of Hystersisters.com: five attractive women, all dressed in white and smiling broadly. Why are these women so happy? They've had a hysterectomy--and obviously enjoyed it!

Yes, if you believe the claims on both Hystersisters and Hysterectomyresources.com, having your uterus removed--and likely your ovaries as well--can not only be anxiety-free but also a happy, happy experience.

If you do believe that, as we say in New York, there's a bridge in Brooklyn we'd like to sell you.

Selling, of course, is what both these websites are about. Selling you not on the idea that most hysterectomies--as many as 90%--can and should be avoided because they are so damaging to women's health. No, not that. Instead, both websites are trying to sell you on a different type of hysterectomy, and preferably, in the case of Hystersisters, one done with the daVinci robotic system.

The convenient Find-a-Doctor feature on that website is sponsored by...you guessed it, daVinci!

Intuitive Surgical, Inc., the company that makes the daVinci systems, is bullish on its future. The company's investor relations website reports that for the first half of 2010 revenue was up 49% from the first half of last year to $679 million.

This company's intensive public relations and advertising campaign--I've seen their press releases turned into glowing news stories by naive reporters in several newspapers--is all about getting hospitals to buy the robotic systems for a sweet $1 million to $2.3 million each.

And the revenue stream just goes on from there. Annual service agreement: between $100,000 and $180,000. Disposable instruments and accessories for each procedure: between $1,300 and $2,200.

Is it any wonder that medical costs in this country are impoverishing us?

The websites are a fabulously clever way of putting pressure on doctors and hospitals to buy the systems.

Women who've been told they need/should have a hysterectomy run to their computers for information.

And what they find at Hystersisters is designed to prompt them to ask their doctors--themselves getting pitched by Intuitive sales people--if they use the robotic systems. It's push-pull marketing at its best.

But pushing daVinci isn't the only thing wrong with these two websites, as I'll explain in my next blog in a few days.

In the meantime, any women who's considering a hysterectomy should go to the HERS Foundation website to get the cold, hard facts about the serious health problems and loss of sexuality that the surgery too often brings about.

In Honor of Ovarian Cancer Month: Hold On To Your Ovaries!

Shame on The New York Times for printing a one-sided article touting the benefits of female castration as a way of preventing ovarian cancer. The article reported on a study of women who had inherited the BRCA1 or BRCA2 mutations that increase the risk for breast and ovarian cancer. Of the women who kept their ovaries, 6 percent developed ovarian cancer, compared with 1 percent of those who gave permission to remove their ovaries.

Ovarian cancer is deadly serious: 15,000 women a year die from it, and the Ovarian Cancer Alliance has marked September for observance of Ovarian Cancer Awareness Month. Fear of ovarian cancer is the major reason why about 300,000 women a year permit doctors to remove their ovaries, usually at the same time as a hysterectomy. However, only a small percentage of those women have the BRCA mutations; they face a lifetime risk of only 1.39% of developing ovarian cancer (or 1 in 72), while the risk of breast cancer over her lifetime is 12.15% (or 1 in 8), according to the National Cancer Institute. So using fear of ovarian cancer to convince a woman who does not have the mutations to have a hysterectomy, is clearly unwarranted.

Now the question is, how warranted is such a recommendation for women who do have the mutation? Well, if all we were talking about was removing some non-essential or at least less-essential body part--even a breast--then trading a 5% risk for a 1% risk of a deadly cancer, for which there is no good treatment, might indeed be a sensible option.

But no woman should make that choice until she understands all that she will be sacrificing along with her ovaries, and the added health risks that accompany this drastic decision.

As I've blogged about before, losing your ovaries is literally castration and brings on not only a sudden, intense menopause, with severe hot flashes, mood swings, loss of energy, etc., but also drastically raises the odds that a women will suffer other serious problems as a result. A study published in the journal The Lancet in October, 2006, found that women castrated before the age of 45 double their risk of death from heart attack. Some previous studies put the increased risk of heart disease at 5.5 times, regardless of age at time of operation.

And then there are the increased risks for osteoporosis and bone fractures and Parkinson's disease and other forms of dementia.

As for women who have enjoyed sex--well, they can say good-bye to their former selves. Our ovaries continue to function long after menopause, still producing some estrogen and other hormones. Without them, welcome to the world of dry. Libido--gone or dramatically reduced. Ability to feel and enjoy--women can't even remember what it felt like. Impact on your relationships--depends on how understanding and tolerant is your partner.

The Ovarian Cancer National Alliance is pushing for an increase in funding for research for a test that would detect ovarian cancer at an early stage, and for a cure. Amen to that.

But the next time The New York Times or anyone else publishes an article about ovarian cancer prevention through castration, they ought to be sure to tell women about the increased risks and poor quality of life that they will be endure as a result.

Feeling Un-Sexy in America

The market is huge and tantalizing: in the midst of a culture drenched in sex, one in three American women say they have about as much interest in sex as Monday Night Football.

That's why the recent rejection by the Food and Drug Administration of flibanserin, the latest drug intended to boost female libido, was such a disappointment to the pharmaceutical industry intent on hitting the jackpot with a female Viagra.

Trials of the drug showed it did too little to warrant approval, and that finding, in turn, sparked the latest debate on why it's so much harder to find a sex drug for women than men. After the usual chatter about sexual desire being so much more dependent on women's emotions then men's came the theories that essentially blame women's drive for equality.

For example, after chalking up some of the apathy to a resurgence of 19th century "bourgeois propriety, " Camille Paglia, writing in a New York Times op-ed, blamed Super Moms who've turned men into "cogs in a domestic machine commanded by women." She also slapped at workplaces where women are finally enjoying some modicum of equality with men as leading to a suppression of physicality and then to boredom with each other.

The sad part of this commentary is that is is so ill informed by facts. Take a look at the recent medical literature on women's sexuality, as I have recently in researching a book on the subject, and you find the authors still quoting 1960s work by Masters & Johnson. Our culture glorifies sex but when it comes to doing actual research on the subject we're stuck in old-fashioned prudery.

The best evidence, however, points to far-different culprits than those plucked out of the air by Paglia: the 600,000 hysterectomies a year performed on women plus women's use of birth control pills and medications like Prozac.

By the time a woman in America reaches the age of 60, the chances are one in three that she will have had a hysterectomy. Afterward, it is common for women to report loss of sexual desire, less sexual activity, decreased genital sensation and difficulty achieving orgasm. This is a reality that the surgeons don't want women to know, and that hysterectomized women most often keep to themselves out of shame and fear.

Why does hysterectomy adversely affect sexuality? Part of the answer is that about 300,000 of the women who undergo hysterectomies also lose their ovaries at the same time. Perhaps half the others also suffer a loss of ovarian function as a result of damage from the surgery done to remove their uterus. That means about 450,000 women will lose ovarian function this year, and every year.

When ovaries are removed or cease functioning, that is castration. Castration is an ugly word, but when you cut out someone's reproductive/sex organs, it is the proper medical word. Shrinking from it just allows doctors to continue to recommend the removal of healthy organs as no big deal, and in fact a benefit to women, a way of reducing their chances of ovarian cancer. Not calling it castration helps conceal the fact that without her ovaries, a woman loses not only estrogen--the main concern of men because it enables vaginal lubrication--but also most of her testosterone, often called the "hormone of desire."

For men, the equivalent would be recommending routine removal of healthy testicles to prevent testicular or prostate cancer. Of course, I've never heard of a man willingly giving up healthy testicles unless he's deliberately changing gender. I once knew a man who consented to surgical castration because he had prostate cancer. Afterward, he told me how indifferent he had become to things like sexy movie scenes that before had turned him on.

Women I've interviewed who have been castrated say there is no artificial cocktail of replacement hormones that comes close to making them feel like their old selves. And believe me, they've tried to find one. Before the surgery, they had ample desire. Afterward, zip. This change had nothing to do with their emotional state, only the very drastic loss of the hormones produced by their sex organs.

When it comes to the birth control pill, the manufacturers have long been coy about the effect on women's sex lives, listing as a side effect "sexual changes." Translation: less desire. Loss of desire is also a side effect of anti-depressants including Prozac.

Now, I'm not saying that over-worked women don't have less interest in sex than women who get enough sleep, or that deeply entrenched negative attitudes toward women's sexuality don't still exist. Of course they do. And women suffering from serious depression may have a need for medication that outweighs any worry about the impact on their sex lives.

But it's certainly anti-woman to suggest, as Paglia did, that the culprit is women's desire for equality in the workplace. Or that our excellent organization skills, which make it possible for us to bring in a critical paycheck while raising children and keeping a home, should be criticized as de-masculinizing our partners.

Women are being castrated by the hundreds of thousands every year. That's a fact, and that's where the focus and the outrage should be because there are organ-sparing alternatives as much as 90 percent of the time.

Let the Gynecologists Hear from You

I've been receiving comments from women who are outraged about the continuing epidemic of avoidable hysterectomies, and it's time the doctors took the heat directly.

The place to voice your feelings is the American College of Obstetricians and Gynecologists, ACOG for short. This is, essentially, the governing body for the doctors, and when they change their standards of practice to say that no healthy ovaries should be removed; that there are organ-conserving alternatives to the vast majority of hysterectomies; then the epidemic will stop.

That's because once the standard is changed, the doctors and hospitals become vulnerable to lawsuits they win now because they always fall back on the defense that, hey, this is the accepted way to deal with women's problems.

So, let them hear from you.

You can call them at 202-638-5577. Either voice your feelings to the person who answers the phone, or ask for the press office and see if you can get through.

You can also send email to: communications@acog.org

Gynocologist's Professional Org Ignores Heart Attack Risk

The professional organization that sets the standards of care followed by gynecologists has just released a new patient education booklet on hysterectomy. While this new version from the American College of Obstetricians and Gynecologists is something of an improvement (I'll get to that later), it leaves out completely the most serious risk facing women who are hysterectomized and/or lose their ovaries: heart attack.

I brought that very subject up with my cardiologist recently (yes, I have heart problems), and this is what he said:

"If they're taking out their ovaries, they're giving these women heart attacks. And you can quote me." Dr. Pavel Romano, Huntington, New York.

The "they," of course, is gynecologists. It's brave of Dr. Romano to put his name on a quote like this, but he's really not going out on a limb on the science. As I blogged about recently, solid research has now established that losing your ovaries greatly increases a woman's risk of heart attack; losing your uterus alone also increases that risk, but not by as much.

So I carefully read ACOG's new patient education booklet, expecting to find mention of this risk. Remember, heart attack is the leading cause of death of American women.

And is that risk mentioned? No, it is not.

I asked the spokesperson for ACOG just who is responsible for the contents of the pamphlet, and she ascribed it to "ACOG Fellows" who base the content on the College's Practice Bulletins and Committee opinions.

I've asked to interview one or more of these Fellows, but in the meantime I've now had the pleasure of reading ACOGs "Guidelines for Women's Health Care," published in 2007. Nowhere in that very long description of how doctors should respond to women's various gynecological problems is any mention of the increased heart attack risk brought about by hysterectomy and oopherectomy.

Absent any other explanation, this seems to be a case of a medical truth that's inconvenient for business. Acknowledging the heart attack risk might force the gynos to confront their tendency to just yank out a woman's organs, and that would leave many of them unable to earn their usual fees. It takes a lot more skill than many gynecologists have, and a lot more time, for apparently no bigger reimbursement from Medicaid, for example, to remove only a woman's fibroids instead of her entire uterus. Fibroids are the most common reason for hysterctomizing a woman, and they are never a good reason for a hysterectomy, much less removal of ovaries. Apparently, learning to do the more difficulty surgery is a problem for many gynecologists, who prefer instead the quicker, more lucrative and simpler job of just cutting out entire organs.

As I said earlier, there is some new information in the pamphlet that is helpful to women deciding whether to consent to a hysterectomy. The pamphlet now admits that the menopausal symptoms caused by ovary removal "may be more intense" (oh, yeah, make that will be horrendous) than if a woman went through menopause naturally. And that there is an increased risk of bone fracture due to osteoporosis.

But most of the pamphlet is still devoted to explaining the different ways surgeons can cut out a woman's organs and the details of how a woman is prepped for surgery.

A woman reading this pamphlet would still come away with only a partial understanding of the functions of her organs and of the consequences of surgery that may very well shorten her life.

It's an outrage that complete information is still absent from this booklet, and no woman agreeing to the surgery based on it is giving truly informed consent.

Maloney Supports Hysterectomy Study, Not Pre-Consent Video

In response to a story I wrote for womensenews, U.S. Rep. Carolyn Maloney, a Democrat from Manhattan, issued a statement today clarifying her position on a video consent requirement.

The story appeared first with a headline saying she would "mull" introducing a law, when she had said only--as the story read--that she would ask the General Accountability Office to look into the matter. The headline caused something of a stir because, as I wrote in my last blog, gruesome pre-consent videos are being used by anti-choice advocates to persuade women not to have abortions.

For that reason, some pro-choice women's groups are just reflexively rejecting the concept of a hysterectomy video.

The headline has now been corrected, and here, for the record, is the statement issued by Maloney's press aide:

Congresswoman Maloney is not contemplating introducing a bill and, in fact, in response to a question from an audience member during the forum, made clear that she is considering looking into if GAO can do a study, not legislation. Indeed, she doesn’t like the idea of Congress mandating that a particular video should be shown prior to any medical procedure. Nonetheless, in 1978 and 1993, Congressional hearings highlighted the issue of unnecessary hysterectomies, and Congress does have a role to play in investigating the reasons why so many women are being encouraged to undergo hysterectomies when less invasive alternatives are often available, particularly since they can have a negative impact on women’s health.

I think that pro-choice women's groups should stop and consider the damage done by hysterectomies and removal of ovaries before they take a position on the video.

One reason avoidable hysterectomies are still being done in the hundreds of thousands every year is because malpractice lawsuits are ineffective against them in all but the most egregious cases. It's a classic catch-22: because so many doctors do them, it's considered standard practice, and juries won't find against doctors when they plead that all they did was what so many other doctors do. So on we go. It seems to me that unless women somehow get the information they need about the health risks of these procedures, surgeons will continue to do these operations despite the evidence against them.

As Rep. Maloney rightly asked, "Where's the outrage?"

Video Consent Requirement May Be the Only Way to Stop Hysterectomy Epidemic

In this second report on the HERS conference, I want to focus on the push to require that women see an informative video before consenting to a hysterectomy.

The HERS Foundation has produced such a video and is hoping for legislative action. But even a proposal to require women to read more about the effects of the procedure before consenting, introduced this year by Indiana legislator, Bruce Borders, (seen here outside the conference room with keynote speaker, U.S. Rep. Carolyn Maloney) has prompted surprising opposition. Of course gynecologists objected, but so did the Indiana chapter of the American Civil Liberties Union.

The women who attended the conference were perplexed by this opposition. Many had told stories all day long of being victimized by doctors who not only failed to inform them about alternatives to losing their uteruses and ovaries, but lied about the benefits of the surgery. Why, the women wondered, would a civil liberties organization oppose an effort to truly empower women with enough information to make an informed decision?

After all, it's not as if it's news that too many women are losing their organs unnecessarily. This effort has been going on for decades. As I've pointed out in earlier blogs, the toll on women's sex lives and health is major, and for many, devastating. Women whose fibroids or bleeding or endometriosis could be treated without removing any of their organs get talked into a hysterectomy. Believing they have no other option, they consent to surgery to remove their uterus--which itself diminishes their sex lives and has other adverse effects--and often wake up to find that their doctor has gratuitously taken out their ovaries, too.

How can this be stopped? With about 600,000 women undergoing hysterectomies every year, what will it take to bring that number down significantly? After 28 years of counseling women, Nora Coffey, who founded HERS, believes required viewing of a video before consent may be the only way.

At the conference, Coffey said she had tried to have a conversation with a woman at the Indiana ACLU about her objections to the Indiana proposal, but had instead been on the receiving end of a loud scolding.

So, I decided to see if I could make sense of the objection, and found this explanation, written by VP, Legislation, Joan Laskowski, in the Spring, 2010 newsletter of the Indiana ACLU:

"Although civil liberty requires informed consent for medical procedures, this bill mandates ideologically inspired information that a woman must certify having read and understood, including risks, discomforts, irreversibility and resulting infertility...This simply parallels for conception the 'informed consent' requirements for abortion and compromises dignity and autonomy protected by reproductive liberty." (Bold face mine.)

Get it? What's disturbing the folks at the Indiana ACLU is the similarity of requiring women seeking abortions to view a video (or jump other hurdles) with efforts to prevent avoidable hysterectomies.

Laskowski, who did not return phone calls seeking comment, seems to be mistakenly assuming that the intent of hysterectomy information is to ensure that women stay fertile, to make sure they can still get pregnant. Note the word "conception" in her commentary.

This argument, of course, first of all ignores the reality that the only real concern most gynecologists have about cutting out a woman's organs is whether she still wants to have babies.

But the fundamental flaw in Laskowski's thinking is that she seems to have reflexively decided that because the form of these consent laws is the same for abortion and hysterectomy that both violate women's dignity and civil rights.

She fails to understand--or perhaps believe--that women are not fully informed by their doctors about the consequences of hysterectomy. This despite testimony at a hearing on the Indiana bill from women who said their doctors lead them to believe they had no choice but hysterectomy. They were coerced by misinformation, incomplete information, and fear-mongering--references to overblown risks of cancer.

It's also worth remembering that this is not the first time that women's health advocates have acted to intervene in the patient-doctor relationship on the grounds that women were not being told the whole story. In 1978, the U.S. Food and Drug Administration mandated that women be given informative information about birth control pills when they picked up prescriptions at the drug store. The FDA had tried years earlier to have doctors give women an informative handout, but the doctors had ignored the material or refused to hand it out.

In an ideal world, physicians' ethics would obligate them to provide women with complete information. But they haven't. The hysterectomy machine grinds on. Doctors and hospitals have financial incentives to keep it up--forever, unless there is a major intervention, yes, between them and their patients.

I teach ethics, with a focus on the media, but the principles for deciding if an action is ethical are the same regardless of the subject. Ethical dilemmas arise when all the means you have of dealing with a problem result in some kind of harm. In the case of the required showing of a video to a patient before consent, you are intruding on the doctor-patient relationship. You are turning an "I trust my doctor" simple decision into a more complex calculation that forces women to question their doctors.

On the other hand, there's the huge evil of avoidable hysterectomies. Since the goal is to protect women's health--not to force a woman to continue a pregnancy or to ensure she remains fertile-- you can ethically justify the intrusion of the video as less harmful than the surgery itself. The contents and tone of the video--or the text a woman must read--however, should be as inoffensive as possible.

This isn't the case with abortion consent laws. Abortion videos show gruesome pictures of actual abortions in what amounts to emotional blackmail. Oklahoma's new abortion consent law--stayed by the courts at the moment--requires women to undergo an ultrasound exam and hear a detailed description of the fetus before having an abortion.

The HERS video shows no gruesome pictures. Using drawings and a calm voice-over, the HERS video attempts to give a non-ideological picture of the functions of a woman's sex organs and their life-long importance to her health. A friend of mine who has spent decades working in the field of doctor and patient education finds some of the wording biased, so I'm sure it's possible to make it even more neutral.

If all women considering a hysterectomy had to view the video, tens of thousands every year might avoid losing their sex organs. Seems to me it's more than worth it to intrude on the doctor-patient relationship.

But if anyone has a better idea of how to stop the hysterectomy epidemic, please speak up. That includes you, Joan Laskowski.

The HERS Conference: Dr. Levine Delivers the Truth

The HERS conference last Saturday delivered a mountain of information in an atmosphere charged with sadness. Much of the audience was in tears listening to women tell about how they had become victims of doctors who continue to ignore the facts about avoidable hysterectomies.

In this first report on the conference, I'm focusing on Dr. Mitchell Levine, a remarkable, Boston-based gynecologist whom we would clone if we could. Here's my report:

Dr. Mitchell Levine, who teaches at the Tufts and Harvard Schools of Medicine, doesn't look much different from other tanned and fit 57-year old male doctors. But when he talks about women and their fate as victims of hysterectomy and removal of their ovaries, his tone because so respectful, even reverential, that it is unexpected, almost shocking.

"It's too sacred, it's too complex, to just take things out," he is saying as he sweeps a laser pointer over a full-color diagram of a woman's internal organs. But, he continues, taking a uterus out is so easy to do: "Clamp, clamp, clamp, clamp. Done." He demonstrates with four quick clenches of his hands.

Levine is speaking at the 28th conference of the HERS Foundation in a Manhattan hotel. He's telling the truth about the consequences of this surgery and why he believes that "at least" 90 percent of the 600,000 done each year could be avoided with other treatments, some as simple and cost-free as waiting.

It's a huge contrast to the paternalistic advice most women get: Your uterus is just a cradle. Done having children? Then you don't need it any more. But you'll still have the playpen! Wink. Wink.

And: You'll love life after your hysterectomy. No more periods!

And: If I end up taking out your ovaries, just think, no more risk of ovarian cancer!

"It's part of their training," Dr. Levine explains to me. "That these (the ovaries) are ticking time bombs. Instead, you end up shortening (a woman's) life because you've increased her risk of heart disease." Yes, that's right, a woman 40 to 44 whose ovaries are removed or which stop functioning as a result of a hysterectomy (that happens in better than one in 10 cases) faces twice the risk of heart disease as a woman with intact ovaries. This added risk more than outweighs the possibility of ovarian cancer, according to medical studies.

"Can you imagine if a man went to a doctor for a benign condition and the doctor said, 'I can fix that by cutting your nuts off?'" Levine asked with a laugh.

"He'd turn right around and walk away."

Indeed. Men would never voluntarily give up their virility, their joy in sex, to cure a non-life-threatening problem. They have no confusion about the fact that their organs are sex organs, not just baby-makers. Yet, women's organs have been labeled by the medical profession as "reproductive" instead of sexual, and the medical professions is more interested in us as baby factories than as sexual beings. So they talk us into castration for non-life-threatening fibroids and bleeding that can be managed in other ways. And we enjoy sex less as a result, some of us losing most if not all of our libido and some or most of our ability to feel sexual stimulation.

The situation has become more perilous for women as new surgical techniques make it possible to do hysterectomies on an outpatient basis.

Levine goes into detail about this. There's the traditional way, via a long abdominal incision; and then there are the newer ways, via the vagina or laparoscopically through small, abdominal incisions. For the small percentage of women who truly need their organs removed, these techniques are better, shortening recovery time from the surgery.

But regardless of how the surgery is done, there are the same consequences for women who could have avoided it. No matter how it's done, says Levine, removing the uterus "is still cutting the ligaments and the blood supply" to not just the uterus but to other organs as well.

As a result, 10 to 15 percent of women who have only their uterus removed lose the function of their ovaries anyway, apparently because of the loss of blood supply. This plunges them, whether they are 25 or 45, into an immediate and crushing menopause.

Furthermore, the ligaments that are cut are critical to the support of the bladder and bowel. When the uterus is removed, it leaves an empty space, and lacking their previous support, the other organs can sag and lean on each other. Urinary and bowel problems become much more likely.

The most common reason for hysterectomy is fibroids. But when Dr. Levine sees women with fibroids, hysterectomy is the last thing on his mind.

"For example, if a routine exam shows a fibroid, but the woman has no symptoms, I reassure her and say, 'See me in a year.'

"Or, if she's bleeding a lot but it's manageable, I just tell her to take some iron and wait" if she is near menopause. Estrogen, he explained, makes fibroids grow, and because estrogen levels drop at menopause, fibroids will then shrink.

If the bleeding is severe and menopause too far off, Dr. Levine may do surgery to remove them, leaving the uterus and ovaries intact.

Women at the conference asked what Dr. Levine would do if a woman had multiple fibroids--30 or even 50--or if some of them were very large. He answered that it didn't matter. He could still remove them, explaining that they are usually in a sort of capsule, like a hard boiled egg, and pop out when the capsule is cut.

But here's the kicker: Even though it takes longer to cut out fibroids and stitch the uterus back together than to do a hysterectomy--clamp, clamp, clamp, clamp--Dr. Levine gets paid less money to do the conserving surgery than to hollow out a woman's insides.

As U.S. Rep. Carolyn Maloney said at the conference, "Where is the outrage?"

Evidence Ignored by Doctors Removing Women's Ovaries

I have been deeply affected by the comments of women in response to my last blog about hysterectomy. Their lives have been devastated by--what should I call them? Ignorant? Arrogant? Unethical? Unprofessional? All of these?--doctors who continue to remove healthy ovaries from women in the face of evidence that they are causing irreparable harm to their patients.

Spurred by these comments, and by my need to prepare to attend the HERS Hysterectomy Conference this coming Saturday, I did some research and found a smoking gun right on the website of the American College of Obstetricians and Gynecologists. It's an August, 2005 article (scroll down the search page to the 7th article) that appeared in the journal Obstetrics & Gynecology. Apparently, it's not required reading for the practicing physicians who continue to castrate women.

Called "Ovarian Conservation at the Time of Hysterectomy for Benign Disease," it takes a comprehensive look at the risks and benefits of removing a woman's ovaries at the same time that she has a hysterectomy for non-cancerous problems like fibroids and heavy bleeding. As far as I can tell at this point, it appears to be one of the latest investigations of the issue, which, despite its importance to women, has not been the subject of much research at all.

Here are some of the conclusions:

• At no age is there any clear benefit to women from removal of the ovaries (oophorectomy).
  
• "For women younger than 65 at the time of surgery, oophorectomy increases the risk of dying from coronary heart disease."
• Evidence from the Nurses' Health Study says that the risk of heart attack was doubled if the women in question were between 40 and 44 years old; and up 40% if the women were older than 50.
• After losing their ovaries, women have higher bad cholesterol levels, higher blood pressure and more hardening of the arteries.
  
• Women who were past menopause when they had an oophorectomy ended up with 54% more bone fractures due to osteporosis than women with intact ovaries.
• The fractures often were of the hip, and having a hip fracture between ages 60 and 64 meant dying early--a loss of 11 years of life!
• It also means that many of those women could never leave their homes again on their own. One study found that before breaking a hip, 28 percent of the women were housebound; after the fracture, 46 percent were housebound.
  

So why do doctors continue to castrate women?

I certainly have no satisfactory answer to that.

But some, apparently, believe that the overriding benefit is to reduce a woman's chance of getting ovarian cancer. But this study notes that removal of the uterus alone lowers the risk of ovarian cancer by 40% below the level of women who retain their uterus.

So, let's see: since men have a risk of testicular cancer, should doctors be removing their testicles just in case? Or treating them with female hormones to reduce the risk of prostate cancer?

We women know that would never happen. Men prize their virility and do everything to keep it. Women prize their sexuality, too, but consent to hysterectomy and oopherectomy too often without realizing what they will be giving up. Thus the need for the HERS Foundation video and consent only after seeing it.

So, is it ignorance of the facts that keeps doctors castrating women? Or what? Theories--and certainly facts--welcome.

Tell the Truth About Hysterectomy!

Do women really get the whole truth about hysterectomy before consenting to this all-too common procedure? I know I didn't.

Nora Coffey, head of the HERS foundation, has been convinced for years that women do not realize that they will certainly lose some sexual feeling; will likely have problems with their bladders and bowels; that they may suffer back pain and see their waists enlarge as their internal organs and bones shift in place because where their uterus used to be is now an empty space. In the years since I underwent a hysterectomy in my mid-40s, I have suffered all of these symptoms, and my doctor never mentioned a single one. (It was a woman, by the way.)

On Friday, April 24, the foundation will hold its 28th Hysterectomy Conference at the Hilton New York Hotel in Manhattan to focus attention on an effort to require that women learn about all the possible consequences of hysterectomy before consenting to the procedure. The conference will feature an Indiana state legislator who is the first to introduce legislation requiring such disclosure.

And, the keynote address will be given by U.S. Congresswoman Carolyn Maloney of New York who will reportedly raise the issue of unnecessary hysterectomies in the House-Senate Joint Economic Committee, which she chairs. Experts estimate the cost of unnecessary hysterectomies at $17 billion a year.

I'll be covering the meeting for womensenews, a non-profit that specializes in news of particular interest to women.

But in this case, I certainly think that men would like to know about a medical procedure that will most definitely affect their sex lives along with their female partners!

The HERS foundation is advocating that women be required to view an 11-minute video it produced before consenting to hystserectomy. The video shows in a very matter-of-fact manner, using only color diagrams and voice-over-text, the story of female anatomy that somehow got left out of all our high school health classes.

"Women who watch that get it: they understand this is very serious surgery," says Coffey, who believes requiring the video is the only way to bring down the number of women who lose their uterus every year. As I've blogged about before, an astounding one out of every three American women have had surgery to remove their uterus by the time they are 60, and of those, 75% also lose their ovaries, the equivalent of male castration.

There is precedent for requiring the showing of videos: Utah, for example, requires women who are seeking an abortion to see one. Drug companies are required to put informative inserts into packages of medication, for example in birth control pills, thanks to the historic efforts of women's advocates including Barbara Seaman.

Losing your uterus is not like losing a tooth. Lose a tooth, and you can still chew with the others or get a false one to take its place. Each woman get's only one uterus, and it's so much an integral part of our bodies that you don't even realize you'll miss it until it's gone. And then, it's too late.

1 in 3 American Women Castrated

Castration is an ugly word, but it's the right word to use when talking about the 600,000 American women who have their uteruses removed every year! And of them, 438,000 simultaneously have their ovaries cut out also. One out of three American women over 60 lives on without her uterus or ovaries, and is never the same for their loss.

Never the same sexually: a woman who always had uterine contractions during orgasm can't have them ever again after a hysterectomy. Furthermore, even if her ovaries are not removed, sexual sensation is diminished because of the severing of nerves and lowered flow of blood to the vagina, labia and clitoris. If a woman consents to removal of her ovaries also, she is thrown into an immediate and crushing menopause.

As someone who underwent uterine removal in her 40s, I am speaking from personal experience, but to get a sense of how bad it is for women take a look at both the website of the HERS Foundation and its associated blog and comments. The foundation's mission is to stop this continuing assault on women by the medical profession. In their comments on the blog, young women, one only 16, others in their 30's and older describe not only devastated sex lives, but loss of energy, depression, memory loss, bone and joint pain.

Nora Coffey, president of the HERS Foundation, is campaigning for a law that would require that women receive complete information about hysterectomy before they consent. They aren't getting that now, with so-called patient education information limited primarily to talking about the uterus's function as a baby incubator. (You don't need it anymore, dear, do you? goes the spiel.) HERS has developed an 11-minute video that makes clear the uterus's other functions as a sexual organ and a muscle that supplies support to the bladder and bowel. The video should be required viewing before a woman gives her consent. In fact, there's a petition to sign to make that happen.

In no other country do so many women undergo hysterectomies, and the procedure is less necessary today than ever because there are now alternatives for treating bleeding from fibroids, for example, the single largest reason for hysterectomy. It's a scandal of which America's oby-gyns should be ashamed.