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!

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.

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.

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.

Gender Diffferences in Treatment of Heart Problems

This is my first blog post in weeks due to emergency treatment for blockage of a coronary artery and then a hemorrhage that left me with untreated anemia for a week. After suffering with the symptoms that result from the loss of well over a quart of blood, I finally received a transfusion of two pints of blood. It's been a slow climb back, but I am now close to feeling my usual amount of energy.

The episode has once again turned my attention to gender differences in health care.

I first addressed this topic in my book, Women Pay More (New Press, 1995). At the time, women were still not being treated as early as men for symptoms of heart disease or coronary artery disease, although heart disease was, and still remains, the leading cause of death for women.

In my case, after a stress test showed the likelihood of a blockage in a coronary artery, a local cardiologist immediately told me I needed a cardiac catheterizataion, an amazing procedure in which instruments are inserted from a point in the groin through the femoral artery up to the heart. The doctors who do these procedures, interventional cardiologists, can then see an image of the coronary arteries, determine the extent of blockages, clear them and then insert one or more stents to hold them open. In my case, I needed one stent. I've since heard from one friend after another about people who have 3, 6, 9 stents holding open their arteries. Who knew?

All this went just fine until I began to hemorrhage internally, and suddenly realized there was a small crowd around my bed. Two doctors were pressing on my abdomen, working to stop the bleeding. My abdomen swelled up, my husband says, about an inch and a half. After some time, I can't say how long, they seemed to have stopped the bleeding.

The next morning, without further discussion of this bleeding episode, I was sent home. This was at St. Francis Hospital in Roslyn, New York, reputedly one of the very best hospitals for heart problems.

After a week of feeling absolutely horrible, I returned there to be subjected to a bunch of tests which finally ended with the conclusion that this bleeding had indeed made me anemic. The two pints of blood relieved my worst symptoms (shortness of breath, pounding heart, fever), and home again I went. I'm slowing getting back to my usual routine of swimming, long walks, golf, tennis, etc. A couch potato I'm not.

Now, here's the kicker: women are twice as likely as men to suffer complications after a cardiac catheterization, according to a comprehensive research study published in the Journal of Invasive Cardiology. Why? No one seems to know. A commentary on the article suggested that women may just react more strongly to the usual anti-coagulant drugs that are given before the catheterization. It is not clear that this is related to body size, hormonal differences, or other factors. Or if the vascular sealing device used by my surgeon and other surgeons--instead of manual pressure for a half hour, followed by putting weights on the site and forced immobility--fails more in women than men.

The surgeon who did my procedure probably does 50 of these per week, and the hospital itself has more than a half-dozen catheterization labs that are in constant use. So it seems reasonable to wonder if extra attention should be paid to complicatons in women. In my case, that surely did not happen.

Anyone with similar experiences?