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.

An "Essential" Guide to Hysterectomy That Isn't

The title, Women's Hysterectomy Stories:  The Essential Guide," gave me great expectations. Here, available on line for $17, was an e-book that I thought might help to enlighten women about the perils to their long-term health and sexuality from hysterectomies.

So, I sprung for the $17. And was sorry that I did.

This book, written by Ruth Steeves and promoted on her website, Hysterectomyresources.com, is only for you if you've already made up your mind that you really need a hysterectomy. It will advise you about making arrangements in advance of your surgery for child care, and meals, and what to expect in the hospital, and once you get home.

But just like HysterSisters, which is promoting the daVinci robotic system for the surgery, this book and Steeves' website see the epidemic of hysterectomies through rose-colored glasses. The goal is to eliminate your anxiety about having a hysterectomy.  The furthest they go in bucking the medical establishment is to encourage women to get a second opinion.

HysterSisters has actually launched a "Give Me a Second" campaign whose purpose is "to strengthen the doctor-patient relationship, to improve women's quality of care through awareness of minimally invasive surgical procedures (italics mine) and to increase confidence in their healthcare decisions."

Once again, it's all about finding a doctor who will use laparoscopy or robots for a less traumatic hysterectomy. Not to avoid one altogether and survive with your organs intact.

The problem with the generic advice to get a second opinion is that too many gynecologists disregard all the evidence about the serious after-effects of hysterectomy and removal of the ovaries and won't volunteer any information about them. These are not side-effects--like an infection due to the surgery--but long-term adverse impacts on health and sexual pleasure.

Without a uterus, a woman can not experience what some refer to as a full-body orgasm in which the uterus pulses rthymically. That is not an opinion. It's an incontrovertible fact, but the gynecologist who will warn you about that is a rare individual. You also won't hear about your increased risk of future bladder and back problems, or about your much higher risk of heart attack if your ovaries are removed. There's no controversy at all about these after-effects of hysterectomy. The evidence has been reported in medical journal articles repeatedly over the last several decades.

Yet, to justify the supposed joy of hysterectomy, The Essential Guide  tells one anonymous woman's tale of painful periods ever since she had her first, and her gloriously wonderful life after hysterectomy.

Other than that one, there are only three other stories included as MP3 downloads or PDFs. One of the women had uterine cancer (an absolutely valid and unavoidable reason for a hysterectomy); another had to be on blood thinners for another condition and this had serious effects on her periods (how common is that one? and who knows what alternatives she had?); and the third said she had "passed out" every time she got her period. Again, thankfully, not a common experience. All end up as testimonials for Steeves' book.

That said, yes indeed, women should get second opinions. And third and fourth, if need be, until they find a doctor whose practice is focused on avoiding hysterectomies, not doing them. Some medical centers now have specific hysterectomy alternatives centers. Search for them. But first, arm yourself for these discussions by learning about the anatomy of our reproductive organs and the essential role they play in our health and pleasure for as long as we are alive.

To get that information, I once again recommend the HERS Foundation website where you can watch a plain vanilla explanation, with diagrams but not any sort of bloody video, of the functions of your uterus and organs. You'll be grateful for investing 10 minutes of your time to save your future health and pleasure.



 

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.

Post Reporter Right to Challenge Paladino

I have to admit I got a good laugh out of the confrontation between a NY Post reporter and Carl Paladino, the Republican candidate for governor of NY State. But it was not just great entertainment. It also offered a good look at a reporter trying to do the job right.

Fred Dicker pressed Paladino for evidence to back up his charge that Andrew Cuomo is an adulterer, just like Paladino himself, who has admitted not only an affair but that he fathered a girl who is now 10. Paladino's admission, of course, was tactical. Rather than wait for someone to out him, he tried to neutralize the situation by openly discussing it. But apparently not satisfied with the public reaction, he accused Cuomo of the same sin.

Too often, reporters respond to this type of situation with what journalists refer to as "he said, she said" stories. That is they report the allegation and then the denial, making no attempt to tell the public who is right. This is what sometimes passes as "objective" reporting, when instead it should be called "stenographic" reporting--just take down what everyone says and put it into some grammatical sentences.

Fred Dicker, on the other hand, was doing what good journalists do: demanding verification of Paladino's charge. He wasn't content to just offer an assist to the mud-slinging unless Paladino showed him the evidence.

His reward was to be called "biased" and a "stalking horse" for the Cuomo campaign. Paladino sounded like a mobster when he told Dicker, "I'll take you out." But one of Paladino's aides caught on the video trying to separate Dicker from the candidate made another threat, one that usually cows journalists into being stenographers. He told Dicker, "You're off our campaign list. You get nothing more from us."

To a reporter, that's a threat with teeth. It means no access to the candidate, no easy way to get comments or advance word about upcoming appearances or policy papers. Ready access to powerful people makes a reporter important to his or her news organization. In Washington, D.C., it makes reporters powerful, virtually guaranteeing front-page or top-of-the-broadcast position.

It also can make reporters dupes for politicians' lies, tools for efforts to sell a war or advance legislation harmful to the public. As we sadly learned about the selling of the Iraq war with a heavy assist from New York Times reporter Judith Miller, a buddy of Dick Cheney.

So it was refreshing to see veteran Albany reporter Fred Dicker get in Paladino's face and demand the evidence.

I showed the video to my Media Ethics class at Hofstra University as an example of a reporter with ethics trying to do his job. Ethical reporting starts with seeking the truth, and Fred Dicker modeled that for everyone to see.

I hope Dicker's career thrives after this episode and that he gets the credit he deserves for doing the job the way it should be done. Washington reporters could well take a lesson from him.

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.