Hippocrates thought the uterus wandered and so drove women to hysteria, but in that belief he was the mad one. If anything, the womb is the body’s Atlas, bearing the weight not only of the human future but of bitter social and medical disputes.
The abortion debate can be viewed as a question of who owns the womb — woman or embryo. The most common surgical procedure in the United States is the much-criticized Caesarean section. And the second most common operation is another, more radical storming of the uterus, the hysterectomy.
The debate over hysterectomies is one of quiet fury. Nobody bombs surgical suites in protest, but for years critics have assailed what they call the hysterectomy industry.
They have campaigned vigorously against the prevalence of the practice, appearing on television and writing articles and books with names like “The Hysterectomy Hoax” and “No More Hysterectomies.”
They have complained that doctors are too quick to take out the uterus at the least sign of trouble, particularly with middle-aged women for whom the organ is supposedly past its purpose anyway. They have blamed greed by doctors and hospitals, pointing out that hysterectomies constitute a $3 billion-a-year business. They have accused surgeons of laziness, of liking hysterectomies because the procedure is relatively easy.
Each year, about 560,000 women in the United States undergo a hysterectomy, making a rate that is among the world’s highest.
At the same time, some in the field insist that rather than being bamboozled or railroaded into having surgery they do not want, many women decide on a hysterectomy only after rejecting the alternatives and after their symptoms become incapacitating.
“A number of recent studies of how women feel after hysterectomy have found that women are much more likely to find their life improved by hysterectomy than not,” said Dr. Joanna M. Cain of the Pennsylvania State University Medical School in Hershey. “We tend to look at this as an issue of there being too many unnecessary hysterectomies, but that may be in part because we don’t validate the pain and suffering some of these women go through.”
By the age of 60, one in three American women will have had her uterus removed. In Italy, by comparison, the figure is one in six women, while in France, it is only one in 18.
The reasons for having a hysterectomy vary widely and are accorded varying degrees of legitimacy. Few would argue against a hysterectomy in cases of cancer of the uterus, cervix or ovaries, but such instances account for only 10 percent of the total. The most frequent reason for having a hysterectomy is the presence of fibroids, benign growths of the uterine muscle that, depending on their location, can cause considerable pain and bleeding.
Other common reasons are sustained heavy bleeding, hormonal imbalances, endometriosis — the abnormal and sometimes painful growth of uterine lining tissue outside the uterus — and pelvic discomfort that cannot be explained.
Critics of the widespread use of hysterectomies emphasize not only the dangers of major surgery, but the role of the uterus in a woman’s lifelong physical, mental and sexual health. The womb, the shape and size of a small upside-down pear, has been regarded primarily as an incubator, a muscular and distensible baby sac that can become, in the view of one gynecologist, a “nuisance” after childbearing.
Yet some researchers insist that the uterus is an integral part of the body’s endocrine system and that it continues to perform essential functions even after menopause. Not only does it respond to hormones — as everybody who has menstruated is well aware — it creates a few compounds of its own. Among these are beta-endorphins, the body’s innate painkillers, and a type of prostaglandin called prostacyclin, which inhibits blood clotting. The loss of this source of prostacyclin could help explain why women who have had hysterectomies are prone to cardiovascular problems.
Nora W. Coffey, director of Hysterectomy Education Resources and Services, a non-profit counseling and information organization in Bala-Cynwyd, Pa., that she started after her own hysterectomy at age 36, contends that the effects of a hysterectomy are profound and that women must be warned of them in detail before undergoing the operation.
“The most frequent problems that women report are loss of energy and stamina, loss of physical and sexual sensations, diminished maternal feelings,” Coffey said. There are consequences of the anatomical change as well. “Without a uterus, you lose bladder support,” she said. “It’s very common to have urinary problems like leakage and increased urinary frequency. And the bowel moves down to take up the place where the uterus has been, so over time it can become very difficult to have a bowel movement.”
Sam Kirschner, a psychologist in Philadelphia who has counseled many women with hysterectomies, said that some became depressed and lost their sexual appetite without realizing the surgery might have something to do with it. For a number of women, the rhythmic contractions of the uterus and cervix during orgasm are an important part of their pleasure, and the loss of that capacity can leave them with a sense of lessened sexuality.
Coffey and many others also strongly oppose the practice of removing the ovaries along with the uterus, an additional bit of surgery that occurs in most hysterectomies even when the ovaries are perfectly healthy and are still carrying out their endocrinological tasks by generating estrogens, androgens and other hormones.
Doctors who perform such oophorectomies argue that for a woman in her mid-40s or beyond, the ovaries are nearing retirement anyway and that their removal prevents any future possibility of ovarian cancer, a particularly deadly malignancy that can show no symptoms until it is too late. The loss of the ovaries can be compensated for with hormone-replacement therapy, they say.
But critics deplore this method of cancer prevention and call the argument for it ludicrous. The same case could be made for other types of cancer, they say — for example, why not remove the testicles and prostate to preclude certain male malignancies?
“The ovaries do not atrophy at menopause,” Coffey said. “They continue to function, producing less estrogen and more androgen. This is natural and healthy.” When you remove a woman’s ovaries, she said, “you castrate her.”
Many surgeons now recommend leaving the ovaries in place, but even that is no guarantee. As it turns out, about a third of the time, the trauma of the hysterectomy damages the ovaries anyway.
Those who have sought to rein in the hysterectomy industry say there are many reasons it is slow going. Coffey argues that doctors almost never tell the whole story, minimizing side effects and obfuscating with jargon.
“If they told the woman, `I’m going to castrate you,’ that might turn the warning light on,” she said. Coffey said that over the past 14 years, she has counseled more than 100,000 women, from all over the world, and that, after speaking with her, the great majority decided not to have a hysterectomy.
Dr. Ivan K. Strausz, of Metropolitan Hospital in New York and the author of “You Don’t Need a Hysterectomy,” said the women’s health movement has helped reduce the number of hysterectomies in major cities, particularly on the East Coast, but that the status quo persists elsewhere.
“Unnecessary hysterectomies occur most often away from the major teaching hospitals, where the message just isn’t reaching women,” Strausz said. “Their gynecologists are not too intellectually motivated to do the right thing.” He said many of the worst abuses were hysterectomies performed for non-specific, chronic pelvic pain.
“Recent information shows a hysterectomy only works for about half these cases,” he said. “And when it doesn’t work, the woman is devastated.”
Some have suggested that the reason American women have so many hysterectomies is that they visit the gynecologist too often. By this argument, the doctor performs a routine pelvic exam, finds a few benign uterine fibroids that had not been bothering the woman, plants seeds of worry in her mind, and, at the first signs of even a minor problem, out comes the uterus. European women undergo fewer hysterectomies, these critics say, because they do not go to the doctor unless they are ill.
Others who are less quick to condemn the entire gynecological profession say that paternalism and arrogance can cut both ways. They agree that some hysterectomies may be unnecessary, but they point out that many women feel better afterward than they have in years. Women who have had hysterectomies and are happy with their choice say they resent being told they are lying to themselves.
“What we fail to understand is there’s a significant group of women who are quite well educated and who don’t want to keep their uterus,” Cain said. “I have found myself in the odd position of arguing for alternatives with women who say, `I know about the alternatives, and I don’t want any of them. I just want this weight off of me.’ “
