Thousands of British women have hysterectomies each year - and yesterday, the Duchess of Cornwall became one of them. But all too often, this invasive approach is completely unnecessary, says Dr Ann Robinson.
The Duchess of Cornwall is recovering well after her hysterectomy yesterday. She’s in the plush, hushed private hospital favoured by the royals, King Edward VII in London. It’s a world away from a frenetic NHS ward and she’s expected to stay until the end of the week.
She’s in good company in having her womb removed. Hysterectomy remains one of the commonest operations in the UK, with 8,000 women a year having it done. But many of these operations are unnecessary and could easily be avoided. Many experts feel hysterectomy should be reserved primarily for women with cancer or the most severe kind of prolapse in which the womb flops down into the vagina, causing discomfort and incontinence.
In fact, the operation is still often performed for heavy periods, even though current medical thinking and National Institute for Health and Clinical Excellence guidelines say it should be the last resort. Consultant gynaecologist Nick Morris, from St John and Elizabeth’s Hospital, London, blames GPs for failing to prescribe the right treatments for heavy periods. “GPs don’t prescribe enough tranexamic acid (a drug that reduces blood loss) or recommend the Mirena coil (which is fitted in the womb and releases the hormone progestogen) nearly enough,” he says. “They still prescribe the drug norethisterone, which is a waste of time and can cause terrible PMT.”
Morris says there are other excellent ways of dealing with heavy periods. “For women aged 45 to 52, when heavy periods and flooding can be a major problem, I recommend a new technique known as NovaSure,” he says. This gold wand is inserted up the vagina and into the uterus. Then it’s opened like an umbrella to measure the exact level of electrical current that is needed to safely destroy the uterine lining (endometrium). A 90-second blast of electrical current fries the endometrium so that the woman is unlikely to ever have periods again. Its use is restricted to women who no longer want to get pregnant, as the uterus won’t support a pregnancy after this procedure. The NovaSure technique is one of the newer ways of destroying the endometrium, which cures the heavy bleeding without needing to remove the whole uterus.
The Value National Hysterectomy study looked at all hysterectomies carried out in England, Wales and Northern Ireland during 12 months in the mid 1990s. Nearly half of the operations were performed because of heavy periods. The authors of the study felt that up to 75 per cent of the women with heavy periods could have been offered alternative treatments, such as endometrial destruction (or ablation).
The study also highlighted the fact that having a hysterectomy is no picnic. Complications occurred during one in 30 of the operations, and usually involved heavy bleeding and occasional serious problems, such as rupture of bowel or bladder. One in 130 women need to return to theatre because of problems like bleeding.
All major operations also carry a small but significant risk of anaesthetic complications, pain, infection, bleeding and blood clots. And even if a hysterectomy goes smoothly, as most do, it takes about six weeks to get back to normal. In the Value study, the ovaries were removed in nearly half of all hysterectomy operations, even if there was nothing wrong with them. The thinking is that if you haven’t got your ovaries, you can’t get ovarian cancer. But removal of the ovaries catapults you straight into the menopause, with the hot sweats, flushes and mood changes that can accompany it.
Controversially, Morris also feels that up to 30 per cent of women who see a gynaecologist have a psychological problem that also needs to be addressed. He worked with a psychotherapist in his clinic and found that although he saw as many patients, he carried out far fewer operations. As women had more chance to talk about their concerns, the rate of operations and interventions fell.
Women with heavy periods have many options to consider before opting for hysterectomy. Anti-inflammatory drugs like ibuprofen or mefenamic acid are good for pain and may slightly lessen the blood flow. Tranexamic acid is a drug taken for the few days of heavy bleeding, which encourages blood to clot quicker so you bleed less. The contraceptive pill is good if you need contraception. The Mirena coil is a fabulous choice if you want light-to-non-existent periods and aren’t thinking of having a baby in the next few years. If these fail, then a minor operation to destroy the endometrium is the next step. The menopause gets a bad press but of course it does mean that your periods stop. Many women with heavy periods in their late forties know that time is going to solve the problem within a few years.
So if hysterectomy is an admission of failure in the treatment of heavy periods, is it ever a good first choice? In Morris’ opinion, the Duchess has probably had a severe prolapse with enterocoele, in which case hysterectomy is the best option. In a prolapse, the support system holding the uterus in place sags and the uterus starts to head south. In most cases, women feel “something coming down” as the uterus bulges down into the vagina. When they cough or sneeze, the increased pressure in the abdomen and pelvis push the uterus even further down. In the most severe cases, the cervix and uterus bulge out of the vagina and can become ulcerated and sore. Stress incontinence, in which a woman wets herself whenever she coughs, sneezes or runs, is a common related problem. To add insult to injury, the bladder can bulge backwards and loops of bowel can bulge forward into the vagina, so a woman ends up feeling like she’s carrying her entire pelvic contents in her vagina. Sex becomes a very unattractive idea. Alternative forms of treatment for severe prolapse are pretty poor.
You wouldn’t catch me having a hysterectomy unless I had cancer or a severe prolapse. Women are starting to ask more questions and look for alternatives, and the rates of hysterectomy are falling fast. But not fast enough.