Women's Health - May 2004

Hysterectomy Leads To Improved Symptoms And Satisfaction

Studies Compare Medication Therapy To Surgical Procedure

Two new studies on hysterectomy and quality of life conclude that, while there is a place for surgery in easing abnormal bleeding, making this choice usually depends on the individual woman.

The reports, presented in the Journal of the American Medical Association (JAMA), show that about 50 percent of the women taking medication to control bleeding eventually had a hysterectomy because of dissatisfaction with the more conservative therapy.

Hysterectomy, which is the surgical removal of the uterus, is the most common major surgical procedure performed in the US for non-obstetric reasons, according to one of the study reports.

In 2000, about 633,000 hysterectomies were performed. Women in the US have an estimated 25 percent risk of having their uterus removed.

The authors note that usually a hysterectomy is elective and performed before menopause for abnormal uterine bleeding and other non-life-threatening reasons.

"It's kind of a judgment call," says Dr. James R. Scott, co-author of an editorial accompanying the two studies in JAMA. "It depends a lot on the woman. A lot of women don't want surgery. Others say they're just tired and want to get it done."

Research Delves Into Satisfaction, Outcomes

There has been a great deal of debate about whether this type of surgery is performed too often. It is, after all, major surgery. It involves significant recovery time, discomfort, and, like all surgery, a small risk of death.

The studies may provide new information that will lessen the negative reputation that is sometimes associated with hysterectomy.

"Hysterectomy has had a bad name, and it probably isn't as bad as has been implied - by some, anyway," says Dr. Scott, who is also editor of Obstetrics & Gynecology.

The first study randomly assigned 63 premenopausal women with abnormal uterine bleeding to receive either a hysterectomy or "expanded medical treatment," including hormone therapy.

The women, all of whom had tried and stopped the hormone therapy medroxyprogesterone, were followed for about two years to assess their mental health and quality of life.

After six months, women in the hysterectomy group showed greater improvements in overall mental health than women in the medication treatment group.

They also had greater improvement in symptom resolution, symptom satisfaction, interference with sex, sexual desire, health desire, sleep problems, overall health, and satisfaction with health.

Interestingly, at the end of two years, more than half (53 percent) of the women in the medication group had requested and received a hysterectomy and reported improvements.

Women who continued with the medications also reported improvements, indicating this course of action may eventually lead to improved quality of life.

In sum, though, hysterectomy seemed to come out ahead.

Women Must Weigh Information, Choices

Dr. Miriam Kuppermann, author of the first study, says, "Women who have abnormal bleeding that have tried medicine and hasn't worked well, [then] hysterectomy is a very good option for them - not that every woman should have a hysterectomy." Kuppermann is an associate professor of obstetrics, gynecology, and reproductive science at the University of California San Francisco.

"For women who have not been adequately treated by medicine, hysterectomy is a worthwhile option to consider," she says.

On the other hand, if a woman really does not want the operation, she can expect to get some benefit from medications, Dr. Kuppermann adds.

Dr. Kuppermann points out that the study was small and reflected the difficulty of finding women to participate who were willing to be placed in either group. She says it is "unclear" whether these women represent the entire population of women choosing between medication and surgery.

The second study, taking place in Finland, compared levonorgestrel-releasing intrauterine system (LNG-IUS) with hysterectomy in women with menorrhagia, the medical term for unusually heavy menstrual bleeding.

Levonorgestrel is a hormone. In Finland, the LNG-IUS is approved for contraception and treatment of menorrhagia while, in the US, it is approved only for contraception. Leiras Co. (now Schering) provided the LNG-IUS free of charge.

Here, the researchers randomly assigned 236 women at five university hospitals in Finland to be treated with the LNG-IUS or hysterectomy. All women were monitored for five years.

The two groups were similar in terms of health-related quality of life and psychosocial well-being. As with the first study, however, a sizable proportion (42 percent) of the women in the nonsurgical group eventually opted for a hysterectomy.

Dr. Kuppermann says, "I can speak more to the [San Francisco] Bay Area. Here, there really has been an emphasis on trying every last thing before resorting to hysterectomy. This [study] may have an impact. It may introduce hysterectomy as an option earlier on.

"There are a lot of choices," Dr. Kuppermann says. "Hysterectomy is a viable option. There has been so much press about overuse, but realize that for that situation, it is a very effective option."

Always consult your physician for more information.