The continuing debate about whether hysterectomy is overused is an issue of great importance for the many women who will ask themselves at some time in their lives, Ts a hysterectomy really necessary for me?’ The debate has been fuelled by findings of large variations in rates of hysterectomy between and within countries for no apparent reason. The United States has the highest rate, followed by Canada, New Zealand, Australia, Holland, England, Wales, Scotland, Sweden and Japan. The disparities are large, with at least three women in the US having hysterectomies for every one in Scotland, and Coloured women traditionally having twice as many as White women.
Various suggestions have been made to account for these differences in hysterectomy rates. It is possible that there are specific inherited tendencies for the development of certain gynaecological diseases in different countries and ethnic groups. Equally, the explanation may lie in environmental factors or lifestyle habits, for example nutrition, physical activity levels, or even methods of sanitary protection or contraception. Perhaps women in some countries are more assertive in taking control of their lives and bodies; or maybe cultural differences in perceptions of the uterus are important — some cultures viewing it as essential to womanhood, others regarding it as an optional extra once the desired family size is reached. Other plausible explanations for variations in rates of hysterectomy are that views about what constitutes a ‘normal’ bleeding pattern differ from country to country as does the acceptability of menstrual disturbances within intimate relationships and the paid workforce. Yet other reasons suggested for the large variations in rates of hysterectomy include different opinions about its acceptability as a sterilisation procedure, particularly among couples for whom religious beliefs preclude other forms of family planning.
Unable to replace the blood, doctors resorted to all kinds of techniques to stop the bleeding. These included hysterectomy and radiological methods of inducing menopause such as bombarding the ovaries with X-rays or placing radium rods in the vagina. A contemporary example of changing medical definitions of illness is the recent claim that menopause constitutes a ‘disease’ and that the cure is to prescribe hormone therapy for all women. This may have implications for hysterectomy rates because, as noted by the US Congress Office of Technology Assessment, women receiving hormone therapy are more likely to undergo hysterectomy, possibly because bleeding is a common side-effect of its use. It has also been claimed that some health systems encourage high rates of hysterectomy through methods of health financing that encourage swift surgical ‘solutions’ rather than more prolonged treatments; the expectations of surgeons that hysterectomy should be part of their professional work and source of income; the availability of hospital beds; and the extent to which doctors get paid for the number of operations they perform.
Most studies that have examined the characteristics of women who have hysterectomies are in agreement on one point at least — the fewer the years of high school or college education, the more likely a woman is to have a hysterectomy. Complementing this rinding, a recent study in the US State of Maine has found that better-educated women are more likely to have non-surgical treatments for fibroids, abnormal bleeding or chronic pelvic pain, all common reasons for hysterectomies. In view of the consistent link between lower education levels and hysterectomy, it is difficult to explain the seemingly contradictory finding that the wives of medical practitioners have more hysterectomies proportionately than other well-educated groups in the US.
Another interesting finding to come out of the Maine study is that women who agree to hysterectomies have symptoms that are both more severe and more incapacitating than women who seek relief through non-surgical approaches. They often endure debilitating symptoms for several years before deciding on hysterectomy. Other studies have revealed that women having the surgery are more likely than average to be overweight, to have diabetes or to have high blood pressure. With some notable exceptions, such as US doctors’ wives, hysterectomy, poor health and low education levels seem to go hand in hand. Researchers studying the phenomenon of hysterectomy rate variations agree that no simple explanation can account for these differences.