xThere has long been a big discrepancy between what doctors tell women about the aftereffects of a hysterectomy and what is reported in the medical journals. And nowhere is the information gap more apparent than in the area of sexuality. Female sexuality is entirely in the mind, according to the basic tenets of gynecologic medicine, and anyone who reports sexual dysfunction following hysterectomy is either an aberration or a neurotic complainer. The prevailing medical attitude is difficult to understand considering that the operation was originally promoted in the 19th century as the cure for “excessive sexual desire.” What’s more, it ignores the last 25 years’ worth of research on female physiology.

Once the techniques for delivering anesthesia were perfected in the late 19th century, it became “open season” on the female reproductive tract, as the authors so aptly put it in a new book called The NoHysterectomy Option by Herbert A. Goldfarb, M.D., and Judith Greif, M. S. Hysterectomy is the second most common major operation in the U.S. It is primarily performed on women in their 30s and 40s, and in about 40% of all who have the operation, the ovaries are removed along with the uterus (oophorectomy). About 660,000 hysterectomies are performed annually in the U.S. If the trend of the last 12 years continues, one out of every three American women will not make it to the age of 60 with an intact uterus, according to the most recent calculations of the Metropolitan Life Insurance Company.

There is no question that it can be a life-saving operation for women who have cervical or uterine cancer and those who, in the rare instance of an obstetrical complication, require an emergency hysterectomy. In such circumstances, the risks of surgery are outweighed by its obvious benefit. These examples, however, represent less than 10% of all the reasons the operation is performed. Concerns that the operation may often be unnecessary and that women may not be receiving in-depth information on after, effects have triggered informed consent legislation in California and New York requiring hospitals or doctors to provide women with details on risks and alternatives to hysterectomy.

The question of how many hysterectomies, if any, are unnecessary is open to debate. In 1981, a study published by the U.S. Centers for Disease Control found 15% of hysterectomies were “questionable,” and this year, Blue Cross/Blue Shield of Illinois found one-third to be medically unnecessary. When the American College of Obstetricians and Gynecologists (ACOG) looked into the question recently, it found no evidence of unnecessary surgery, a spokesman told HEALTHFACTS. The well-documented regional variations in hysterectomy rates are difficult to explain. A woman under the age of 45 living in the South, for example, is more than twice as likely to have her uterus removed than her counterpart in the Northeast.

“Hysterectomy is associated with a substantial complication rate; one-fourth to one-half of women who undergo hysterectomy for all indications will sustain one or more complications,” wrote Charles L. Easterday, M.D., and colleagues at ACOG and the Centers for Disease Control (Obstetrics & Gynecology, August 1983). Fever is the most common complication, and as many as one in every ten women who undergoes hysterectomy will require a blood transfusion due to hemorrhage. Depression, sexual dysfunction, bladder lacerations, development of chronic pain in the intact ovaries, and adhesions (scar tissue from the surgery) were also found to be common.

Compared to other major operations, the mortality rate for hysterectomy is low-perhaps because the operation is primarily performed on younger women. But its death rate of one out of every 1,000 operations should be looked at in the context of overuse. If, for example, the Blue Cross/Blue Shield study is correct in its estimate of one-third unnecessary hysterectomies, this would mean that over 200 American women die each year because of an operation they didn’t need.

The debate over its usefulness is likely to continue for some time because of the lack of well-designed studies to identify the appropriate indications for hysterectomy. Incredibly enough-considering the prevalence of this operation-the first steps toward this end have been taken only recently. The results of these studies, now in progress, will not be ready for two years.

Until more research is published, we are left with agreement among physicians on only two indications: cancer is a good reason for having hysterectomy and sterilization is not (there are safer alternatives). In between these two extremes lies a large grey area that encompasses the majority of the reasons why this operation is performed. They include excessive bleeding (menorrhagia), fibroid tumors of the uterus (myomas), sagging of the uterus into the vagina (prolapse), pelvic pain, and a disease called endometriosis in which tissue fragments of the uterine lining migrate outside the uterus causing pain and discomfort. More than half of the healthy adult female population has one or more of these conditions at any given moment. Many find the symptoms painful or distressing enough to seek treatment. In short, hysterectomy is performed primarily to improve the quality of life in women with conditions that are not life-threatening.