Hysterectomy: When Does It Become Necessary?

Are more women in their 40s and 50s opting to get their uterus removed?

India has low rates of hysterectomy. According to the National Family Health Survey 2016, only 3.2 percent of Indian women (aged 15-49) underwent hysterectomy. However, the numbers in some states are staggering – 47 and 42 percent in Telengana and Andhra Pradesh. Yet not so staggering as in the US where over 600,000 women undergo hysterectomies (removal of uterus surgery) every year. Soon 1 in 3 women above the age of 60 will not have a uterus.

That’s a glaring statistic, but does it apply to urban India? In a straw poll I did among 9 women between the ages of 40 to 55, 3 had their uterus removed. (Doctors assure me it’s an abnormally high statistic.) All of them had fibroids.

A friend I spoke with says for her it was a lifestyle choice. While the fibroid itself was not that painful, but the heavy bleeding during menstruation made it very difficult to move around. The heavy pressure on her bladder meant she had to run to the loo often.

In her 40s, with two kids, it was not a difficult choice. While the uterus was removed surgically, her ovaries and fallopian tubes have been left intact.

Why do Women Get Hysterectomies?

The most common reasons why hysterectomies are done include:

• Ovarian, Uterine and Cervical Cancer: In such cases the entire uterus, cervix and lymph nodes are removed.
• Endometriosis: It’s a painful condition where some tissues that should be growing inside the uterus, start to grow outside – sometimes on the bladder, on bowls - making pain unbearable, especially during their period.
• Fibroids: Non malignant growth on the uterus

Hysterectomy as an option is presented by doctors largely when the woman has passed the child bearing age. Most doctors are reluctant to remove uterus in women between the age of 20 to 40.

In 2018, Lena Dunham, an actor/comedian and a pop culture icon in the US wrote an essay in the Vogue magazine about getting a hysterectomy at the age of 31. She suffers from endometriosis and the condition had left her delirious with pain. Her doctors agreed to do the procedure only after two independent therapists had assessed her.

View this post on Instagram

Yesterday I had a two hour surgery to remove my left ovary, which was encased in scar tissue & fibrosis, attached to my bowel and pressing on nerves that made it kinda hard to walk/pee/vamp. Over the last month it got worse and worse until I was simply a burrito posing as a human. *** My mother took this picture after I spent 9 hours in the post op recovery area with v low blood pressure that the nurses were diligently monitoring. I was so out of it that I thought I looked sensually moody a la Charlotte Rampling (turns out it was more of a constipation vibe.) *** A lot of people commented on my last post about being too sick to finish promoting my show by saying my hysterectomy should have fixed it (I mean *should* is a weird one). That I should get acupuncture and take supplements (I do). That I should see a therapist because it’s clearly psychological (year 25 of therapy, y’all. These are the fruits!) But a big lesson I’ve learned in all of this is that health, like most stuff, isn’t linear- things improve and things falter and you start living off only cranberry juice from a sippy cup/sleeping on a glorified heating pad but you’re also happier than you’ve been in years. I feel blessed creatively and tickled by my new and improved bellybutton and so so so lucky to have health insurance as well as money for care that is off of my plan. But I’m simultaneously shocked by what my body is and isn’t doing for me and red with rage that access to medical care is a privilege and not a right in this country and that women have to work extra hard just to prove what we already know about our own bodies and beg for what we need to be well. It’s humiliating. *** My health not being a given has paid spiritual dividends I could never have predicted and it’s opened me up in wild ways and it’s given me a mission: to advocate for those of us who live at the cross section of physical and physic pain, to remind women that our stories don’t have to look one way, our pain is our gain and oh shit scars and mesh “panties” are the fucking jam. Join me, won’t you? *** 📷 @lauriesimmons

A post shared by Lena Dunham (@lenadunham) on Oct 17, 2018 at 6:47am PDT

Unfortunately, in parts of rural India no counselors are around and women in their 20s and 30s are advised to remove their uterus for even the most minor ailments, according to this report. Lack of education and awareness means they are willing to go ahead with the surgery recommended by the doctors.

When Do You Need It?

Removal of the uterus has been linked to a host of health problems. Removal of ovaries along with the uterus is known to advance menopause by as much as 15 years. Lack of estrogen is linked to heart disease and osteoporosis.

So who should get a hysterectomy? We spoke with Dr Deepa Dewan, Associate, Director and Head of Unit - Obstetrics and Gynaecology, Max Hospital, Gurgaon. She says the increasing number of hysterectomies in the women in their 40s and 50s comes from awareness.

They are more aware. Earlier women would have lived with their painful symptoms considering them to be the norm. Now there is awareness, they come to us and after complete medical investigation if we find hysterectomy is the answer, we present it to them.

Dr Deepa Dewan

Only 1 in a 1000 fibroids may turn cancerous and hysterectomy is not the first line of treatment. Fibroids can be removed surgically. Other medical interventions exist that don’t involve removal of the uterus.

Hormone releasing interuterine device (IUD) are known to be effective in tackling heavy menstrual bleeding.

But if a woman in her 30s comes to the doctors, the approach remains conservative.

If a patient in her 30s was to come to me for a hysterectomy to treat her endometriosis, I’d advise her to opt for medical approach first. If she wishes to have a family, to complete that process before opting for hysterectomy. In endometriosis, quite often, removing of ovaries becomes essential to remove pain.

Dr Deepa Dewan