ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Tuesday, March 12, 1996 TAG: 9603120102
SECTION: EXTRA PAGE: 3 EDITION: METRO
COLUMN: Personal Health
SOURCE: JANE BRODY
Marie Natale's gynecological problems began 16 years ago. When she was 29, shortly after her son was born, she developed pelvic pain and excessive bleeding caused by extensive growth of uterine tissue outside the uterus that pressed on other organs and bled into the pelvic cavity.
She had surgery to remove the errant tissue and relieve the distress, but two years later, the pain returned.
This time, the cause was uterine fibroids. A hysterectomy was recommended, but Natale hesitated, having heard many reports about unnecessary hysterectomies.
Instead, she struggled to endure the increasing discomfort caused by the enlarging fibroid, complicated by a return of her endometriosis.
Finally, barely able to walk because of the pain and finding no other treatment, she decided to have a hysterectomy.
Because she had waited so long, her fibroid was too large to permit a vaginal hysterectomy and she had to have the more debilitating abdominal operation.
But she is not sorry. For the first time in 10 years, Natale says she is free of pain and anxiety and ready to resume her busy life with enthusiasm instead of fear.
Natale's experience is a classic example of a helpful health message gone awry. For much of the last two decades, women have been warned repeatedly that too many doctors are operating to remove uteruses more to line their pockets than to help women live better lives.
Indeed, studies showed that many hysterectomies could not be medically justified. Women wisely started asking questions when their doctors recommended hysterectomy, insurance companies started looking more closely at surgery rates, and doctors began exploring alternative therapies and redefining circumstances that would make hysterectomy the treatment of choice.
The result has been a sharp decline in surgery rates, from 724,000 in 1975 (a rate of 8.6 per 1,000 women) to 580,000 in 1992 (a rate of 5.6 per 1,000 women). And many experts say the rate should fall even lower.
But the concern about overuse of hysterectomy has had some negative effects as well. Some women have become so frightened or wary of hysterectomy that they refuse to have the operation even when they really need it.
Dr. Robert Barbieri, who heads the department of obstetrics and gynecology at Brigham and Women's Hospital in Boston, pointed out that, by waiting too long when hysterectomy is necessary, women may be unable to have the procedure done vaginally, which results in more complications, a longer hospital stay and slower recovery and return to normal activities.
Barbieri, Dr. Thomas Stovall, a gynecologist at Wake Forest's Bowman Gray School of Medicine in Winston-Salem, N.C., and Dr. Robert Summitt Jr., a urogynecologist at the University of Tennessee College of Medicine in Memphis, recently outlined the five main reasons for performing hysterectomies:
Uterine fibroids: These benign tumors, which form in the muscle layer of the uterus, account for a third of all hysterectomies. Fibroids do not get better on their own, but if they do not grow and cause no medical or cosmetic problems, current thinking is to leave them alone.
But when fibroids become very large, cause severe pelvic pain or pressure, or cause abnormal bleeding, a hysterectomy may be necessary, Barbieri said.
Endometriosis: Endometriosis can become so disabling that women cannot go to work or school or lead normal, active lives. When the disease is advanced in women who have completed their families, and hormone treatments and more conservative surgery fail to bring adequate relief, a hysterectomy becomes the only alternative to continued suffering, Barbieri said.
Urogenital prolapse: As women age, the tissues that support pelvic organs may become overly stretched. Incontinence is a common consequence. While surgery to lift up the bladder is often needed, doing a hysterectomy at the same time ``does not help and may even compromise the success of bladder neck surgery,'' Summitt said. But more than 16 percent of hysterectomies are done to ``correct'' urogenital prolapse.
Adenomyosis: This very common condition, a form of endometriosis that occurs within the wall of the uterus, usually causes no symptoms. But some women experience prolonged periods with heavy bleeding and severe menstrual pain. If hormone therapy and antiprostaglandin painkillers (for example, Motrin, Ponstel or Anaprox) fail to bring adequate relief, hysterectomy is the only solution.
Cancer: Cancers and precancers of the uterus, cervix or ovaries account for about 10 percent of hysterectomies. And while most of these operations would be considered medically necessary, Dr. Joanna M. Cain, a gynecologist and oncologist at the Pennsylvania State University Medical School in Hershey, said more-conservative surgery could achieve as good results for some cancers of the cervix and ovary, depending on their cell type and whether they have invaded nearby tissues.
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