Making a Difference – A study of unindicated hysterectomies in Andhra Pradesh

DR. S V KAMESHWARI AND DR. PRAKASH V.

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Life-Health Reinforcement Group (Life-HRG), a Non Government Organization, has been providing basic healthcare services to rural masses in the arid district of Medak, 100 kilometers from the state capital, Hyderabad in Andhra Pradesh. We have observed that a large number of young rural women undergo hysterectomy, recommended by qualified allopathic and even rural medical practitioners as a solution to many gynecological problems [16] like white discharge, painful intercourse, heaviness in the pelvic region, etc. This is despite the fact that hysterectomy is not a standard recommended practice in modern medicine. It is to be carried out only as a last resort, because all the above conditions can be successfully treated with alternatives to hysterectomy such as antibiotics, simple procedures and treatment of the partner. Many times hysterectomy is done with bilateral salpingo oophorectomy (BSO), i.e., removal of the fallopian tubes and ovaries, which is supposed to prevent ovarian cancers.

Life-HRG has campaigned against unindicated (not considered necessary for treating the condition) hysterectomy since 2001, and presented these facts to The National Human Rights Commission in 2004.  These facts have been presented in various medical and non-medical gatherings as an urgent ethical issue which must be addressed. In the next phase Life-HRG undertook a study to deal with the questions of early hysterectomy with/without BSO, in 15 villages of Munipalli mandal of Medak District of AP from May 2008-May 2011.  171 women between the age groups of 20-40 years, who had hysterectomies done between 1-14 years ago participated in the clinical study. Most of them had already been through family planning operations before the hysterectomy.

Background of the women– 82% of the study group women belong to BC/SC/ST/Muslim communities. Average age at hysterectomy in the study group was found to be 29.2 years. The average age at marriage was 14 years and average age at first delivery was 16 years. In 80% of cases indication for hysterectomy was white discharge.

Early Menopause– 41% of these women showed consistently high blood levels of the hormone FSH >40 Iu/ml indicating early menopause. Of these women, 31% were still under the age of 30 years. (In natural conditions, premature menopause occurs only among 1% of women between 30-40y age group, while for those below 30 years natural incidence of menopause is 0.1%).

Early Age at Hysterectomy and Bone Thinning– Women who had total abdominal hysterectomy (TAH) with BSO before 30 years of age had  5% less  bone mineral and 3% less bone density, when compared to women who had TAH with BSO after 30 years of age. The decision to remove ovaries at this young age should not be permitted because women are at a low risk of developing ovarian cancer at this age. It is important to note that the incidence of cervical cancer is 0.08 %, however  in AP, 9.2 % of women in reproductive age group have had their uteruses and ovaries removed surgically, and the highest being 16 – 18 % in six districts of AP. In other words, about10,000 to 20,000% excess hysterectomies are being performed !

Furthermore, bones of women who are less than 30 years of age have not reached maximum mineral content, and bone loss due to hysterectomy starts even before the bone has been mineralized adequately.

Duration since surgery– All dual X-ray absorptiometry (DXA) parameters in these women who had consistently high FSH above 40 Iu/ml, irrespective of whether ovaries were removed or not, showed progressive deterioration of bone parameters over time.

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Preserving the Ovaries– The medical fraternity generally perceives sparing the ovaries as a wise medical choice to prevent early menopause. [17] Our study found that despite retaining the ovaries during hysterectomy, 33% of women showed high levels of FSH hormone (menopausal levels). And among all those who had high FSH levels, 21% had ovaries conserved. Thus our study questions the medical wisdom of conserving only the ovaries to postpone menopause, because it is now known that the uterus along with the ovaries is necessary for appropriate hormone production (uterine-ovarian-pituitary axis).

All the above mentioned results point to the need for a thorough investigation into the relation between hysterectomy and early menopause in Indian women to estimate risk of early ovarian failure following hysterectomy. The issue has shifted from unindicated gynecological intervention and questions of how to retain the uterus, to iatrogenic (surgically induced) consequences of hysterectomies.

Our study on hysterectomy had thrown up gaps in medical practice pertaining to women’s health care. The myth that “Surgery is the option” and “the only remedy” is impressed upon the patient, even for minor gynecological complaint. For that matter, hysterectomy is being recommended for any complaint/s in the body and also as a measure to prevent cervical cancer in due course. Thus an artificial, detrimental and unusual clinical situation is being created with these aggressive interventions, even as we are yet to understand how to deal with natural menopause.

[10]The entire issue reflects the need to strengthen gynecological care at primary and secondary levels, and also to integrate cervical cancer screening into regular government programs. Secondly, there is also a need to bring the members of the medical profession on board so that they initiate a change in gynecological practice. Thirdly, it is important to note that a large number of women have already been hysterectomized without adequate reason, and that modern medicine has little to offer to women who undergo early menopause as a result.  Since the government is liable for the iatrogenic morbidity of this unnecessary medical intervention, it should initiate measures to draw on parallel systems of medical knowledge like Unani, Siddha and Ayurveda to alleviate the suffering undergone by the victims.

Impact of this study -The results of this study were shared with the medical fraternity and with NGOs on Jan 9^th 2010 at National Institute of Nutrition. At one of these meetings the IAS officer Smt. M. Chaya Ratan, special chief secretary to Dept. for Women, Children, Disabled and Senior Citizens, intervened and held consultations with Life-HRG group. After several sittings, she recommended a ban on hysterectomies in the Aarogyasri program on 18^th Jan 2011. In fact a ban was imposed on all organ removal surgeries.  (See Government Orders reproduced). It was clear that “white discharge” could no longer be read as an indicator for hysterectomy.

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The chronology of Life-HRG’s activism against hysterectomies 2006 – Aarogyasri is put in place and starts functioning. July 17th 2008 – Aarogyasri 2nd phase comes into force and allows laproscopy assisted vaginal hysterectomy (LAVH) and vaginal hysterectomy (VH) with or without repair. July 17th 2008 to 30th Nov 2010 – 26,712 hysterectomies with repair are done in AP under Aarogyasri. Nov. 2010- March 2011 – After many meetings with IAS officers, Dr. Chaya Ratan, Special Chief Secretary (Women, Children, Disabled & Senior Citizens) issued a GO to stop ALL organ removals under Aarogyasri. These are Hysterectomy Appendicectomy Gall Bladder removal (Cholecystectomy) Tonsillectomy Removal of the thyroid glands

The social part of the study was done with the financial support of SET-DEV (Science, Ethics and Technological Responsibility in Developing and Emerging Countries- project funded by the European Commission under the 7th Framework Program). The clinical study is partly supported by DBT (DBT Project Title: Development of support systems to rural women who underwent early hysterectomies) & NIN –Government of India.