Given that an astounding 40% of American women have had a hysterectomy by age 45, and about one-half have had both normal ovaries removed, if you are a woman, and you have had menstrual problems, it is likely that you have talked to your doctor about hysterectomy. You may even have considered scheduling it, particularly if the pain persists as so often it does.
Gynecologists and Hysterectomy
For many women, the gynecologist drives conservation. He thinks you’re ready for the hysterectomy now. It’s the only solution to your problems. There’s an ever-so-subtle pressure for you to pick a date for your hysterectomy already. And so, you pick the date, and he practically stumbles out of the room to go get it on the Schedule.
As he’s leaving and just before the heavy door closes, he says his nurse will give you the details. Not knowing any better, you sit in your blue, stiff paper garb, freezing cold and still bleeding from your fibroids. You feel like he just told you that all your problems will melt away, and your life will start over again.
Did I Consent to this?
You are just too busy smelling the roses to stop and ask yourself, “Wait. What does this mean?” But really, it nags at you. You further contemplate: what’s wrong with this picture? Several huge and glaring things suddenly hit you like a smack in the face. It’s like you just heard the buzzing of a bee in the middle of the rose you are about to sniff.
No Informed Consent was given, and you don’t even know the risk: benefit ratio (Aranda, 2013).
Hysterectomy Second Opinion
You haven’t had a Second Opinion from another surgeon (eHow, 2014; Cornforth, 2014). Big Boo-Boos, because maybe you don’t need the surgery at all. “C’mon me. Get a hold of ourself.” “I have to know that getting a hysterectomy isn’t like getting my tooth pulled out.” It is this author’s personal opinion is that surgery should be used as a ‘last’ resort, not a ‘first’ resort. Additionally, alternatives should be sought and tried before resorting to any surgery that requires general anesthesia. I was an anesthesiologist. My opinion. Take the time to get a second opinion and maybe even a third before finalizing the hysterectomy.
In my case, my second opinion Ob/Gyn was female, had two children of her own, the last one by C-section. She knew the drill, and gave a detailed analysis of the algorithm she would use; it led to my decision to have an open hysterectomy. I agreed, and scheduled it with her, later cancelling with the first doctor.
She told me that the risks of surgery are about 10% for complications related to infection, inability to see structures and a need to operate with an “open” (large) incision, bleeding, transfusion(s), adverse drug reactions, death, etc. Informed consent includes (a) the general risks of the procedure, and (b) the specific risks for me. If the doctor does not discuss the risks of the surgery specific to you run, don’t walk, out the door and find another doctor. For more information on what an informed consent should include: Informed Consent is the Law: Stop, Talk and Show Should be the Standard.
I should note that this conversation has to be between patient and the surgeon, not the patient and a nurse, not the patient and a doctor-in-training.
In my case, I happen to be both a patient and an anesthesiologist. I know the general and the specific risks of anesthesia; most women do not. We’re talking general anesthesia, a breathing tube down the windpipe, anesthetic gases breathed in from a ventilator, a high chance of vomiting afterwards; the whole shebang.
I knew that I would be bloated and blown up like a 7 month old pregnancy for a matter of days. Or could it be it weeks? Or…could it be months? Most women do not know this and sadly many surgeons do not discuss this with the patients either. She reminds me to bring gym pants with an elastic waist.
About the Hysterectomy: In the Operating Room
The doctor will fill her belly up with CO2 gas, and will leave it blown up for the duration of the surgery. She will be in ‘extreme’ lithotomy and ‘extreme’ Trendelenburg position. Legs wide open, head down, feet to the sky. The anesthesiologist will have to add positive airway pressure (PEEP) to push her lungs opened to fill with oxygen, and sometime the surgeon argues saying, “Hey, anesthesia, I can’t see anything.” Then a classic argument ensues: lungs for the patient vs. visibility for the surgeon. So they both work together, sometimes screaming, to get it done for the patient. Anesthesia always wins. No one wants a pneumothorax, a popped lung on the O.R. table. Then it will become a blame game and both of them are responsible. Sometimes the poor patient needs a chest tube and an ICU stay instead of going home.
Some people get shoulder blade pain that hurts like the dickens, and she already knew that if your shoulder blade hurts afterwards, it is ‘referred’ pain coming from your belly. Most of my patients had not been told that information by their surgeon, but if they are lucky, a good anesthesiologist will give her the down low.
Who will be Performing the Hysterectomy and How?
The types of hysterectomy procedures themselves aren’t always explained to the patient (Aranda, 2012). Admit it. You were so eager and desperate to have your uterus out, that you didn’t really even care how it came out; as long as it was gone by the time you woke up. You didn’t care if a medical student, resident, intern, Fellow, or Attending did it with or without a morcellator. Oh. A morcellator. What’s that (Fulton, 2014) ? Or the daVinci robotic hysterectomy robotic machine ~ Are they using that on me? Uhm. Each of these technologies carries with it discrete risks. You should know those risks to make the decision most appropriate for your health.
The Morcellator Problem
It wasn’t generally known until recently, but in order to get the ball of the uterus out of the large straw of the laparoscopic instrument, Ob/Gyn surgeons have been using, for the last 20 years, what is called a power morcellator once you are good and asleep. It pretty much goes into the laparoscopic scope and into the uterus to churn and blend it up like a garbage disposer, so it can be sucked up the tube.
Problem is…no one can possibly know if you have uterine cancer or not, until after the whole uterus is out. It is simply undetectable until then. Some women, like Amy Reed, M.D., an anesthesiologist and internist at Harvard, got her uterus, along with undiagnosed uterine cancer, splatted all over the abdomen at the same time (Reed, 2014). Now that was a big Oops.
As it turns out, they’ve been doing it to our mothers, aunts, and sisters for decades, and even invented the daVinci robot to do the hysterectomy instead of a surgeon. What do you think the Ob/Gyn Associations have let their surgeons do? No one knows if it’s 1:1000, or 1:500, or 1:400, or 1:315 women that actually does have uterine cancer, but splat!splat!splat! There it all goes! All over the woman’s abdomen, it is upstaged from a Stage I to a Stage IV cancer because the doctor has now iatrogenically done the bad deed. Never should have happened. Never should have been allowed. Ethics Committee should have been involved. One woman in the same hospital as Dr. Reed had also been upstaged to uterine Stage IV cancer, one year before. “Hush! Hush!” There was no need for Dr. Reed to be placed in this position. But “Hush! Hush!” She was. An “n” of 1 is too much. We don’t want one woman to ever suffer this known fate.
No one knew this was really happening until Dr. Amy Reed’s husband, Dr. Hooman Noorchasm, and his love for his wife and family of six children, that he took this to Change.org, then the Senate, then to the FDA.
The July 10-11, 2014 FDA Hearing where Dr. Noorchasm spoke, resulted in these conclusions by the FDA:
- Little to no evidence that morcellation can be performed without spreading cancer to other parts of the body;
- Informed consent, including the risk of spreading an unknown cancer, should be included from now on;
- There is no evidence that the bags…prevent the outcome we are trying to prevent.”
- “There is at present no safe way to offer morcellation as part of gynecological surgery.”
Watch the video of Dr. Noorchasm’s testimony to the FDA. Now, he has accomplished the seemingly impossible for all women: he has all but put a ban on most uses of the morcellator. ROCK ON, Dr.Hooman Noorchasm! There’s always more work to be done, but once the people have a heart, a Movement has started.
What about the Ovaries?
Are they planning to keep your ovaries in? And the Fallopian tubes? If they take the ovaries out, you will not only have your uterus out when you wake up, but you will be in surgical menopause. Surgical menopause sounds benign enough, but really it isn’t. The rapid depletion of hormones can cause serious mental health issues, along with a compilation of physical health issues that will be with you for the rest of your life. And although hormone replacement is available, hormone management is never as easy as popping pill or pasting a patch on your abdomen.
If the ovaries are removed with the hysterectomy, women enter surgical menopause overnight, leaving them with huge fluctuations in the estrogens, progesterone and the androgens. There’s no ‘gradual’ menopause for them over the course of 1-10 years, as other women naturally have. They hit the menopause wall POOF! When they wake up and oh! Eeeh! Was surgical menopause part of the Informed Consent? These ladies are ready to throw in the towel by now, as they are living in “hell”.
Symptoms range from precipitous drops in hormones if the ovaries were taken out: hot flashes, night sweats, they can’t sleep with their husbands any more, thinning hair, pain on intercourse, insomnia, disturbance in day/night cycles, depression, irritability, and with the uterus gone. Hormones need to be tested and hormone replacement is used on an individual basis, in light of lab results, contraindications to hormones, family history, and other risk factors.
It is important to note that surgical menopause also means faster aging, increased risk of heart attack, cognitive dysfunction, osteopenia, osteoporosis, a fractured hip from a fall. Ask any woman who has had her ovaries removed about the complications and health issues she has faced. It might just change your mind.
Making the Hysterectomy Decision
Weigh the pros and cons and above all realize that your health matters. Whatever you do, speak up! Ask questions. You are expected to ask questions, like ordering food at a restaurant. So ask them.
Your body belongs to you. It is your temple, meant to be treated with respect and care. Ask if the if the daVinci robotic and morcellator will be used. Make sure you understand. The choice is yours, and no one can take it away from you.
Hormones Matter is conducting research on hysterectomy outcomes. If you have had a hysterectomy, please take a few minutes to complete The Hysterectomy Survey.
- Aranda, M. The Different Types of Hysterectomies. Perseverance: Being that One in a Million. October 9, 2012. http://drmargaretaranda.blogspot.com/2012/10/the-different-types-of-hysterectomies.html (Accessed July 18, 2014).
- Aranda MD. Archives of the Vagina: A Journey through Time. Tate Publishing, Mustang, OK. 2014. Ovarian Conservation, Ethics, and Informed Consent. Pp 252-259.
- Cancer Therapy Advisor. Uterine Sarcoma Treatment Regimens. http://www.cancertherapyadvisor.com/uterine-sarcoma-treatment-regimens/article/218132/ Haymarket Media, Inc. Last revised 4/2014 (Accessed July 18, 2014).
- Cornforth, T. Hysterectomy Questions: Should I get a Second Opinion? About.comWomen’s Health. December 28, 2003. http://womenshealth.about.com/cs/uterinediseases/a/hysterqa7.htm (Accessed July 18, 2014).
- eHow Contributor. How to get a Second Opinion before a Hysterectomy. eHowHealth. http://www.ehow.com/how_2056230_get-second-opinion-before-hysterectomy.html (Accessed July 18, 2014).
- Fulton, Denise. VIDEO: Public testimony gets heated at FDA panel meeting on morcellation. Ob.Gyn. News digital network. July 11, 2014. http://www.obgynnews.com/home/article/video-public-testimony-gets-heated-at-fda-panel-meeting-on-morcellation/dbc6c83d0197903d427559aa6ed0cbbd.html July 11, 2014. (Accessed July 18, 2014).
- Iglesia, Cheryl. Why FDA Hearing on Morcellation safety could drive innovation. Current Psychiatry. Clinical Psychiatry News. July 2014. 1http://www.clinicalpsychiatrynews.com/news/from-the-journal/article/why-fda-hearing-on-morcellation-safety-could-drive-innovation/d1071c5e8326e8a2de76a30f0446b1ab.html (Accessed July 18, 2014).
- Keshavarz, M.D., Homa, et al. CDC Morbidity and Mortality Weekly Report. Hysterectomy Surveillance – 1994 – 1999. July 12, 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm (Accessed July 18, 2014).
- PewResearch Center. Baby Boomers Retire. December 29, 2010. http://www.pewresearch.org/daily-number/baby-boomers-retire/ (Accessed July 18, 2014).
- Reed, Amy and FDA Warns Routine Fibroid Surgery May Spread Hidden Cancer. April 24, 2014. CBS Los Angeles; and other references on You Tube:
- http://www.youtube.com/watch?v=sSP7FkbCtzg (Accessed July 18, 2014).
- http://www.youtube.com/watch?v=gIwxfkXGekw (Accessed July 18, 2014).
- http://www.youtube.com/watch?v=Qvg5OXaiEiM (Accessed July 18, 2014).
- http://www.youtube.com/watch?v=n6226ic0Mpk (Accessed July 18, 2014).