It’s appalling how little data is actually available on women-specific health issues, particularly in this country. Repeatedly, on multiple counts, data is lacking on women’s health conditions; thus the true magnitude is never known, impeding funding and the attention of policymakers. The availability of data is at the root of addressing these issues, in order to raise the profile of these diseases and take awareness about their remedies to women across the country. In an attempt to set right this analogy, at least in a particular area — hysterectomy — a study by Gaurav Gunnal, Dhruvi Bagaria & Sudeshna Roy maps reasons for undergoing hysterectomies, in various regions in India.
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Published in Women’s Reproductive Health as ‘Reported Reasons for Undertaking Hysterectomy Among the Women Aged 45 Years and Above: Evidence From Longitudinal Aging Study in India (LASI) Wave-1 (2017–2018)‘, the paper attempts tounravel the prevalence and underlying reasons for undergoing hysterectomy among women (45 years and above) across India. It uses the LASI Wave-1 data set to examine hysterectomy prevalence within a sociodemographic prism. Explaining the reasons for undertaking the study, the authors argue: “Evidence of hysterectomy is limited due to a lack of nationwide statistics. Most of the literature on hysterectomies is either from research done in developed countries or samples taken at clinics. The amount and variety of literature in India is relatively small. To our knowledge, a population-based investigation on a sizeable, nationally representative data set that can examine all of India has yet to be carried out. For the first time, a series of direct questions on hysterectomy and the reasons for having one were included in the National Family and Health Survey’s fourth wave.
Frequent procedure
Removal of the uterus or hysterectomy is one of the most frequently conducted surgeries among women globally. It is considered a major surgery, though advances in technology now allow for minimally-invasive removal of the uterus too. Gunnal et al. quote studies to show that worldwide, the most common causes for doing a hysterectomy include: fibroids (47.6%), uterovaginal prolapse (13.4%), benign ovarian cysts (12%), malignancy (9%), and adenomyosis (6%). Sometimes a hysterectomy may also include the removal of other parts of the female reproductive system, such as the ovary, fallopian tubes, and cervix. The surgery is done, when all else fails, to alleviate symptoms of gynaecological disorders — irregular bleeding, menorrhagia, and pelvic pain, and bodily discomfort. It can also reduce anxiety and depression in women, enhancing their quality of life according to many studies.
Naturally, like most medical interventions, a hysterectomy is not an unvarnished good. Despite the clear health benefits, it also carries several long-term ramifications for women’s health, longevity, and quality of life. This includes early menopause, increased risk of cardiovascular disease, increased risk of stroke, urinary incontinence, obesity, endocrine and metabolic complications, and loss of sexual desire (Goktas et al., 2015). Additional studies have also identified other consequences of estrogenic decline caused by hysterectomy, including bone mineral density loss, vasomotor symptoms, frailty, depression, and a decline in cognitive function.
Wave-1 of the LASI covered a panel sample of 72,250 people aged 45 years and over and their spouses (regardless of age), including 31,464 people aged 60 years and over and 6,749 people ages 75 years and over from 35 states and union territories (UTs) of India (excluding Sikkim). A dedicated module on women’s health was included, which asked the question, have you removed your uterus? When there was a positive response, a follow up question was asked on the reasons for the procedure.
Most cited reasons
The authors found that heavy menstrual bleeding or pain (32.1%), fibroids or cysts (24.2%), and uterine prolapse (16.3%) are the most frequently cited reasons for surgery. The percentage of hysterectomies performed for reasons such as cancer and severe post-partum haemorrhage was the least reported. Overall, 11.5% is the countrywide hysterectomy prevalence rate while the southern (18.2%) and western (12.7%) Indian regions reported the highest prevalence. The paper concludes: “A significant proportion of these may be attributed to unnecessary rampant surgeries prescribed by doctors in certain parts of India, which requires strict regulation by the government.”
Analysing the available data from a sociodemographic context, and co-relating it with earlier studies, the authors found that women from the OBC category, women belonging to the richest wealth quintile, those with a lower education level, and those with a lower age of marriage were at a higher risk of undergoing hysterectomy. More women with three or more children had a higher chance of undergoing the procedure.
In recognition of the seriousness of the problem, the Union Ministry of Health and Family Welfare issued a set of guidelines last year to prevent unnecessary hysterectomies. The document records: “In developed countries, hysterectomy is typically conducted amongst premenopausal women above the age of 45. In India, there is increasing concern about patterns of hysterectomy at a population level. Community-based studies have consistently found rising hysterectomy rates amongst young women, ranging from 28 to 36 years. Further, evidence indicates a higher risk among poor, less educated women in rural areas. Field-based reports have also suggested that there are unnecessary hysterectomies performed in cases where medical or non- invasive treatment would have been sufficient. There are also reports of potential coercion for financial benefit under health insurance schemes and concerns pertaining to a lack of information provided to women on side effects.”
As per the NFHS-5 (2019–2021), 3.3% of women in the age group of 15–49 years under went hysterectomy, which was marginally higher than the NFHS-4 (3.2%), but, starkly, both surveys show that 50% of the women got these surgeries before attaining age 35. According to a recent study, the average prevalence rate of hysterectomy in India is estimated to be 17 per 1,000 among ever-married women in the ages of 15–49 years. Andhra Pradesh had the highest prevalence rate (63 per 1,000 women), followed by Telangana (55 per 1,000 women), Karnataka (29 per 1,000 women), and Punjab (23 per 1,000 women).
Ministry guidelines
The MoHFW document lists the common indications for hysterectomy in India as: Abnormal Uterine Bleeding/ dysfunctional uterine bleeding, vaginal discharge, lower abdominal pain/pelvic inflammatory disease, an abnormal looking cervix and uterocervicovaginal prolapse. Besides defining indications for hysterectomy, it goes on to offer guidance to prevent unnecessary hysterectomy by raising awareness among health providers regarding alternative methods of treatment available for gynaecological diseases as well as in the community.
The reason for the large number of hysterectomies could be the reproductive function ascribed to women by patriarchal norms, obstetricians say. “Any discussion on regulating hysterectomies is definitely necessary — it continues to be very relevant. Unfortunately the uterus is viewed as organ that is no longer needed, in mothers,” says Jaishree Gajaraj, senior obstetrician and gynaecologist, former president of the Obstetrics and Gynaecological Society of Southern India.
“Any number of hysterectomies are being performed regularly without any clear instruction or rationale. Even for some white discharge, a small fibroid or an abnormal uterine bleed, that can be medically and conservatively managed, surgery is being recommended. When doctors introduce the fear of cancer, patients are left petrified and agree to the procedure,” she explains. Women as young as 28 or 30 are advised hysterectomies, once they have had children, and they are not even offered the option of Hormone Replacement Therapy. This will lead to a drastic reduction in long term quality of life, she adds. Sometimes, doctors, believing that they are treating the patient conservatively, remove only one ovary. “This actually makes no sense. Leave both in, or remove both ovaries,” Dr. Gajaraj says.
However, she added that, among a small segment of gynaecologists in the country, the number of hysterectomies has dropped radically, wherever the disease is simple. Medical management must first be attempted, and very effective treatments can now be employed to give women relief from their pain and bleeding. “When abnormal uterine bleeding is caused by hormonal imbalance, and not a more serious complication, for instance, the Mirena Intra Uterine Device has proven to be very effective,” she says. The Union government’s guidelines underline: A hysterectomy is a major operation with a long recovery time and is only considered after less invasive treatments have been tried. Although hysterectomy is often the definitive treatment for many gynaecological conditions, nonsurgical alternatives should always be attempted in elective cases.
