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Hysterectomy: Destined to be a Dinosaur?

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Decline in Hysterectomy Rates: How Much and Why?

A February 2009 article in a major ob-gyn journal discussed the decline in the national hysterectomy rate and its implication for training future gynecologists. Nationally the rate of hysterectomy dropped by nearly two percent from 1999 through 2005. In some states, such as California, hysterectomy plunged  twenty percent.

Currently residents training in obstetrics-gynecology do an average of 120 hysterectomies during their training. These are divided among several different techniques: abdominal, vaginal, laparoscopic, subtotal and cancer (radical) hysterectomies. A decline in hysterectomy rates means these physicians-in-training may have less and less surgical experience over time. Is this a bad thing? Well, yes and no.

While the decline in hysterectomy training can be a self-perpetuating thing resulting in less training in the procedure, hysterectomies are declining for a good reason: there are better, safer, more cost-effective methods now available for treating common gynecologic problems. In other words a major surgery is being replaced by safer, effective, less expensive treatments. And while physicians in training may not be doing as many hysterectomies they are becoming better trained at managing bleeding with more conservative measures (see below).

Emergence of Newer and Better Treatments

The decline in hysterectomies is due to the advent of new ways to treat old problems. Ninety percent of hysterectomies done in the United States are for benign (non-cancerous, non-life-threatening) conditions. The most common reasons for hysterectomy are abnormal bleeding, uterine fibroids, and prolapse (falling) of the uterus.

With the advent of global endometrial ablation techniques to combat abnormal bleeding, uterine artery embolization, medications, and other methods to shrink fibroids, and new data about the ineffectiveness of hysterectomy for prolapse, hysterectomy rates for these conditions has begun, and will continue to decline.

Some Hysterectomies are Here to Stay (for now)

Because of gyn cancers such as ovarian and advanced cervical cancer, the need for extensive hysterectomy techniques to treat these conditions will always be present. Cancer hysterectomies are usually done by a gynecologic oncologist–someone who’s completed a full four year ob-gyn residency and a three year sub-specialty training in cancer surgery and treatment.

As a gynecologist I’m very excited about all the new and emerging technologies to deal with common problems: bleeding, pelvic pain, and prolapse. The trend has been to find ways to deal with these problems through better medications, less invasive procedures that can be done in the office with local anesthesia, and are less expensive, and require less down-time from work.

Why I don’t Miss Hysterectomies

Over the past few years I’ve modified my practice to be primarily office-based. I stopped delivering babies and performing in-patient surgery over a year ago due to lifestyle choices. Last week an anesthesiologist who does anesthesia for my office-based procedures asked me, “Don’t you miss doing major surgery–you have such a talent–it would be like a violinist not playing violin anymore.” My response to him was, “No, really I don’t miss it. There are so many wonderful opportunities to care for women in ways that are safer and more respectful of women than doing a hysterectomy, I’m glad to be the one gynecologist in my area who is actively embracing and promoting logical, safe, implementation of new techniques to treat ancient problems. I still play violin, just in a different way.”

Consider this: If men had genital problems for which the primary treatment was to remove most of their genital organs, don’t you think there would have been a real hurry to find a better way?

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