Are American Women Having Unnecessary Hysterectomies?
The drastic surgical procedure is one of the most common among women in the U.S., but some doctors say it's being overperformed.
Removing a woman's uterus, the organ responsible for growing, and carrying a baby and menstruation is a big deal. So you might be surprised to know that the hysterectomy — irreversible surgical removal of the uterus — is one of the most frequently performed surgeries on women in the U.S. Yep, you heard that right: Some 600,000 hysterectomies are performed every single year in the U.S. And by some counts, a third of all American women will have had one by the age of 60.
"Prior to modern medicine, hysterectomies were seen as the treatment for pretty much any issue a woman would come to a doctor or a healer for," explains Heather Irobunda, M.D., a board-certified ob-gyn in New York City. "In more recent history, any problems that a woman would bring to her doctor that involved her pelvis could have been treated with a hysterectomy."
Today, many ailments — cancer, debilitating fibroids (non-cancerous growths in the muscle of your uterus that can be super painful), abnormal bleeding — can lead a doctor to recommend a hysterectomy. But many experts argue that the surgery is overperformed and over-prescribed, especially for certain conditions such as fibroids — particularly to women of color.
So what do you need to know about this common procedure, these racial disparities, and — most importantly — what should you do if you're ever offered one as a treatment?
First, what is a hysterectomy?
In short, it's a procedure that removes the uterus, but there are different types of hysterectomy. The American College of Obstetricians and Gynecologists (ACOG) notes that a total hysterectomy is when your entire uterus (including your cervix, the lower end of your uterus that connects the uterus and vagina). A supracervical (aka a subtotal or partial) hysterectomy is when just the upper part of your uterus (but not the cervix) is removed. And a radical hysterectomy is when you have a total hysterectomy plus the removal of structures such as your ovaries, or Fallopian tubes (say, in the case of cancer).
Hysterectomy is commonly used to treat a slew of health conditions from fibroids and uterine prolapse (when the uterus sags down toward or into the vagina) to abnormal uterine bleeding, gynecologic cancers, chronic pelvic pain, and even endometriosis, according to ACOG.
Depending on which type of hysterectomy you need (and what your reasoning for needing it is), the surgery can be performed a few different ways: through your vagina, through your abdomen, or via laparoscopy — where a tiny telescope is inserted for visibility and a surgeon is able to perform the surgery with much smaller incisions.
Why are so many women getting hysterectomies?
Some hysterectomies (like those done via your abdomen) are far more invasive than others (one done via laparoscopy). And it's also worth noting that many times, even when hysterectomy is indicated, there are other treatment options available (say, for issues such as fibroids or endometriosis). The problem? Those options aren't always presented as realistic options everywhere.
"Sometimes, depending on the part of the country you are in, there are surgeons who are not comfortable with less invasive treatments which lead to all of those women getting hysterectomies," explains Dr. Irobuna.
Here's an example: When used for fibroids, hysterectomy does tend to ensure that symptoms won't return (after all, your uterus where those fibroids existed is now gone), but you can surgically remove fibroids and leave the uterus in place. "I think there are hysterectomies that are recommended by doctors just because they find fibroids on an exam," says Jeff Arrington, M.D., an advanced minimally invasive gynecologic surgeon and endometriosis expert at The Center for Endometriosis in Atlanta, GA. And while fibroids can be incredibly painful and debilitating (and hysterectomy can help eliminate that pain), fibroids can also be painless. "There would be a number of patients who would be fine understanding that fibroids are there and that they're benign," says Dr. Arrington of the option to not operate.
Other less aggressive procedures include myomectomy (surgery to remove fibroids from the uterus), treatments like uterine fibroid embolization (cutting the blood supply off to fibroids), and radiofrequency ablation (which basically burns the fibroids). Plus, there are numerous non-invasive treatment options such as oral contraceptives and other medications.
But, here's the thing: "Hysterectomies have been around for a long time, and every gynecologist learns how to do them in their residency training — [but] that is not true for all of the treatment options," including these less invasive procedures, says Dr. Irobuna.
In this vein, while hysterectomy is considered a "definitive" (read: permanent) treatment for endometriosis, "there is no evidence — not a single study — that shows that just going in and removing a uterus magically makes all of the other endometriosis go away," explains Dr. Arrington. After all, by definition, endometriosis is when tissue that's similar to that of the lining of the uterus grows outside of the uterus. Hysterectomy, he says, can improve some people's endometriosis pain levels, but it doesn't in and of itself treat the disease. (Related: Lena Dunham Had a Full Hysterectomy to Stop Her Endometriosis Pain)
So why is hysterectomy often offered to women with endometriosis? It's difficult to say, but it could come down to training, comfortability, and exposure, says Dr. Arrington. Endometriosis is best treated via surgical removal of the endometriosis itself, known as excision surgery, he says. And not every surgeon is trained in this kind of surgery in the same way hysterectomies are commonly taught.
Racial Differences In Hysterectomy
This overprescribing of hysterectomies becomes even more apparent when looking at the history of the practice among Black patients. Some research suggests Black women are four times more likely to get a hysterectomy than white women. The Centers for Disease Control and Prevention (CDC) also reported data that highlights a racial disparity among those who have the procedure. And other research finds Black women have hysterectomies at higher rates than any other race.
The research and experts are clear: Black women are indeed more likely than white women to undergo a hysterectomy, says Melissa Simon, M.D., director of the Institute for Public Health and Medicine Center for Health Equity Transformation at Northwestern's Feinberg School of Medicine. Notably, they're also more likely to undergo the more invasive abdominal hysterectomy, she adds.
There could be many reasons for this. For one, Black women experience fibroids — one of the common reasons for hysterectomy among any race — at higher rates than white women. "The incidence rates are two to three times greater in American African women than in white women in America," says Charlotte Owens, M.D., medical director of general medicine at AbbVie. "African American women also tend to develop more severe symptoms and earlier, often in their 20s." Experts aren't quite sure why this is the case, says Dr. Owens.
But there's likely more to the racial disparity than fibroids incidence. For one, that issue of access to less invasive treatments? It could hit women of color harder. "Funding for some of the technology that is needed to perform more advanced, less invasive treatments may not be available at hospitals that serve some of the communities in which some Black women live," explains Dr. Irobunda. (Related: This Pregnant Woman's Harrowing Experience Highlights the Disparities In Healthcare for Black Women)
Also, when it comes to options for care for women of color and fibroid treatment, various options aren't often discussed, says Kecia Gaither, M.D., M.P.H., an ob-gyn and maternal-fetal medicine doctor at NYC Health Hospitals/Lincoln. "Hysterectomy is given as the sole therapeutic option." But the truth of the matter is, while hysterectomy is often a choice on a woman's menu of treatment options, it's usually not the only choice. And you should never feel like you have to take it or leave it when it comes to your health.
To this extent, there's systemic racism and bias that plays a role here, say experts. After all, many pelvic and reproductive procedures have racist roots as they were originally and experimentally performed on Black female slaves. In the early 2000s, there were also cases of non-consensual sterilization in the California prison system, explains Dr. Irobuna.
"It is well-known that bias exists as it relates to Black women and medical care — I have personally witnessed it," says Dr. Gaither.
Biases of surgeons can also shine through. If a surgeon, for instance, thinks that Black women would be less likely to be compliant with treatment options like a daily birth control pill or a shot (like Depo Provera which can help with pelvic pain and heavy menstrual bleeding), they may be more likely to offer a more invasive treatment like hysterectomy, she says. "I, unfortunately, have had many Black female patients come to see me with concerns after being offered hysterectomies by other surgeons and were not sure if a hysterectomy was the right form of treatment for them."
How to Get the Care You Deserve
Hysterectomies are valuable treatments for certain medical problems — no question. But the procedure should be offered as a part of a potential treatment plan, and always as an option. "It is imperative that with a decision as important as removing an organ, the patient understands what is going on with her body and what types of options are available for treatment," says Dr. Irobunda.
After all, a hysterectomy comes with side effects — everything from no longer being able to bear children to constipation or emotional downs and early and immediate menopause if you haven't naturally gone through this already. (BTW, hysterectomies are just one of *many* causes of early menopause.)
Some things to keep in mind if hysterectomy comes up in conversation? "I always advise patients, especially patients of color and Black patients, not be afraid to ask questions," says Dr. Simon. "Ask why a surgeon or a physician is recommending a certain approach to treatment for a particular condition, ask if there are other treatment options, and — if it's determined that a hysterectomy is the way to go — ask about the approaches that could be used, such as a minimally-invasive approach."
In short: You should feel that you've had your questions answered and that you're being heard. If you don't, seek a second (or third) opinion, she says. (Related: 4 Things Every Woman Needs to Do for Her Sexual Health, According to an Ob-Gyn)
Ultimately, hysterectomy is a personal choice that depends on everything from what issue you're facing, what stage of life you're at, and what goal you have. And the bottom line is that making sure you're as informed as possible is key.
"I try to go through all of the different options, the pros and cons, and then help a patient decide what option is best for them," says Dr. Arrington.