19 A Study in Scarlet

Surgical operations and diagnostic procedures are subject to inadequate evaluation almost everywhere. Drug companies hawk their wares using methods that typically obfuscate, rather than clarify, the choices that are best for patients. Prevention is pitifully neglected. Doctors and patients alike wait till illness has reach an advanced stage and then look for a quick fix - one that can often cost a fortune and still not work...
Medical training is increasingly biased against primary care and general practice, against prevention and early intervention, against the simplest tactics of nutrition and exercise, immunization and monitoring, housecalls and home help. Unnecessary operations by the tens of thousands, including Caesarean sections, pacemaker implantations, coronary bypasses, hysterectomies and prostatectomies, occur throughout the industrial world whether a profit motive exists or not. Drugs without merit, and many more that have no merit beyond those already available, are developed at enormous expense, which is passed on to patients. And doctors who devote themselves to the simplest, most effective measures of primary care and prevention are looked down upon by their colleagues and by medical students as non-scientific second-class citizens.
Dr Melvin Konner The Trouble with Medicine

In the foreword to Medicine and Culture, by Lynn Payer, Dr K L White says that "it is values, both individual and collective, both the people's and the profession's that govern the character and quality of the clinical encounter on the personal level, and the social contract on the political level."
At the age of 33 Ms Payer had a grapefruit sized fibroid mass and in the US was pressurised to accept a hysterectomy. American doctors emphasized that fibroids might recur, some exaggerating the risk of recurrence, and said that a second myomectomy would be impossible. In France, where breeding potential is more highly valued, hysterectomy was not even suggested as an option and fibroid recurrence was not mentioned. As Ms Payer noticed the doctors' recommendations were influenced less by the medical facts of her case than by the value their culture placed on the ability to have children.
Ms Payer, who is obviously used to getting what she wants, had a myomectomy and when her fibroids did return had a second myomectomy.
Yet although French gynaecologists may make an effort to preserve the organs of women of breeding age (defined by the medical profession as being under 40) there is no indication that they respect the views or values of the womb owner any more than the American hysterectomist does. So even in France a woman over 40, such as myself, would automatically be consigned to mutilation as the medical profession regards the womb as merely a box in which to grow babies. In neither country is the mere womb owner to be allowed to decided for herself whether she wants to keep her organs or not. Her doctor is to make that decision based on his cultural and professional preferences and prejudices.
Some of these were outlined in 1971 by Eleanor B Easly, who said of hysterectomy that, "It is an excellent procedure for sterilization. A woman is a more reliable worker after she's had one. It is advantageous at the menopause if only to simplify estrogen therapy. For some time I've been telling women that in another twenty years I expect hysterectomy to have become almost routine at the menopause."

O Brave New World of female neuters, for these women will, of course, also be castrated and considering that breast cancer kills more than 3 times the number of women as does ovarian cancer they should logically also have their breast tissue replaced by pert silicone peaks.

Two reports of the Maine Women's Health Study in Obstetrics & Gynecology, April 1994, appear to conclusively demonstrate that hysterectomy "is highly effective for the relief of symptoms associated with common nonmalignant gynecologic conditions". Moreover "Symptom relief following hysterectomy is associated with a marked improvement in quality of life" and only a "limited number of women" report new problems.
It all looks very impressive, especially all the highly significant statistical proofs of the great efficacy of hysterectomy in vastly improving physical and mental health.
But there are lies, there are damned lies, and there are statistics and in 1975 the Lancet published a Brtish Petroleum Corporation study which concluded that working for long periods in a vinyl chloride plant actually reduced the risk of getting cancer. However the US National Institute for Occupational Safety and Health found that this study artificially reduced expected death rates in workers exposed to VC for 15 or more years while death rates in workers with less exposure were artificially inflated. Their re-analysis of the data showed a fourfold increase in death from all cancers after 15 years VC exposure.
So statistics can prove anything you want it to and there are some strange things about the measurements of symptoms and the numbers these statistics were based on.
The first report concerned outcomes of hysterectomy and the second women who had medical treatment only for their menstrual conditions. As data was collected from doctors did this mean that the poor, who usually do not have a personal doctor, and have to go to hospital emergency rooms or clinics if they need medical attention, were largely ignored? The fact that of the hysterectomised women 84% had private insurance, 80% were working, 98% were white, and all had telephones suggests solvency. Otherwise the women surveyed seem to have been representative of the population as a whole. Of the 418 women surveyed 15% lost one ovary and 32% were totally castrated. And, strangely, while 73% had an abdominal hysterectomy 37% had a vaginal hysterectomy, so 10% lost their womb both abdominally and vaginally! Also the distribution between the age categories 25-34, 35-44 and 45-50 was 25%, 47% and 33% - 105% in total.
The data presented came from a variety of sources - doctor questionnaire, hospital database, personal patient interview, telephone patient interview and patient questionnaire. Women were categorised as suffering from fibroids, abnormal bleeding, chronic pelvic pain or "other". Less than half the women had an ultrasound scan before being mutilated and only 45% had their womb linings examined. The researchers noted that the use of diagnostic tests was "more limited than expected", with only a third of abnormal bleeders having their womb linings examined and a third of those with chronic pain having no laparoscopy to see if there was some some visible abnormality, such as adhesions, that could be treated. Table 2 gives the percentage of women bleeding more than 8 d/mo (presumably 8 decilitres - 80 mls - per month). The measurements describing menstrual loss within the normal range, "bleeding", and more than the normal 80 d/m, "heavy bleeding", are reversed and the figures for women with chronic pain are reversed, with an alleged 28% losing more than 80 mls but only 21% losing 40 mls. Such obvious errors do not invite confidence.
Menstrual extraction (tedious, expensive and unpopular) is not mentioned and since even basic diagnostic tests were underused I should be surprised if any such tests were done at all. So how menstrual flow was measured remains a mystery and, as we have seen, women often have so little idea of what constitutes heavy bleeding that Rees found that only 40% of English women referred for hysterectomy because of heavy bleeding were, in fact, in the heavy range. Yet although the UK hysterectomy rate is half the US level, suggesting that American women are operated on with less severe symptoms, the Maine thought that 65% of their abnormal bleeders lost in excess of 80 mls per month.

Symptom Abnormal Bleeders Fibroids Chronic Pain

Anaemic in last year 4% (6%) 21%* (7%) 4%
Heavy Bleeding 68% 38% 21%
Mean Days of Bleeding 14 (10) 10 (6) 8 (7)

(medically treated women) * recorded as 19% in second study

The mean number of days of bleeding for the three groups, given in the second study, follows the downward trend for heavy bleeding but the anaemia rates did not. If fewer fibroid women were heavy bleeders why did 5 times more develop anaemia? And if heavy bleeding was 3 times less common amongst those with chronic pain, compared to the abnormal bleeders, why was the anaemia rate the same?
However the second study stated that more fibroid women (49%) had their condition for less than a year before mutilation than abnormal bleeders (21%) or the pain (13%) group. Since only anaemia within the last year was counted a higher percentage of fibroid women would have been recently found to be defective, and therefore discovered to be anaemic, though totalling the 3 different groups of time length of condition for the hysterectomised fibroid women gives 109%, suggesting another inaccuracy somewhere.
Assuming the 49% figure to be correct it seems that fibroid women with an obvious physical abnormality (an enlarged womb) were far more likely to be hysterectomised within the year - 1 in 2 fibroid women but only 1 in 5 bleeders and 1 in 7 chronic pain women. This suggests to me that if there is an obvious lump which can be demonstrated on a pathology report then doctors have no hesitation in recommending immediate surgery because no matter how benign the growth, nor how unrelated it may be to any symptoms, merely having a fibroid "justifies" mutilation. In fact 30 (7%) of the hysterectomised women were so little affected by whatever physical symptoms they had that they reported no or little discomfort, limitation of activity or worry. Yet major mutilating surgery was "justified" on the grounds that the woman had completely symptomless endometriosis, minimally troublesome fibroids or traces of pelvic inflammatory disease. Would drastic heart surgery be undertaken, in the absence of any symptoms, on the grounds of slightly narrowed arteries? Well in the US maybe!
For fibroid females non-availability of alternative treatment was said to be the reason for 36% of the mutilations. Presumably myomectomy, possible in almost every case of fibroids, was not even considered. Another 32% had experienced "failure of other treatment", which presumably must have been for symptoms such as pain or bleeding since there is no medical treatment for fibroids. Half had growths less than 12 weeks in size. Although Reiter found no increased risk with surgery on larger fibroids 11% were persuaded to have surgery for this reason, 5% were frightened into it by the cancer bogeyman and a further 11% volunteered to have it - no doubt convinced of the uselessness of their female organs, the safety of modern surgery and the advantages of being a non-bleeder.
The symptoms studied are differently defined in different tables and the figures given refer to different numbers of women. Only 80% of those with a main diagnosis of chronic pelvic pain actually suffered significant pelvic pain, defined as being ">8 d/mo", obviously a nonsensical measurement for pain. Table 2 shows that 59% of all women (247 of 418) were affected with pelvic pain ">8 d/mo" while Table 4 assessed pelvic pain in one of 4 categories of "not at all", "a few times", "fairly often" and "very often", only using responses from the 355 women who provided replies (though not always complete replies) for all time intervals. The authors write that pelvic pain persisted in 5% of the 273 patients, (93% of the total reporting pelvic pain before surgery), which would presumably mean that 294 women replied to the pain question and only 21 (7% of 294) had no pain preoperatively. However no actual numbers of replies are given in the table and in Table 6 only 33 women (out of how many was not stated) are recorded as not experiencing pelvic/abdominal pain pre-operatively, now defined in terms of "none" to a "big" problem. A very impressively muddled situation. With this complete lack of consistency in symptom description and little information about the figures used it is very difficult to relate one table to another.
Chronic pain was the symptom most improved by hysterectomy, an effect which has also been reported by others. But although only 5% of women reported the same or increased pain and the frequency of some degree of pelvic pain fell from 93% to 36%, nevertheless 39% of those with symptoms of pain still had pain a year later. And while "problems with urination" are said to persist in only 9% of patients, urinary symptoms are described in Table 4 as "urinary frequency", "incontinence" and "urinary urgency" and 26%, 30% and 24% still had "very often" symptoms 12 months after hysterectomy.
Combining the figures for all groups of "fairly often" and "very often" symptoms together gives the persistence of "often" symptoms as 15%, 24%, 21%, 26%, 31%, 44%, 31%, 34%, 32%, 30%, 42%, and 21% - on average nearly a third of women still had their "often" symptom a year later.
Table 2 showed that in the month before surgery 81% found "some" or "a lot" of discomfort due to their condition and 65% found "some" or "a lot" of limitation to activity due to their condition. Given the general negative attitude to menstruation and the fact that many women experience pain, discomfort or inconvenience during normal menstrual cycles I would expect many normal menstrual women to find bleeding limiting or uncomfortable. As no survey of normal women was recorded the baseline level of discontent is not reported.
Symptoms reported at the time of hysterectomy include feelings of anxiety, depression and fatigue. Is any normal woman facing major surgery free of these feelings? Another is "abdominal swelling" - whatever that is. After surgery far fewer women suffered from the symptoms "interest in sexual activity" and "enjoyment of sexual activity". This sounds like they experienced a profound drop in sexual satisfaction, which I can well believe. No doubt the authors interpret the response "not at all", as being not at all worried by a lack of sexual interest or activity.
They state that only 7% of women experienced less interest in, and 1% less enjoyment of, sex after hysterectomy. However these figures relate only to women who reported no sexual problems before operation and who had a problem BOTH 6 and 12 months afterwards. The figures for problems at 6 OR 12 months are 9% and 12%. It would be interesting to know whether these figures show a temporary problem at 6 months or an increasing number of women finding that their libido has vanished. However it has been reported that satisfaction with hysterectomy decreases with time. And remember Carol in Hysterectomy: The Positive Recovery Plan who was fine for a year after her operation before completely losing her sexual feelings.
Another error occurs in this table as 25 women reported hot flashes at BOTH 6 and 12 months but only 22 at EITHER 6 or 12 months, unless of course the categories are exclusive and a total of 47, out of 192 patients with no initial symptoms, reported problems with hot flashes at some time after surgery.
It seems that 28.9% of the medical group and 45.9%, of the hysterectomy group, only a third of whom were 45 or over, were suffering from hot flashes before the operation. With such high levels of menopausal symptoms I couldn't help wondering if some women were being encouraged to have a hysterectomy quick before a natural menopause halted their bleeding problems and the "need" for surgery.
Another interesting fact is that 91% of the castrated women, 30% of the total number, were treated with HRT, much touted by many of the medical profession as a cure for all female ailments, yet this apparently made no difference to their symptom relief.
Scores on the "quality of life" General Health, Mental Health and Activity Indexs after hysterectomy all showed significant increases no matter whether the preoperative degree of discomfort was mild, moderate or severe. I think it highly significant that losing your womb is shown as being definitely good for your social health no matter how insignificant your symptoms. This shows clearly that losing menstrual function is seen as a great social advantage - and to be a bleeding women is to be socially handicapped.

In second study, of medically treated women, it was found that 23% (86 of 380) were hysterectomised anyway. Again high numbers were employed (84%) or insured (87%). It was noted that the women who persisted with medical treatment were more likely to be college educated (53% v 39%). If having a hysterectomy is so innocuous, even beneficial according to those who make a living from it, and being a bleeding women is to be socially disadvantaged, why are educated women are more likely to avoid it?
Table 1, initial symptom severity, is restricted to discomfort and activity limitation and how long the condition had been present. The symptom categories of normal bleeding, heavy bleeding, pain ">8d/m", womb size or anaemia - all part of the presurgical profile of the hysterectomised women - are not shown. Womb size is now measured as greater than 10 weeks, instead of 12 or more weeks in size and the difference between the medical and surgical group of 49% v 54% is significant although the difference between in bleeder anaemia rates of 6% v 4% is not.
We are however told that "objective findings in patients with abnormal bleeding and chronic pelvic pain were similar in the two treatment groups" and that 38% of medically treated bleeders had "an enlarged uterus". Although there were "no significant differences between the surgical and nonsurgical groups for these measures" the hysterectomy study had reported that 0% of their abnormal bleeders had a womb 12 or more weeks in size. How large is an "enlarged" womb?
Not only is a different womb size chosen by the second report but bleeding is now categorised by "mean days" of bleeding or by "bleeding a problem" and pain by "mean days of pain" and "pain a problem". Actual physical measurements of women's conditions are scarce. Where there are results, for womb size and anaemia, they are not impressive, except for an excess of anaemia rates in hysterectomised fibroid women compared to medically treated ones. Anaemia is, however, not a definite indication for surgical treatment and Professor Tinker stated that he had medically managed for as long as 10 years women bleeding so badly that they needed iron treatment for at least part of the year.
Splicing together the figures for hysterectomised women from the two studies shows that redefining bleeding and pain as a "problem" gives much higher percentages of women with symptoms than by using the term ">8d\mo",
although the discomfort and activity limitation figures remain constant.

Symptom (%) Abnormal bleeders Fibroids Pelvic pain

Bleeding >8d\mo 65 38 21
Bleeding a problem (88) (55) (61)

Pelvic pain >8d\mo 66 45 80
Pain a problem (80) (61) (95)

Discomfort 91 (89) 75 (74) 99 (96)
Activity Limitation 78 (76) 57 (55) 79 (80)

Number 91 (78) 146 (123) 74 (68)

Hysterectomised women - Hysterectomy study (Medical study)

Describing symptoms as "problems" appears to reap much higher symptom levels than attempting to describe them objectively in terms of actual blood loss, anaemia or increased womb size.
For medically treated fibroid women the mean number of bleeding days rose from 6 to 7 while the percentage who considered bleeding a problem fell slightly from 23% to 19% and while pain remained constant at 5 days the number who considered it a problem fell from 23% to 12%, suggesting that the length of time a symptom exists may be less important than the patient's attitude towards it.
It would seem that the women who were hysterectomised were much more likely to described something, whether pain, bleeding or feelings about symptoms, as a "problem" though there seems to be little evidence that they are physically in a worse condition.

The Health and Activity Index figures all show great improvements in women's health after hysterectomy, though it is noticable that the surgically treated group all show lower initial values than the medically treated groups.
What is interesting is that the social index scores of the medically treated fibroid women were as high before treatment as the after figures for both hysterectomised and medically treated bleeding and chronic pain women. The medically treated bleeders showed improvements in activity and general health while the chronic pain group showed improvement in activity only, reflecting the falls in the number of days of both pain and bleeding in bleeders and in days of pain only in the chronic pain group. Fibroid women had no reduction in days of bleeding, which was a normal 5. That is, the normal period length of the medically treated fibroid women was associated with normal social indexes even though with their enlarged wombs and their 7% anaemia rate they appear to have more severe objective symptoms than the bleeders or those with chronic pain.
It is interesting that the success of a treatment for menstrual complaints seems to rely chiefly on whether it will reduce the number of days of bleeding. The plethora of symptoms shown to be reduced by hysterectomy - urinary, sexual, pain, constipation etc - are only mentioned to say that that, on average, they did not change in the medically treated groups. Presumably medical treatment has no effect on urinary problems, anxiety, depression, constipation etc. There is no indication of whether the medical group experienced the same frequency or intensity of symptoms as the hysterectomised groups. However Table 5 gives the numbers of those with no initial problems for 12 symptoms. Assuming that these numbers refer to the 355 hysterectomised and 249 medically treated women for whom complete data was available, the percentages with no initial problem can be calculated, and only for weight gain is the figure for hysterectomised women higher. For every other problem fewer of the medical group have symptoms. If this is correct I would have thought that the researchers would have quoted the figures to stress that the medical group were not really as unhealthy as those hysterectomised.
The objective findings, whose of anaemia and womb size, were the same in both hysterectomy and medical groups of abnormal bleeding and chronic pelvic pain and though the medical fibroid women had less anaemia and slightly smaller wombs than the hysterectomised group they were more severe than in the other groups. Yet these medically treated women not only had higher social indexes but would appear to have complained less of a whole range of symptoms. Are women facing major surgery less perky, and more likely to complain of symptoms, than those not having operations. Or are the less perky more likely to be hysterectomised?
Not only was the perception of pain as a problem related to the number of days of pain but the perception of bleeding as a problem was related to the number of days of bleeding. There also seems to be a tendency for the number of days of bleeding to be related to the number of days of pain. It might be said that having a period is a drag and if it goes on longer than normal it is seen as a painful drag.
Remembering that my GP had dismissed the idea that I could possibly have any menstrual problems since my periods were of normal length, can it be that women are frequently judged as heavy bleeders only if they report many days of bleeding, even though they may, in fact, be losing very little blood for most, or even all, of this time? As the number of bleeding days of the medically treated women was lower than those in the hysterectomy groups does this reflect a medical view that these women are not really bleeding seriously? Or is the inconvenience of abnormal bleeding, and therefore willingness to undergo surgery, often related more to the amount of time spent bleeding rather than the amount of blood lost? It is, however, noticable that though hysterectomised bleeders, with more days of bleeding, had an anaemia rate only a fifth of that of the hysterectomised fibroid women more, (88% v 55%), of them thought bleeding a problem.

Abnormal bleeders Fibroids Pelvic pain

Symptom - %
Bleeding a problem 88 (61) 55 (23) 61 (30)
Pain a problem 80 (49) 61 (23) 95 (84)
Anaemia 4 (6) 21 (7) 4
Womb size >= 12wk 0 49 1

Mean Days of
Bleeding 14 (10) 10 (6) 8 (7)
Pain 15 (8) 11 (8) 19 (16)

hysterectomised and (medically treated) women

After 12 months all groups showed significant improvements in "positive feelings about symptoms" - even the medically treated fibroid women whose numbers of days of pain and bleeding remained unchanged and 68% of whom had no treatment at all. Also half of the medically treated abnormal bleeders had more positive feelings about their symptoms after 12 months, an increase from 14% to 64%. Since medical treatment increases positive feelings so much how come only 14% of bleeders started with positive feelings when 62% of these women had sought medical attention a year or more before the study started and had therefore presumably already been treated for over a year? Had their doctors refused to treat them or done so inadequately?
Complications are reported in only 7% of cases but fever, the most frequent complication, is not even mentioned. And although hysterectomy was pronounced effective at relieving symptoms, producing a marked improvement in quality of life, nearly half the women consulted their doctors because of their condition within 3 months and 3% of them were rehospitalised within the year.

Studying 236 hysterectomised women Schofield et al found that although more than half of the patients had symptoms they believed worsened or caused by hysterectomy they still reported high levels of satisfaction with surgery. Why on earth should so many feel satisfied with such a high level of bad effects?
Is it significant that the researchers also found that relief from bleeding was the most frequent and the most important benefit of hysterectomy? And that another report found that 53% of 576 women mentioned lack of bleeding as an advantage of the operation. Social disapproval of menstruation is still very much in evidence and a recent study found that not only did many men think that women should not bleed but 39% of women also thought so.
Being a normal bleeding female is viewed as being disadvantaged. But bleeding is the one thing that does NOT come back after hysterectomy and it would seem that what makes many women eagerly embrace the operation is the removal of the inconvenience of normal femininity. Is this the reason for the great improvements in the Health and Activity Indexs?
Why do I feel that preoperational symptoms have been bloated and postoperational effects minimised? Women wouldn't co-operate in emphasising symptoms - would they? Well if a woman has been convinced by a nice, kind doctor that a quick mutilation will rid her of all unpleasant female complaints, like inconvenient bleeding, forever then she might very well become impatient with the slightest inconvenience. Moreover the American female has not only to convince herself that this major surgery is necessary but to come up with enough symptoms to convince her insurance company to cough up. And if Mrs Stokes is correct many women believe that a hysterectomy is a risk-free, permanent solution to their contraceptive problems.
And after surgery?

Dr White says that "between 40 and 60 percent of all therapeutic benefits can be attributed to a combination of the placebo and Hawthorne effects" while "only about 15% of all contemporary clinical interventions are supported by objective scientific evidence that they do more good than harm." Menstrual complaints are particularly likely to be influenced by placebo treatment and it has been shown in drug trials that up to a third of patients given ineffective, placebo pills have experienced symptomatic improvements. As Mintz writes of a 1963 Scandinavian journal that reported a placebo producing a statistically significant fall in pulse rate and blood pressure when presented as a depressant, and increases when presented as a stimulant, it seems that "ineffective" placebos can even have measurable physical effects.
The placebo effect also applies to surgical treatment as Dr L Cobb of Seattle demonstrated in 1959 when patients given a sham heart operation experienced as much benefit from merely being cut open as those whose who had the real operation. They had pain reduction, took fewer pain control tablets, resumed normal activity and even had improvements in their ECG trace.
Just getting some kind of treatment persuades many people that they feel better. And the more extravagant the treatment the more strongly the patient feels that it MUST be doing them good. As women are generally of low status and impressionable so they are particularly susceptible to being psyched into believing that, of course, the surgery has done them good and any unwanted effects they cannot totally ignore, like lack of libido, may be conveniently ascribed, as Dinah Gould did, to aging.
With passing time this "feelgood" factor fades somewhat and unpleasant side effects become more noticable. But who wants to admit that having your organs ripped out has not banished the aches and pains that flesh is heir to? Especially to the nice, kind, so self-assured surgeon who deigned to operate on you, after telling you how much better it was to get rid of your clapped out organs right now, before they really became bothersome and turned malignant.
And some hysterectomy risks, like hormonal disruption, ovarian aging and osteoporosis, may not develop until years later, when the patient will have forgotten the surgical trauma and, like the genitally mutilated peasant with birth complictions, will make no connection between the two.

Studies which are clearly medically sponsored report the highest rates of satisfaction with medical treatment. Non medical studies find less contented subjects and one social scientist, interviewing patients in their own homes, found that 61% of patients complained that they did not get adequate information about their treatment. The medical system intimidates those it processes. One study found that 33% of British patients would not question a doctor because they thought he would think less of them, and 20% were scared they would get a bad or hostile reaction. If a woman doesn't even dare to ask a question how could she imply that Doctor Wonderful was wrong by saying that she is dissatisfied with the operation - no matter how many unpleasant side effects she is left with? And if she does mention any ill effects she will very probably be told that they have nothing to do with the operation or that it is her own bad attitude that has caused them. She may even be told that what she needs is a premarin pill to perk her up.

Like anybody else medics and medical associations have the ability to hear only what they want to and dismiss or disregard observations that do not fit in with their view of life, the universe and everything. Thus a Swedish study reported that after hysterectomy 39% had better sex life and for 40% it was unchanged but ignored the logical deduction that, even with lower rates of womb neck amputation in Sweden, 21% had a worse sex life. In this way positive or neutral effects may be emphasized and negative effects glossed over.
In the US coronary artery bypass surgery was widely accepted before any demonstration of any effectiveness while many studies showing that most women can deliver naturally after a caesarean section are persistently ignored. Most US doctors like to do as much operating as possible (it's good for their bank balance) and disregard any studies that show that surgery is unnecessary. One result of this aggressive policy is that a third of American hospital patients suffer from medically caused damage.
In The Politics of Cancer Epstein remarks that the apparent willingness of some industrial companies to investigate cancer risks to workers often "masks a biased operation in which the preordained outcome is a clean bill of health. Indeed, a collection of statistical devices with built-in biases for handling data have become standard strategy to avoid regulation of carcinogens and other toxic chemicals." Even a 1973 Lancet editorial noticed that medical men and scientists directly employed by industry are "chiefly concerned with their employers' and their own profits" and are indifferent to the health of employees exposed to production hazards. It also noted that firms may "set up supposedly independent research institutes whose scientists seem always to find evidence to support the stance taken by the firm, despite massive evidence to the contrary. Thus, when some high-sounding institute states that a compound is harmless or a process free of risk, it is wise to know whence the institute or the scientists who work there obtain their financial support".
Epstein also notes that "Constraints on data, from gross inadequacy, biased interpretation, manipulation, suppression and outright destruction, are commonplace, especially when profitable products or processes are involved". And hysterectomy is a very profitable process indeed for the medical profession, being the second most common US operation with over half a million (at anywhere from $3,000 to $11,000 each) performed every year - which comes to lots of greenbacks.
Although industry may be regulated by government agencies, airline pilots have stringent medical examinations, and many professions have to proove that they are competent and up-to-date, the medical profession is virtually uncontrolled. The idea that the doctor can prescribe any treatment he likes is so engrained in medicine that even where some standards exist the doctor can safely ignore them. The Maine group noted this, writing that the use of diagnostic tests was less than expected "judged by current ACOG criteria". But why bother generating income for labs when you can proceed directly to your standard bread-and-butter mutilation, ensuring that a large percentage of the insurance payout goes as doctor's fees. It is very noticeable that American doctors are very keen on reducing the amount of time spent in hospital by hysterectomy patients. I wonder if minimizing hospital fees per patient makes insurance companies more likely to agree to cough up fees for unnecessary operations.
The Maine researchers also noted a high frequency (a third) of multiple diagnosis which Reiter had found associated with a lack of justification for surgery - if you can't find a good reason for committing surgery put down lots of reasons, the pathology department is almost sure to find something wrong with the woman. In fact the Maine study had a section entitled "principal diagnosis at discharge" or "what the pathology lab found that could be used to justify ripping out your organs". Thus endometriosis, forming 10% of the preoperation "other" category, goes up to 20% at discharge, whether it is the cause of symptoms in the extra 10% or not, and the diagnosis of fibroids goes up from 35% to 39% as more fibroids are found in the pathology specimens. In fact the relationship between the presence of endometriosis and menstrual problems is far from simple as some women with severe symptoms have minimal endometriotic patches and other women found to have dense patches have no symptoms. And there have been many women who have had very large and virtually symptomless fibroids.
The Maine Women's Health Study was backed by the Maine Medical Assessment Foundation, an example of "medical self-scrutiny", organised in the 1980s, in the wake of the hysterectomy boom of the 1970s, to investigate variations in numbers of operations and to find the "right rate" of female amputation. And the study was published in the official journal of the American College of Obstetricians and Gynecologists, the official club of the men who make a good living from the frequent performance of "routine" hysterectomies.
Am I being unreasonably cynical in suspecting that this is a whitewashing exercise on the part of American medics to "justify" their high rates of hysterectomies by finding that mutilated women are all much better off without their reproductive systems? Is this study riddled with biased interpretation and manipulation and suppression of data?
I wrote to Dr Carlson, one of the authors of the Maine papers, about my reservations.
She did not reply.