6 Dear Gynaecologist
Optimal selection of appropriate patients and surgical techniques for hysterectomy is particularly relevent as we move into what may ultimately be viewed as the decade of the hysterectomy. If current trends continue more than one third of all women in the US will have a hysterectomy by the time they reach 60 years old. Hysterectomy is now the second most common major surgery in the US.1 Furthermore that total is expected to rise another 30% to almost 800,000 procedures annually by the year 1995 as baby boom women reach the age of highest hysterectomy rate.
Dr Dennis Lutz
I didn't understand why so many women had their wombs removed. Why did all the medical books say the womb could be preserved in "almost every case" and then say the nasty mutilation of hysterectomy was better. Why was it better when it came with a long list of unpleasant physical and mental effects? I decided to ask those who should know - those who wrote the books. So in September 1992 I wrote to T Coltart.
Dear Dr Coltart
I have seen your book "The Woman's Guide to Surgery". Chapter 11 on Fibroids states:-
"But if you wish to have children or simply want to retain your womb, perhaps to "keep your options open" these fibroids can be removed by myomectomy."
It says "A myomectomy can be quite straightforward" and though "If the womb is much misshapen by fibroids, so that it could be extremely difficult to restore it to its normal size and function, the surgeon may want to reserve the right to do a hysterectomy". "Hysterectomy is rarely needed, however."
I have a pelvic mass of some 23 weeks size, probably uterine fibroids, though the second gynaecologist I saw couldn't say it wasn't an ovarian cyst and certainly couldn't say a how many or what type my probable fibroids were. She did however say that a myomectomy would be difficult and require a long recovery time. I find it hard to believe that definite statements could be made about the removal of a mass about which nothing is apparently known. She did not mention GnRH-a treatment though I would have thought this would be indicated for such a large mass, and might have sorted the fibroids from the cysts.
The first gynaecologist was only interested in hysterectomies, but at least she said it WAS fibroids.
I am not interested in hysterectomies - a little mutilation I regard as suitable for rampant domestic animals and persons in mortal peril.
Since your book states that these, or possibly even this, lump(s) can be removed could you tell me how I go about finding a competent person in the National Hysterectomy Service that can in fact do just that?
Yours sincerely
Pamela Nomark
PS I read that Kelly's Medical Gynaecology, published in 1911, gives mortality rates for myomectomy and abdominal hysterectomy as being 3-5% and 6% respectively. As myomectomy is supposed to be the more difficult and dangerous operation did more of these women survive because they had reason for doing so?
His reply, dated 17 November, was addressed to Ms ADAM. I was not aware that my handwriting was so illegible and afterwards usually typed my name. The first line of his letter started GYANEOLOGY CLINIC: 16.10.92.
Dear Ms Adam
Thank you for your letter which was received on 15 September 1992. I must apologise for not having replied before but I have been away.
You clearly have a difficult clinical problem, but not one I would have thought which was insuperable. You will have to appreciate that gynaecologists often differ in views on the best way to manage clinical problems and on occasion of course this makes it difficult for the patient. I cannot say whether you would require a hysterectomy but can only suggest you might like to consult your own family doctor again to see whether there may not be another gynaecologist you could see who would take a more sympathetic view. It may be of course that at the end of the day that hysterectomy may be the best solution. A lot depends on factors such as age, future childbearing etc.
I wish you well.
Kind regards.
Yours sincerely
T M Coltart PhD FRCS FRCOG Consultant Gynaecology
I wrote back in December.
Dear Dr Coltart
Thank you for your well wishes. I am of the opinion that the 20th century female over 40 who wants to keep her reproductive system is sorely in need of all the well wishes she can get. Though a small fortune to pay a person (American, probably) experienced in conservative female surgery would be of more practical use.
I should like to think that gynaecologists DO differ in views on the best way to mange clinical problems but the facts do not support this view.
"Principles and Practice of Clinical Gynecology" by Weingold, Kase and Gershenson states:-
"The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids."
And later say:-
"For the patient who has completed her family or does not plan to bear children and who has symptoms or uterine size equivalent to 12 week gestation hysterectomy is the procedure of choice."
Monaghan's edition of Bonney's Gynaecology, 1986, describes the results of myomectoy as "excellent" but also says:-
"The sole purpose of myomectomy is to improve fertility; it should never be used as a surgical exercise, nor to preserve the uterus in the mistaken belief that such an act will maintain the femininity or sexuality of the patient."
Other authors say the same.
Coulter et al Br J Obs Gy, 1991 August 98(8) 789-96 says:-
Of 205 patients 71% (145) had menorrhagia and 60% of these were hysterectomised within 5 years.
"In the group of patients for whom one might have expected the GP to prescribe drug treatment before referral (menorrhagia not metrorrhagia) the proportion who had received treatment was 58%."
"As many as 43% of patients referred to outpatient clinics had first mentioned symptoms to the GP less than 1 month before referral. Nearly half of these do not appear to have presented with symptoms which would have indicated referral and yet their GP do not appear to have tried a course of medication before referral."
"Many experts have stressed the importance that should be accorded to patients preferences in treating menstrual problems. But GPs notes rarely include a record of patients' views of the available alternative treatments, so it is not possible to assess this reliably in an audit study."
Roos, Am J Public Health Jan 1984 74 (1) : 39-46 says:-
40 per 1,00 had complications requiring hospital readmission during the two years after hysterectomy and associated repair procedures..
After hysterectomy women visit less frequently for gynaecological problems but more frequently for psychological, urinary tract infections and menopausal symptoms...
"In conclusion hysterectomy may expose a woman to significant risks and yet the frequency with which she contacts her physician is likely to be little changed by the surgery. The findings suggest that women and their physicians should carefully weigh the risks and benefits of non-mandatory, non emergency hysterectomy."
Besides the operational hazards of pain, scarring, adhesion formation there is the residual ovary syndrome, depression, sexual dysfunction, increased risks of osteoporosis, cardiovascular disease and osteoarthritis and probably increased risks of vaginal prolapse and vaginal cancer. And of course premature ovarian failure.
These effects are all blithely ignored by:-
Derek Llewllyn-Jones "Fundamentals of Obstetrics and Gynaecology" Vol 2 "Gynaecology", 1978.
"Total hysterectomy is indicated in caes of symptomless myomata if the uterus is larger than a 14 week gestation and the patient is aged 40 or more (or younger but has no desire for children).
The physician must explain that removal of the uterus has no side effects."
In 1898 Alexander of Liverpool removed 25 tumours from a single uterus.
Bonney, who retired in 1937, found it possible to remove 225 fibroids from a single uterus.
So why do contemporary gynecologists apparently have such limited abilities that they prefer to amputated rather than conserve?
A cynic might suggest that it is because in the words of Arabella Melville in "Natural Hormone Health", 1990
"Medicine is a male-dominated profession, where women's organs are little appreciated and women's concerns often dismissed as being neurotic and irrational."
Is the truth that the female reproductive system is treated as being expendable and for the female over forty totally disposable?
If there are good medical reasons for subjecting women to the psychological horrors (I'll vouch for them), physical trauma and long term risks of hysterectomy rather than at least attempting conservation I should like to know what they are.
In an earlier edition of Bonney's book I found this;_
Since cure without deformity or loss of function must ever be surgery's highest ideal the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable.
So where do I go to find a cure without deformity? Boston? Bruges? Paris? Russia? Even Australia! But apparently not to England, which has produced no reference to myomectomy that I could find on Medline. I feel sure that Bonney would not have been pleased to find England reduced to a nation of hysterectomists.
If there are good reasons why my womb should be rushed to summary execution I would like to know what they are.
By the way I omitted to say that I am an ancient crone of 44 years with no intention of being conned out of any part of my reproductive system. I have also complained about my now ex-GP's lack of care to the Family Health Authority and am not happy with the present one who appears to know less about fibroids than I do now and has not come up with my computer records as requested.
Yours sincerely
Pamela Nomark
I had no answers from Dr Coltart and I heard no more from him. Of course as he had interpreted my name as "Adam" perhaps he didn't know who I was or what I was complaining about.
Or perhaps he didn't give a damn. Especially as his hospital was one of those facing the axe in the new look, capitalistic, NHS market.
On 23 September 1992 I wrote to Mary Anderson.
Dear Mrs Anderson
I have read in your "An A-Z of Gynaecology" on myomectomy:-
"It is reserved for younger women who wish to preserve their childbearing function. Older women with fibroids are better advised to undergo hysterectomy."
As an older woman (44) with fibroids I should like to know why I should be better advised to undergo a mutilation, the thought of which fills me with horror and which is associated with:-
I quoted the list and "The Woman's Guide to Surgery" on how myomectomy could be "quite straightforward".
I note that conception is possible throughout the menstruating years and with the advent of GIFT and the birth of a son this year to a 61 year old Italian woman even beyond them.
In spite of this and in spite of the many negative effects of hysterectomy it remains extremely popular with the medical profession.
I feel that I am treated as the disposable sex, fit only for amputation after age 40 and routinely dumped on a conveyor belt to mutilation.
My GP has been unable to give me an explanation for the preference shown for this hideous operation. As a medical writer I expect that you can.
Yours sincerely
Pamela Nomark
She wrote back on 30 September 1992.
Dear Mrs Nomark,
Thank you for your letter of 23rd September. I would say first of all, that the patient's choice is everything and even in older women I would have no doubt about accepting their wishes in so far as retaining the uterus is concerned. As a doctor and with a knowledge over many years of physiology and anatomy, I would nevertheless, still say that in someone who no longer has plans to have a family (and this includes women over the age of 40) the procedure of hysterectomy is still better than anything else. Particularly, if it is associated in due course with hormone replacement therapy. Myomectomy, as an operation, is still a major procedure and requires the same sort of surgery as hysterectomy apart from the attempt to retain the uterus. It is, I quite agree, a wide subject which merits much debate and I fear that in the context of your letter I cannot give justice to it. I accept all that you say and would reassure you, in so far as this is sufficient, that my views as a Gynaecologist although firmly on the side of the scientists, are nevertheless sympathetically inclined towards women's choice. I am not sure whether this goes any way at all in answer to your letter, but please feel free to correspond with me again if necessary.
Yours sincerely
Mary Anderson FRCOG
Well NOBODY calls me unscientific. I wrote back on 22 October.
Dear Miss Anderson
With regard to your letter of 30 September I have always been interested in sciences from archaeology to zoology and worked for some years in a chemical analysis laboratory. As I also have A levels in botany, zoology, chemistry and computing and a degree in Zoology I have always regarded myself as scientific.
Since 1 in 5 women will be relieved of their womb (and in many cases their ovaries as well) by the age of 75 and since 1 in 3 hysterectomies are for fibroids this means that 1 in 15 women lose their wombs because of fibroids. It is said 1 in 5 women develop fibroids which means that one third of these women will be hysterectomised because of their "benign" growths.
As you and I, and Victor Bonney, all know "Fibroids of the uterus beyond the scope of conservative surgery are uncommon". And that was half a century ago! Since then there have been slight improvements in surgery such as lasers, ultrasound and hysteroscopy as well as drug treatment like the GnRH-a therapy Friedman is so enthusiastic about.
Removal of fibroids alone appears perfectly possible in nearly all cases. However in nearly all cases it is the uterus that is removed and few women are offered any other option.
As T Clayton and J B Beecham say on page 427 of "Controversy in Obstetrics and Gynaecology " edited by Reid and Christian:-
"Leiomyomas are found often enough in the reproductive years to make myomectomy a more common procedure than it appears to be. Enthusiasm seems low for this restorative operation, presumably because fertility rates afterwards are not encouraging. In addition the recurrence of myoma is said to be high enough to usually warrant hysterectomy in the first place.
Neither of these arguments is powerful."
Jeffcoate's Principles of Gynaecology revised V R Tindall
Hysterectomy is a relatively easy operation to perform and often easiest when least necessary. Many women die annually as a result of having this operation unnecessarily...
"It is not exaggerating the situation to say that an-ever ailing woman is sometimes deprived of her uterus and appendages so that the gynaecologist can thereafter shun responsibility for her care on the grounds that there is nothing left in "his department" which can possibly cause her symptoms."
I also quoted Coulter and Arabella Melville and finished by asking:-
So what is the scientific basis of the wholesale mutilation of women perpetrated in the name of medicine? I would really like to read the papers that demonstrated that mutilation is better for the patient, not just easier for the surgeon, than conservation.
Yours sincerely
P Nomark
Actually fibroids are practically ONLY found in the later reproductive years, since they appear to be dependant on oestrogen. Also if aversion to mutilation - not desire for offspring - is the reason for preferring myomectomy then subsequent fertility, or sterility, is irrelevant. On 10 January I wrote again, after all she did say to feel free to correspond.
Dear Ms Anderson
Although it has been more than 2 months since I wrote to you, in response to your letter of 30 September, I have heard nothing regarding scientific justification of the statement that "the procedure of hysterectomy is still better than anything else".
In view of your many years experience of physiology and anatomy I must conclude, as a logical person, that this is proving more difficult than expected.
This is entirely as I would have expected.
Your sincerely
Pamela Nomark
Miss Anderson responded on 13 January.
Dear Ms Nomark,
Thank you for your letter of 10 January. I must confess I thought that our correspondence had ceased and I have little really to add at the present time. I am quite sure, that as time passes, other approaches than hysterectomy will indeed take precedence.
Yours sincerely
Mary Anderson FRCOG
I wish I could be sure that other approaches would take precedence. All the evidence is that hysterectomy rates are still rising.
Over a year later I read Germaine Greer's book on the menopause, in which she berates Dr Anderson, referring to her "contempt for women" and "her view that people with penises can do no wrong, whatever it is they choose to do." I was greatly entertained.
On 20 November 1992 I wrote to Dr Weingold, professor of the department of Obstetrics and Gynecology at the George Washington University Hospital School of Medicine and Health Services in Washington DC.
Dear Dr Weingold
I note that your book "Principles and Practice of Clinical Gynaecology" is dedicated "To our patients". As I have a 23 week mass presumed to be uterine fibroids, I have a query for you.
You state:-
The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids."
And then say:-
"For the patient who has completed her family or does not plan to bear children and who has symptoms or uterine size equivalent to 12 week gestation hysterectomy is the procedure of choice."
I repeated most of what I had written to Dr Coltart about hysterectomy and its bad effects and finished with:_
If there are good medical reasons for subjecting women to the psychological horrors (I'll vouch for them), physical trauma and long term risks of hysterectomy rather than at least attempting conservation I should like to know what they are.
As a zoology graduate I have good basic biological knowledge and anything I don't understand I can look up.
Hoping to hear from you soon.
Yours sincerely
Pamela Nomark
He never replied.
On 21 November 1992 I wrote to Dr Monaghan.
Dear Dr Monaghan
Your edition of Bonney's Gynaecology, 1986, states:-
"The sole purpose of myomectomy is to improve fertility; it should never be used as a surgical exercise, nor to preserve the uterus in the mistaken belief that such an act will maintain the femininity or sexuality of the patient..."
At the time Bonney was working, a subtotal hysterectomy was considered to be the treatment for fibroids.
Today with the many advances in medical science a greater mutilation, a total hysterectomy, is considered the treatment of choice for fibroids.
I should like to know why my organs are regarded as unworthy of any attempt at conservation and only of use for bearing children for men.
I repeated my list of nasty hysterectomy effects and then continued.
Many hysterectomised women suffer sexual dysfunction, Filiberti et al recording that 17 out of 30 women hysterectomised for benign pathologies described their sexual life as unsatisfying. So it would seem that preserving the uterus might indeed be said to maintain the patient's sexuality.
In an earlier edition of Bonney's book I found this;_
Since cure without deformity or loss of function must ever be surgery's highest ideal the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable.
So where do I go to find a cure without deformity? Boston? Bruges? Paris? Russia? Even Australia! But apparently not to England, which has produced no reference to myomectomy that I could find on Medline. I feel sure that Bonney would not have been pleased to find England reduced to a nation of hysterectomists.
If there are good reasons why my womb should be rushed to summary execution I would like to know what they are.
Yours sincerely
Pamela Nomark
He never replied either.
I also wrote to Angela Holder, a Clinical Professor in the Department of Pediatrics (Law) and Counsel for Medicolegal Affairs in New York.
Dear Dr Holder
The Principles and Practice of Gynecology
Kase, Weingold and Gershenson
In the above mentioned book you quote the following:-
"Sterilization may be said to destroy an important part of a person's social and biological identity - the ability to reproduce. It affects not only the health and welfare of the individual but the well-being of all society. Any legal discussion of sterilization, must begin with an acknowledgement that the right to procreate is fundamental to the very existence and survival of the race. This right is a basic liberty of which the individual is forever deprived through unwanted sterilization.
Supreme court of New Jersey re: Grady."
The same book also states with regard to fibroids.
"The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids."
And later:-
"For the patient who has completed her family or does not plan to bear children and who has symptoms or uterine size equivalent to 12 week gestation hysterectomy is the procedure of choice."
Since hysterectomy is of course also a sterilisation and since myoma are rare outside the reproductive years could it be said that any physician who performs an elective hysterectomy for myoma without at least mentioning that fibroid removal only is possible in "almost all patients" is in fact depriving his patient of her basic liberty to procreate?
I am not well aquainted with the right to informed consent to surgery necessary in at least some parts of the U.S. (such useful legislation wouldn't get past the medical mafia in England) but wouldn't this also require a patient to be informed of conservative alternatives, even if such an operation would not be the operator's "procedure of choice"?
I wonder if you could shed any light on my speculations.
Yours sincerely
Pamela Nomark
But of course she didn't and on 20 December 1992 I wrote to Dr Friedman, of Harvard Medical School.
Dear Dr Friedman
I have a large (about 23 week size) fibrous mass, presumably uterine fibroids and have been reading about them. At 44 I find that my reproductive system is generally regarded by the medical profession as totally disposable and conservative surgery although practised over a century ago denied to almost all fibroid females.
In 1989 Alexander of Liverpool removed 25 tumours from a single uterus.
Victor Bonney, who retired in 1937, found it possible to remove 225 fibroids from another.
Yet the book "Our Bodies, Ourselves" records a 29 year old woman denied myomectomy and told that her womb had been "destroyed" by a mere 21 fibroids.
I repeated my findings about the usual treatment for fibroids and its nasty effects.
From your writings you would appear to be very experienced in conservative surgery. So could you tell me if myomectomy is much more difficult than hysterectomy and why hysterectomy is "the operation of choice" for - though I doubt of - so many women.
Also as Ross records that weight is strongly linked to fibroid development and Shikora reports that women undergoing hysterectomy for fibroids as being heavier than the average American population should myomectomy patients be advised to keep their weight under control.
Is there any link between fibroid recurrence and patient weight, either absolute or relative? Are women hysterectomised for fibroids heavier than those who have fibroids but are not operated on? Do fibroids develop faster in fatter women and do they stop growing if the woman diets? In fact should a woman be told to reduce weight at the first sign of fibroid development?
Yours sincerely
Pamela Nomark
Dr Friedman did reply. United Kingdom was written in capitals on the letter. I had never thought to write the country of origin on my letter and wondered if my envelope had been discarded, and if so had been it been easy to guess where I had been writing from. He said:-
Dear Ms Nomark
I received your letter from December 20, 1992. You have clearly done your homework in reviewing the controversial issue of surgical management of uterine fibroids. You have identified some of the issues which have been dogma in the past but are now being challenged. In my own practice, I individualize the care and recommendations I make to women with myomas. I feel that it is my job to inform women fully and then to have them participate in the decision as to what therapy (if any) is most appropriate in their specific situation.
In regards to your questions about a patient's weight and fibroids, preliminary data (which needs to be confirmed) suggested that a patient's weight may be related to the size of the myomas. I am not aware of any data looking at the risk of fibroid recurrence and patient weight or whether women undergoing hysterectomy are heavier than those women with fibroids who do not have operations. All of these areas remain inadequately studied at the present time.
I hope this is helpful to you. Best of luck in the future.
Sincerely
A J Friedman
Chief
Division Of Reproductive Endocrinology
He had had plenty of experience at performing myomectomies but did not say if myomectomy was more difficult than hysterectomy. Perhaps he did not like to say it was easy just because it was easy for him.
I wrote to America again on 15 June 1993.
Dear Dr Marut
Since I was found to have a pelvic fibrous mass of about 23 weeks size I have been reading up on fibroids and came across your article in the Obstetrical and Gynecological Survey.
This states that "Previously, hysterectomy was the only technically feasible procedure for many women." This does not accord with the statement of Weingold, Kase and Gershenson in their tome Principles and Practice of Clinical Gynecology, which states "The removal of leiomyoma with preservation of the uterus can be accomplished in almost all patients without regard to the size, location or number of fibroids."
I have also read that in 1898 Alexander of Liverpool removed 25 tumours from a single uterus and Bonney, who retired in 1937, found it possible to remove 225 fibroids from a single uterus and 40 weighing a total of 21 pounds from another. Since such surgical feats were performed without the benefits of modern technology over half a century ago, could you tell me why so many modern women are faced with only hysterectomy?
As Nobel nominee Dr Hufnagel, and hysterectomy victims all over the world, will tell you the adverse effects of hysterectomy are many and unpleasant. So why hysterectomy? If there are significant disadvantages to conservative surgery I should like to know what they are. I know that there is a possibility of further fibroids requiring later hysterectomy but would you want your reproductive system amputated because there was a 10% chance of conservative surgery being unsuccessful?
From the medical attitude illustrated by the following quote I have concluded that hysterectomy is the "operation of choice" because medics DO NOT RESPECT THE FEMALE REPRODUCTIVE SYSTEM. If you know of facts that disprove this conclusion please tell me of them.
Te Linde's Operative Gynaecology ed Mattinley & Thompson, 1985
"Myomectomy is occasionally justified in a woman over 35. It is rarely a reasonable procedure when she is past 40. Only in cases of late marriage in which childbearing is greatly desired should myomectomy be considered in the late thirties or early forties."
This sounds like a female is only permitted to retain her reproductive system if a man wants to breed from her.
Yours sincerely
Pamela Nomark
And I wrote to the USA again on 19 June 1993.
Dear Dr Hasson
Since last spring when I was found to large pelvic mass (either uterine fibroids or presumed uterine fibroids depending on whether you believe the radiologist or not) I have been reading up on fibroids.
I found that in 1898 Alexander of Liverpool removed 25 tumours from a single uterus and Bonney, who retired in 1937, found it possible to remove 225 fibroids from a single uterus and 40 weighing a total of 21 pounds from another. Bonney's Gynaecological Surgery stated that:-
Fibroids of the uterus beyond the scope of conservative surgery are uncommon.
And I quoted Kase and Co on the possibility of myomectomy and the "choice" of hysterectomy.
So it is possible to conserve a fibroid uterus in almost every case yet in spite of the known adverse effects of hysterectomy (risks of ovarian failure, cardiac disease, osteoporosis, depression, etc) conservative surgery is rarely performed or even considered.
Your article in Obstetrics & Gynecology, November 1992 says:-
"It was partly because of these concerns (operative bleeding and adhesions) and partly because of the popularity of hysterectomy that myomectomy did not become the standard treatment for symptomatic leiomyoma in the United States."
Would you mind telling me WHO hysterectomy is popular with. And whose is the choice of procedure. Personally I find hysterectomy as popular as an arsenic cocktail.
In his book The No-Hysterectomy Option Dr Goldfarb states that in his experience 8 out of 10 women want their uterus preserved.
In the American Journal of Obstetrics and Gynecology, June 1990 Drs Smith and Uhlir state that they estimated 20% to 25% of their cases were either referred or sought second opinions because other physicians recommended hysterectomy as a first choice or told them that there was no alternative. This latter was obviously a blatant lie since all the patients had a myomectomy.
From these facts I conclude that women are routinely mutilated in their millions because it is convenient for the surgeon, and that as little consideration is shown for their feelings as for their organs.
If there are good medical reasons for the preference shown to mutilation of the female reproductive system rather than its conservation I should like to hear them since all I have found is increasing numbers of adverse effects resulting from hysterectomy. I should also like to know why women are apparently regarded as something to be operated on but never informed or consulted.
Also why didn't you pretreat larger fibroids with GnRH-a? Wouldn't it have made their removal easier.
Yours sincerely
Pamela Nomark
Another deafening silence. On 17 July 1993 I was writing to much closer to home - to Manchester, in fact.
Dear Dr Steele
Re: your article on fibroids;
I'm glad to hear that myomectomy is not totally unknown to the NHS. I searched Medline and although I found references to myomectomy from the USA, Russia, Japan, Belgium, France, China and Africa I couldn't find a single article from England.
And I told him about my own hysterical history and what I had read about the favoured medical treatment for it, especially about how older women were at less risk of recurrence.
It would seem to me that mutilation is ordered for precisely those women (aged 40+) for whom hysterectomy cannot be logically justified. And since younger women are very likely to want to breed and more likely to suffer medically from uterine amputation it can't be justified for them either. Which leads to the logical conclusion that myomectomy should be the treatment of choice for ALL cases of uncomplicated uterine fibroids.
Could you please tell me then if there is any logical explanation for the wholesale mutilation of fibroid women apart from the obvious one of ingrained misogyny on the part of the medical profession?
I have written on this subject to a few gynaecologists but they either evade or ignore the question.
Yours sincerely
Pamela Nomark
The article on fibroids was in TV Quick and it was obvious why the fibroid female involved was not sold a convenient hysterectomy. As a 27 year old nursery school teacher it was a pretty sure bet that she would have reacted very negatively to the suggestion that she didn't really need a reproductive system. She went to the Women's Endoscopic Laser Foundation to have her growths removed by keyhole surgery.
In March 1994 Dr Steele got round to hysterectomy in his column. This time the female involved was left with heavy periods after treatment for early cervical cancer. The suggestion that a hysterectomy could solve her problems was described as a "bombshell". As she was in her 40's no effort was made to spare her reproductive system - in fact her expert, Mr Garry of the Women's Endoscopic Laser Foundation, wanted to gut her entire reproductive system. But as he did it by keyhole surgery at least it didn't leave a large scar and she soon recovered from her neutering. Endometrial resection, also available at the Women's Endoscopic Laser Foundation, would very probably have fixed the bleeding in a quick outpatient procedure without cuts of any sort. But perhaps as she had already had a cervical malignancy it was thought better to dispose of the organs which Wright had described as "useless, bleeding, symptom-producing and potentially cancer-bearing".
Of course Dr Steele made no mention of ovarian failure, depression, sexual difficulties, or complications after hysterectomy. Have a hysterectomy and within 6 weeks you will be training at the gym several times a week and feeling full of energy and vitality.
Surgically laparoscopy is much less traumatic and patients recover quickly. But I sometimes wonder if this is not "sugaring o'er the devil himself". If laparoscopic hysterectomy is still going to produce the same hormonal and anatomical disruption as traditional abdominal hysterectomy then it has no long term advantage and the same symptoms are going to appear in hysterectomised women.
In 1959 Dr Katerina Dalton reported that while 83% of women were satisfied with their hysterectomy in the year after surgery between 1 and 5 years later 41% were still satisfied and at 6-10 years only 33% were satisfied.
Of course since then the importance of ovarian hormones for health has been established and women are now much less likely to be left to rot after castration. Unfortunately they are now much more likely to be unnecessarily castrated, since the medical profession would rather medicalise a womans life with drugs than leave her organs alone.
The same week that the hysterectomy article appeared I received a letter from the TV program "This Morning". It said:-
Date as postmarked
Dear Sir/Madam
Thank you for your letter.
Unfortunately Dr Steele is prohibited by medical ethics from advising on individual medical problems. You should always discuss your fears with your own GP who has ultimate reponsibility for your health and well being.
However, your letter is being passed on to Dr Steele's producer, who may considering covering this subject when planning future programmes.
I'm sorry we could not be of more help, but wish you well for the future.
Every good wish.
Yours sincerely
Geraldine Woods
HEAD OF VIEWER INTERACTION
Wouldn't you think that if you were going to be pissed off with a mass printed form that it would take a little less than 8 months to post the damn thing? I found it more insulting than complete silence.
On 18 July 1993 I wrote to Wales.
Dear Dr Slade
Re: your article in the journal of Obstetrics and Gynaecology entitled "Leiomyosarcoma and transcervical resection of the endometrium - a cautionary tale".
The unfortunate 44 year old fibroid female involved was told after suffering heavy bleeding for 12 years that she should have a hysterectomy. Since Professor Weinstein in his "Principles and Practice of Clinical Gynecology" states quite clearly that fibroids can be removed with preservation of the uterus in almost all cases why was this woman not offered a myomectomy?
Dr Goldfarb in "The No-Hysterectomy Option: Your body, Your Choice" says that "if a woman is 40, the chances are overwhelming that she's not going to have problems after myomectomy because the menopause will intercede" and hysterectomy is known to be associated with depression and sexual dysfunction along with heart disease and osteoporosis risks due to ovarian damage.
As the womb at this time was only 12-14 weeks in size and Bonney over half a century ago removed 40 fibroids with a total weight of 21 pounds myomectomy at this time should have been an easy operation.
Dr Goldfarb also says:-
"The number one job of the gynecologist is to address the patient's needs and desires, and put into perspective for her within the context of those needs and desires what her chance of success will be when availing herself of any particular plan of care. Today, when so many alternatives are available and so much is known about the consequences of hysterectomy, if a gynecologist just says, "You don't need your uterus, let's take it out", his statements are both unwarranted and uncaring" and:-
"As long as a woman understands that the alternative to hysterectomy she has selected may not offer a permanent solution or 100 percent cure, then she is entitled to make the choice."
Would you say that this woman's needs and desires had been addressed or has she been offered only a convenient mutilation and treated as an experimental animal in a new procedure when she said that she didn't want the mutilation?
I should be very interested to hear your comments.
Yours sincerely
Pamela Nomark
It was very strange but I could find no trace of Mr Slade on the staff lists of the hospital he was based at. I suppose that he was some sort of research person. Of course he had no comments for mere guinea pigs.
On 8 August 1993 I wrote to sunny California.
Dear Dr Indman
At the age of 44 I was found to have a 23 week sized fibroid womb. I have been informed by the gynaecologist that I should have a hysterectomy NOT a myomectomy. She went on about how myomectomy was a long operation and required a long recovery time and how fibroids could recur. Since seeing her I have read Dr Goldfarb's book The NO-Hysterectomy Option which says "if a woman is 40, the chances are overwhelming that she's not going to have problems after myomectomy because the menopause will intercede". If Dr Goldfarb is to be believed I need not worry about fibroid recurrence.
You wrote the following in the Obstetrics and Gynecology journal in May this year, "Myomectomy has traditionally been reserved for those women who wish to retain fertility or who refuse hysterectomy because of the time required to recover from major surgery, personal or psychological reasons, or medical problems."
The "time to recover from major surgery" section surprises me. I assumed from what my gynaecologist said that myomectomy was a longer and more traumatic operation but this implies the reverse. Can you tell me what the relative operative times and risks are likely to be given that ultrasound shows that I have a single melon sized, fundal fibroid sitting on top of what is apparently an otherwise normal reproductive system?
Dr Goldfarb also says "Furthermore, a woman, regardless of her childbearing plans or potential, may have physical and emotional
reasons for wanting to preserve her uterus and her feelings must be respected".
I do not feel that my feelings HAVE been respected by this gynaecologist but I do not know if Dr Goldfarb is correct in his assertion about fibroid recurrence or what the operative risks relative to myomectomy and hysterectomy are. Can you provide illumination on this subject or refer me to some source of information on it?
Yours sincerely
Pamela Nomark
I should have thought more about what Dr Indman was writing about. His article was on vaginal myomectomy, removing fibroids from inside the womb without cutting open the body. I would have thought only a brain dead female would have preferred the risks and six inch scar of any abdominal surgery to a vaginal myomectomy with no scars at all.
What was quite amazing was that I received a reply from Dr Indman, a "Professional Corporation", dated 13 August, only five days later than my letter. It was a brief note which said:-
Dear Pamela
Here are some articles that we hope are educational for you. We provide these to our patients to help make decisions a little easier. Since you are not a patient of ours, Dr Indman is not able to comment on your situation.
Thank you
It was unsigned and was probably sent by a receptionist but it came with an copy of an article by the doctor and a very interesting item from the American Consumers Society.
None of the gynaecologists I wrote to produced any justification at all for the routine mutilation of the female, though they all recommended it for women over 40. Of course as none of them had a womb they were all sure that nobody really needed one. After writing that myomectomy is nearly always possible in all cases Weingold writes, "Generally, myomectomy is the applicable procedure in the patient desiring further childbearing and under the age of 35.
Beyond that age the patient should be made aware of the possible need for repeat surgery for recurred myomas and should be carefully counselled in order to be certain that an informed consent is obtained."
Of course the younger patient is much more likely to require repeat surgery and to suffer badly from ovarian damage but it is the older woman who is to be harried into unnecessary mutilation. Because when it comes down to it Professor Weingold has no respect for the wombs he so casually amputates. He is also in flavour of the amputation of a totally symptomless womb if it is bigger than a 12 week pregnancy.
The Oxford study has shown that the greatest risk of hysterectomy for fibroids occurred in women aged 45-49, where fibroids were given as the excuse in nearly half of all hysterectomies. As these women are close to the menopause they are the least likely to require further surgery because of fibroids regrowth but conservative surgery is virtually never considered.
1 Caesarean section is the most common.
writings
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womb
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chapter 6