The hysterectomy story in the United Kingdom.

Gynaecologists in India should be deeply concerned by the message broadcast on the BBC by Jill McGivering (6(th) February 2013) in which she suggested that hysterectomy is abused in India, with the overwhelming number of women being subjected to the operation unnecessarily. Their counterparts in the UK should be no more complacent because although the hysterectomy rates have fallen over the years, yet there is widely and wildly varying rates between regions, hospitals and individual gynaecologists. Until research can be undertaken to establish what the true rates of hysterectomy should be, clear simple guidelines could go a long way to ensuring that women are not subjected to an operation they do not need, while those who would benefit are not denied an intervention that can improve their quality of life.

INTRODUCTION

Hysterectomy is indeed the most frequently performed major gynecological operation the world over. While this remains the case in the United Kingdom (UK), the rates showed a marked decline between 1995 and 2002-2003.[1] It is generally assumed that the advent of minimally invasive endometrial ablative techniques in the late 1980’s and early 1990’s account for this decline, but other factors are likely to have been contributory, including effective proactive management of menorrhagia in primary care, and increased patient awareness and involvement in decision-making regarding their care. Endometrial ablation was first described in the UK in 1981 and now has become an accepted alternative to hysterectomy for menorrhagia. Between 1989/90 and 1994/95 an average of 23,056 hysterectomies annually were performed for menorrhagia in the National Health Service (NHS) in England.[1]

In contrast to India, where the numbers of hysterectomies performed every year are likely to be vastly under-reported, in the UK under-reporting in the NHS is likely to be minimal, although, the same cannot be said of the private sector, where there is no organized system of reporting. However, the numbers performed in the private sector are also likely to be relatively small, and on average it would be fair to say that the NHS data reflects fairly accurately what is happening in the UK. Thus the overwhelming numbers of unscrupulous hysterectomies performed in India highlighted by Jill McGivering in the British Broadcasting Corporation (BBC) world service on the 6th of February 2013 is truly shocking.[2]

Data from the UK suggest a hysterectomy rate of 42/100,000 population, with higher-rates in the United States (143/100,000) and Canada (108/100,000).[3] Countries with no waiting times for surgeries have even higher-rates, with Germany reporting rates of 236/100,000 and Australia 165/100,000.[3] We evaluated the data for hysterectomies performed in the UK between 2001 and 2012 [Figure 1]. It is interesting to note that while the trends showed a decline from the 1990’s to early 2000, from 2002 till date the rates show a plateau, suggesting that the alternatives to hysterectomy such as endometrial ablation and the levonogestrel–containing intrauterine devices have had their maximal impact on reducing hysterectomy rates. Presumably, there is a point beyond which alternative therapies simply become ineffectual and hysterectomy becomes the only viable option, and this might tempt one to presume that the hysterectomy rates in the UK may be close to the ideal?

Figure 1

Trends in hysterectomy rates UK. Data obtained from HES (Hospital Episode Statistics) online (data from 2004 to 2005 not available). Hysterectomy rates 2001-2012. TAH: Total abdominal hysterectomy, STAH: Subtotal abdominal hysterectomy, VH: Vaginal hysterectomy

The vast majority of hysterectomies are performed for benign indications, and thus to improve the quality of life rather than to save lives. Thus, fundamental outcome measures for hysterectomy must include cost-effectiveness and impact on quality of life. Research has shown that hysterectomy, when compared to alternative conservative therapies such as endometrial ablation and pharmacological therapies, is a cost-effective modality for managing menorrhagia.[4] Virtually, all research that has addressed issues of satisfaction rates and quality of life has shown hysterectomy to be a supremely effective operation.[56] However, that this operation is cost-effective and has a positive impact on quality of life does not justify its unbridled use, for it is also not without complications. A significant cause for concern and disquiet are the hugely varying hysterectomy rates. Within the UK, rates vary widely between regions, and between hospitals within the same region, and even between consultants within the same hospital. There is no obvious or clear explanation for these widely and wildly varying rates. The correct or acceptable hysterectomy rate is not known. Given the statements above regarding the impact of hysterectomy, it is just possible that in areas with low hysterectomy rates, women may be being denied an operation that could vastly improve their quality of life, while in areas, such as India, with extremely high-rates, women are being subjected to an operation they do not need, with the attended risks and complications.

What is the way forward in this conundrum? It must be possible to conduct research to establish the correct hysterectomy rate for a given population, which would provide a measure against which the performance of gynecologists can be assessed, exposing those who over-use or under-use this operation. The design and execution of such research is likely very challenging, or else it would long have been done. While it is awaited, simple guidelines would go a long way towards ensuring that women are offered this operation only when they need it, and are not denied it when it could significantly improve their quality of life. Such guidelines could include issues such as the alternative therapies that should be offered before hysterectomy, the duration of such alternative therapies, and the involvement of women in decision-making when hysterectomy is considered. The latter would not only empower women in deciding upon an operation that impacts on the very core of womanhood, but research has shown that where women are involved in such decision-making, then satisfaction rates following the intervention are high. Gynecologists in India should be gravely concerned about the current hysterectomy rates, while those in the UK should not be complacent about the widely and wildly varying hysterectomy rates in the country.