NZ's low hysterectomy rate is one of the great gynaecological success stories

by Ruth Nichol / 07 March, 2018

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Hysterectomies used to be common, but women now have less-invasive options available.

Auckland gynaecologist Cindy Farquhar can remember a time when she would perform four hysterectomies in a morning. But these days, Farquhar, postgraduate professor of obstetrics and gynaecology at the University of Auckland, says a falling hysterectomy rate is making it hard to find enough uncomplicated cases to train young gynaecologists in the procedure, which involves removing a woman’s uterus and in some cases the cervix.

“We’re finding that the only hysterectomies we’re doing are the difficult ones. We used to do a lot of hysterectomies for women who had normal-appearing uteruses, whereas now most of the women have underlying conditions such as endometriosis, fibroids or adhesions, so they’re more difficult to do.”

Hysterectomies were once commonly performed on otherwise healthy women who were experiencing heavy menstrual bleeding or had fibroids or a prolapsed uterus. According to a study published in the New Zealand Medical Journal in 1984, an average of 4.1 women in every 1000 had a hysterectomy, and they had a 39% chance of having the operation by the age of 85. Now, hysterectomies are used largely as a final resort, rather than as a first-line treatment.

We don’t have up-to-date national figures – partly because private hospitals, which in 1984 performed 42% of all hysterectomies, no longer have to provide them. However, a report published last year by the Australian Commission on Safety and Quality in Health Care suggests our rate could be as low as 1.5 for every 1000 women. That compares with 2.3 in Australia.

It’s part of an international trend that Farquhar describes as one of the great gynaecological success stories of the past 30 years. And she says it’s come about because a range of alternatives to hysterectomy are now available.

Gynaecologist Cindy Farquhar.

“We don’t really talk about it a lot, but it is a success story, as we have several options for women now.”

One of the most successful of these options is using a hormone-releasing intrauterine device (IUD), such as a Mirena, that provides contraception and also reduces heavy menstrual bleeding. These IUDs stop periods altogether in about a fifth of women.

A study published in the Medical Journal of Australia last month found that the use of hormone-releasing IUDs to treat heavy bleeding has almost doubled in Australia in the past five years. Earlier US research found that the IUDs were more effective at treating heavy periods than the oral contraceptive pill and non-hormonal medications that help stop bleeding.

It’s also possible to treat heavy menstrual bleeding using endometrial ablation, which involves using heat to remove the lining of the uterus. “It’s not so commonly used, but it is definitely an option,” says Farquhar.

There have also been advances in the surgery used to treat women with prolapse without removing the uterus. However, finding non-surgical methods to treat fibroids, which cause problems for many women until they reach menopause, is proving more difficult. The fibroids can be removed laparoscopically, but this can weaken the uterine wall, which may cause problems in subsequent pregnancies. Taking the contraceptive pill or having hormone injections can shrink fibroids. So can injecting them with a special fluid to block the blood flow – a procedure called embolisation.

But the fibroids often grow back and some women end up needing a hysterectomy.

“Fibroids are probably the one thing we’ve had difficulty getting traction on. Embolisation is not the final answer for many women, but it can give them some time so they can have children.”

Women who have finished having children or who are approaching menopause may feel they can get by without their uterus. However, there’s growing evidence that hysterectomies can cause long-term health problems – even when, as is most often the case, the ovaries are not removed and continue producing vital female hormones. These problems include early menopause, heart disease, high blood pressure and obesity. Research published in the journal Menopause in January found that the risks are greatest for those who have a hysterectomy under the age of 35.

The surgery itself can also cause complications. “It’s a major operation that involves securing large blood vessels,” says Farquhar. “There’s potential for harm at the time of the surgery and it usually requires a recovery period of up to six weeks, so it’s good that we can offer other options.”

This article was first published in the March 10, 2018 issue of the New Zealand Listener.

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