Dr. Sharda Jain Secetory General

Dr. Ila Gupta Secreatary

Delhi Gynaecologist Forum

For public / Administrators & Doctors Awareness

TOI Sept. 2010Landmark article

80% of Andhra Village women are minus their uterus

Uterus chopping States

Andhra Pradesh , Madhya Pradesh, Punjab, Bihar, Delhi

Modus Operandi Same as

Female Feticide

22 Sept.2012 appealed to Gynaecologists To be kind to uterus

Why Did he say so about Hysterectomy ?

• Promptly offered following a diagnosis H.M.B.

• Creating fear of cancer in a Small benign tumour

.

There has been unnecessary hysterectomy performed by the doctors in several corners of India. There could be several reasons which might be leading to this rampant practice of hysterectomies amongst health service providers.

. Reasons might be

•lack of knowledge and training on new, less-invasive therapies.• The other reason when doctors are quick to recommend this surgery is cancer prevention. •The knowledge on the individual effects of this operation amongst doctors might be very limited.• However one of the major reasons for recommending hysterectomy is very clearly the greed to make more money

BIG FACT !!

Women AGE early even if ovaries

are retained At

Hysterectomy

All Elders endorse this fact

Dr Duru Shah, former president of FOGSI said

• that modern medicines could fix 95% of woman's menstrual problems without the need for surgery.

• It has been scientifically shown that women who undergo hysterectomy at a young age, reach menopause a few years earlier than those who have their uterus intact."

• This is because during hysterectomy, the blood supply to the ovaries does get marginally disturbed.

It has been shown that hysterectomy (even without oophorectomy) during a woman's reproductive years, increases the risk (triples the risk according to some studies) of heart attack during the remaining reproductive years. If the ovaries are removed as well, the risk of developing heart disease and osteoporosis is further increased,"

• Removal of ovaries also increases the women's risk of death by 40 %

• They also suffer from Depression• ’decreased libido,• heart disease • and osteoporosis

Hysterectomy should not be taken up lightly

KJ Carlson, NEJM 328:856, 1993

DisadvantagesDisadvantages• Anesthesia• Long hospitalization and recovery time• Mortality (USA) 0.6-1/1,000• Major complications 3%• Minor complication 24-43%

Hysterectomy is Not 100% safe

Do You want to guess the

Number of

HYSTERECTOMYdone in India ?

USA 5.9 lac

UK 1.3 lac

Russia 3.12 lac

India 23.2 lac CDC

Numbers of Hysterectomies Per year

1990-2000

Life time riskOf

Uterus Removal

USA 1:3

Women before 60 years had Hysterectomy

U.K. 1:5 Women before 60 years

had Hysterectomy

DUB 20%DUB 20%

FibroidsFibroids 30%30%

Endometriosis/Endometriosis/Adenomyosis 20%Adenomyosis 20%

(Pre) cancer (Pre) cancer 10%10% Chronic pelvic pain 10%Chronic pelvic pain 10%ProlapseProlapse 15%15%

Indications of Hysterectomy Indications of Hysterectomy In USAIn USA

1990 - 2000

90% for benign

problems

Bilateral Salpingo-Oopherectpomy Rate 65%

↓↓↓

45%

Hysterectomy Rate

↓↓ To 1/10th

In western world in last 20 years

Average AGE of Hysterectomy in

USA 46 yrs

(40 – 50 yrs)

Uterus Removal In India 10 to15 yrs. earlier

Who has Caused this Menace in India ?

Gynaecologists&

Surgeons

How western world has ↓↓↓ Hysterectomy Rate?

Big Question

ACOG / Royal College

February, 2000, Vol 95, February, 2000, Vol 95, No. 2, Pages 199-205No. 2, Pages 199-205

The Appropriateness of RecommendationsThe Appropriateness of Recommendationsfor Hysterectomyfor Hysterectomy Michael S. Broder, MD, David E. Kanouse, PhD, Michael S. Broder, MD, David E. Kanouse, PhD, Brian S. Mittman, PhD, and Steven J. Bernstein, MD, MPHBrian S. Mittman, PhD, and Steven J. Bernstein, MD, MPH

76% of the patients who 76% of the patients who were taken up for were taken up for

hysterectomy hysterectomy did not meetdid not meet ACOGACOG

criteria for criteria for hysterectomyhysterectomy

*Obstet Gynecol 2000;95:199-205*Obstet Gynecol 2000;95:199-205

““The most common reasons for which The most common reasons for which hysterectomies were considered hysterectomies were considered

INAPPROPRIATEINAPPROPRIATE were were

• lack of adequate diagnostic evaluationlack of adequate diagnostic evaluation

• failure to try alternative treatmentsfailure to try alternative treatments

before hysterectomy.”before hysterectomy.”

*Obstet *Obstet Gynecol 2000;95:199-205Gynecol 2000;95:199-205

KJ Carlson, NEJM 328:856, 1993

HYSTERECTOMY as Treatment

Should be last resort

• 20-40 yrs – 10 / lac• 40-50 yrs - 36 / lac

Risk of Endometrial Carcinoma

FIBROIDS

More than 1 in 5 30s & 40s suffer from

HEAVY PERIODS(Unmanageable)

Good 80% - Uterus can be saved

PALM - COEIN

FIGO

TVS

Gold Standard

Gold standard for HMB

but not cost effective in India first line diagnostic tool.

Office Hysteroscopy

• Has replaced conventional

D & C under GA • No therapeutic value

Office EB - Diag. ProcedureGold Standard

Treatment

Medical management of DUBMedical management of DUB Effectiveness Effectiveness Side effectsSide effects CostsCosts

Contraceptive PillContraceptive Pill 50%50% + +

ProgestagensProgestagens 20%20% + + + +

DanazolDanazol 100% ( 100% (dose!)dose!) + ++ + ++

GnRH`agonistGnRH`agonist 100% 100% + + ++ + + ++

NSAIDNSAID 30% + 30% +

Antifibronilytic agentsAntifibronilytic agents 50% + ++ 50% + ++

IUD with Progesteron 65%-97%IUD with Progesteron 65%-97% + ++ + ++

20-30% success after 35 years

Is Is Not HysterectomyNot Hysterectomy

THE IDEAL TREATMENTTHE IDEAL TREATMENTFOR HMBFOR HMB

Current Treatment Current Treatment Recommended for HMBRecommended for HMB

Drug therapyDrug therapy

HysterectomyHysterectomy

20%-30% after 35 years

UBTMirena 80%

20%

Mirena (LNG IUS)(5 yrs)

is a

Magic Stick

• Mirena provides most effective medical

treatment with least side effects

• IT CAN REPLACE IN ABOUT 50 % CASES THE NEED FOR ENDOMETRIAL ABLATION OR HYSTERECTOMY

• Especially useful when presently contraception

is required but future fertility is desired

Conclusions about Mirena

• SuccessSuccess is is 8080 to to 90%90%•Repeat procedure / Hysterectomy Repeat procedure / Hysterectomy – –

10 to 20%10 to 20% Amenorrhea, ↓↓ bleeding in over Amenorrhea, ↓↓ bleeding in over 90%90%

GLOBAL ENDO. GLOBAL ENDO. ABLATIONABLATION TECHNIQUES TECHNIQUES

(15-20 years)(15-20 years)

Pooled ResultsUBT

Amenorrhea/ spotting 36%

Eumenorrhea22% Minimal or no

Reduction inMenses 4.0%

Hypomenorrhea 38%

For Treatment of DUB

Uterine Balloon Therapy(Many Types)

GYNECARE* THERMACHOICE*

Performance

> OVER 50,00,000 procedures worldwide

10 minute Solution

for‘Heavy

Periods’

Very Effective

UBT’s Biggest Use

Is In Bad Surgical

Risk cases

Profile of the cases of U.B.T• Peri menopausal HMB - 60 % - Proliferative endometrium - Simple hyperplasia - Complex hyperplasia • Post menopausal bleeding – 20 % - Proliferative / Simple hyperplasia

Poor Surgical Risk patients – 20 %

Let us come forward to stop this menace of uterus removal.

• Think rationally about yourself.• Counsel the patient.• Do not say –if we will not do,

someone else will do.• Vow yourself & Join the

Movement for motivating 10 other gynecologists to do the same.

No way should SURGEONS be

allowed to do hysterectomy in

India ……

Such practices should become

history !!

TAKE HOME MESSAGE• Do not consider uterus a vestigial organ after completion of family• Do not be in haste of removing the uterus without indication• Consider long term suffering of this woman• Find out alternative method first for treatment• Counsel the woman if she insist for removal when it is not essential• Following the guidelines for decision making is ethical way and it is a

gynecologist prerogative

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