Funding Agency: - PGIMER, Chandigarh (India)

Introduction

Hysterectomy has been advocated in women for a variety of indications. In America, it has been reported as the most common non-pregnancy related surgical procedure among women. One third of them have had hysterectomy by the age of 65 years₁. Compared to a higher frequency of hysterectomy (10-20%) in other countries ₂,₃,₄, a lower rate (4-6%) has been reported from India₅,₆,₇. Higher tolerance threshold of Indian women and a ‘low level of medicalization' have been proposed as the reasons for this lower rate₄. However, the issue needs further in depth study since the literature on this aspect is scarce in India. Keeping this in view the present study was planned with following objectives:-

• to estimate the rate of hysterectomy in the adult women of study area

• to describe the profile of women who have undergone hysterectomy in the study area

Material and Methods

A female social worker was selected for the study. She was trained in interviewing techniques. A semi - structured interview schedule was developed and modified after pretest/pilot study. A sample size of 864 was determined for this study (Estimated prevalence 10% or less, precision =0.02 at 95% level of confidence). ₈ To account for non-cooperation, non-availability we decided to screen 1000 women.

Three roadside villages in Panchkula district, Haryana of north India were purposively selected. These were part of field practice area of the department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India. All the houses (~ 1500) of these villages were covered. Every second house was included in the study. Married women aged above 15 years were registered through house-to-house survey by the social worker. They were questioned about hysterectomy. Thus, a list of the women who had undergone hysterectomy was made. Help of key informants (Traditional birth attendants, health workers, child care workers) was also taken for this purpose. All such identified cases were individually interviewed by the social worker. The interview had a focus on collection of information of socio-demographic data, reproductive health profile, reason for hysterectomy, treatment seeking pattern, money spent, relief obtained, response of husband and the family to the hysterectomy. Information was also sought on any problem encountered due to operation. All information was recorded on the interview schedule. Manual analysis was done using percentage, mean, standard deviation and chi-square test. All information was kept confidential. Consent of the respondents was taken for the interview.

Results

Overall, 3 villages were surveyed (population 9786). Of the enlisted 1000 married women aged above 15 years 7% women (70) had undergone hysterectomy (Table-1). Prevalence of hysterectomy was significantly more in women aged above 35 years (X² -29.4, df. =2, P<0.001). All women who have undergone hysterectomy except one were aged above 30 years. All except six women had been married for more than 15 years. In all except 8 women, the last child birth was more than 10 years back. Three had no children. Age at marriage was below 20 years in 87% women.

Figure 1

Table 1: Agewise Prevalence of Hysterectomy in Study Women

Excessive menstrual bleeding was the main indication for HT (52/70; 74%). Uterine prolapse (10) and fibroid (3) were the other indications. Duration of symptoms was one year or more in 59 (84%) cases (> 10 years in 10 cases). Three or more treatment agencies were consulted by 62(89%) cases. First person to be consulted was traditional birth attendant (TBA) health worker/faith healer or local unqualified registered medical practitioner in 21 cases. Private qualified doctors were consulted by 17 cases. Government doctors were consulted by 29 cases. Two cases consulted Ayurvedic doctors first. In 18 cases HT was done within last 12 months. In rest 52 (74%) cases, it was done more than one year back. In all except 7 cases it was done in women aged above 30 years. In 46 (66%) cases the operation was done more than one month after it was advised (in 15 cases the lag was > 12 months) In rest 24 (34%) cases it was done within one month after it was advised. Reason for such gap was fear of operation, lack of money,’ problem was tolerable',’ children were small' etc.

More than half of the women (41; 58.5%) told that they were afraid of the operation when they were first advised about hysterectomy. Majority (51; 72.8%) of the husbands were quite supportive when they were first advised for hysterectomy of their wives. In few cases they told that they were sad (3) or afraid (6). In many cases (22; 31.4%), blood transfusion was done after the operation. Husbands were the donors in two cases only. In rest, relatives or friends were the donors. Husbands escorted the wives to hospital in majority of cases (55; 78.6%). In rest, some relatives escorted the case. (Four were widows).

In majority of cases (48; 68.6%) the husbands stayed with their wives in hospitals. In rest of the cases, other relatives stayed with the women.

In almost half of the cases, hysterectomy was done in government hospitals (33; 47.1%). In rest it was done in private hospitals. Referral to the concerned surgeon was mainly done by relatives (39; 55.7%). In some cases referral was made by government (4) or private (10) doctors. In others it was by friends (2) husband (8) or self (3). Four or more hospitals visits were made before operation by the women in 45 (64%) cases (mean =4.8 visits). After operation 3 or more follow up hospital visits were made in 25 (35.6%) cases. (Mean =2.2 visits). Hospital stay was for less than 7 days in 16 (22.8%) cases, 8-15 days in 51 (72.8%) cases and for more than 15 days in 3 cases. In 22 (31.4%) cases Rs.5000-10000/- were spent and in 35 cases (50%) more than Rs.10000/- was spent on hysterectomy. In rest, less money was spent or it was free of charge (reimbursed).

It was an abdominal hysterectomy in 59 (84.2%) cases. In rest it was vaginal. No complication was reported in 38 (54.2%) cases. In others, bleeding (5), fever (9), pain (4) or other problems were reported (incontinence, gas, backache, cough). In majority of cases (43; 61.4%), total relief was obtained after the operation. In remaining 27 (38.5%), some relief was reported. No specific feeling was reported by 41 cases after HT. In 10 (14.3%) cases feeling of a ‘sense of incompleteness' was reported after removal of uterus. Half of the women told that they had consulted a successfully operated case before deciding about hysterectomy.

Some of the women reported late medical problems after hysterectomy viz., backache (44; 62.9%) vaginal discharge (3; 4.3%), weakness (11; 15.7%), pain (11; 15.7%), weight gain (3; 4.3%), gas (7; 10%), incontinence (8; 11.4%), difficulty in sitting/walking (5; 7.1%).

Only 3 (4.3%) women told that they repented their decision for operation, 5 (7.1%) said it was too early, 3 (4.3%) said it was avoidable and 11 (15.7%) said it was not necessary. Only one woman (1.4%) reported hormone replacement therapy (HRT) prescription after hysterectomy.

Eighteen (25.7%) women said that after hysterectomy they were relieved off the botheration about menses. In 7 (10%) cases sex life was affected. Visiting religious places (23; 33%), walking (13; 18.5%) washing clothes (15; 21.4%), mopping (11; 15.7%) and kitchen work (9; 12.8%) were also affected after operation. Sixteen (37.2%) respondents did not report any symptom after surgery whereas 17 (39.5%) respondents complained of a sense of emptiness and 6 (14.0%) reported pain/fever and urinary problems.

Discussion

Our study revealed that fear of operation was the first reaction of wives and husbands when HT was advised. Surgery of any kind is a major event in our lives, particularly for women. Our earlier studies on uterine prolapse and menopause ₆,₇ had also revealed that for women in India, family responsibilities take precedence over their own health concerns. Even if they have any uterus related disease a desire to complete the desired family size often delays the decision to get one's uterus removed. So, in India, more often than not, the hysterectomy, even if indicated and advised, is delayed till the children are old enough and women have a sense of having fulfilled their family commitments.

Our study revealed that prevalence of hysterectomy rose with age, maximum being in 45-54 year age group. Like our study, Wilcox et al₁ also reported that HT was uncommon before age 25. They reported 35-44 year age as the most common age group for HT. Our respondents took their own time before they finally agreed for hysterectomy. The longer treatment lag observed in our study may be because of higher tolerance threshold of women, their low status in society, the ‘culture of silence' among them for reproductive health problems and their poverty. Fear of operation might be another reason for the delay.

Most of the husbands provided physical and emotional support to their wives for HT. They escorted them to hospitals and stayed with them. Yet, blood donation by husbands for their wives was less frequent (2 cases out of 20 cases). This was probably because of the fact that husbands were the main breadwinners in the family and blood donation is usually believed to cause weakness.

Routine life was affected after HT in 11-25% respondents of our study. In terms of money spent, the number of visits made to the hospitals and duration of hospitals stay, hysterectomy appeared to be a major drag on family resources. Still, it provided relief from the symptoms in all the cases. Carlson et al also reported that postoperative quality of life after HT was better in 88% cases.

They reported that sex life was adversely affected in 15-30% cases₉. In our study it was affected in 10% cases.

Uterus as the childbearing organ with regular monthly menstrual bleeding is usually identified as an essential feature of womanhood in India. It was natural that after hysterectomy many of our respondents reported a sense of ‘emptiness' inside. They felt that they were not women anymore. Similar feelings have been reported by menopausal women in our earlier studies₆,₇,₁₀,₁₂. As per biomedical perspective physically uterus occupies a very small space in abdomen. So, its removal should not be physically felt by the women. However, in view of the comments of the women who have undergone hysterectomy it seems that the lay women's conceptual framework of reproductive health assigns a large space for uterus in abdomen so much so that after HT they reported a sense of emptiness inside. Some even complained that after hysterectomy they were not able to tie their pajama cord since nothing was left in the abdomen to support the knot.

The degree of discomfort faced by women due to excessive menstrual bleeding or other indicators symptom that led to their opting for hysterectomy can be judged by extent of relief reported by many respondents in our study after the operation as one of the women said ‘All my sorrows are over'

In the West, gynecologists have been criticized in general because it is alleged that they perform hysterectomy rather too readily. In fact, the high incidence of HT in the West was highlighted as the manifestation of misuse of gynecological surgery to control women ₁₃. However, hysterectomy rates may vary upto six fold between different countries and even between neighboring health districts. Rate of hysterectomy upto 20% have been reported in UK / US₁₄. A rate of 10% for Thai women has been observed in Thailand₄. Hysterectomy rate in the present study was observed to be 7% among the married women aged above 15 years as compared to 5% reported by the authors₁₁in a neighboring area in 35-55 years old women and 6% in a neighboring city by others₁₂. Lower rate for hysterectomy in India, particularly for getting relief from menstrual bleeding may be due to various reasons viz. considerably lower level of medicalisation of menopause among women, their lower status in society, poverty, illiteracy and the fact that their tolerance threshold was higher and that they considered menopausal symptoms as a part of life and had a positive view of menopause₁₁.

In rural Maharashtra (West India), however, a doctor lamented that indiscriminate hysterectomies were being conducted by unqualified people.₁₅

In another study from North India₁₁ majority (84%) of the respondents who underwent hysterectomy, stayed in hospital for upto 20 days (for upto 10 days in 54%). In our study, 96% cases stayed in hospital upto 15 days (upto 7 days in 23%) . As a contrast in West 98% hysterectomy cases had a hospital stay of 1-7 days₉. In majority of the respondents, total abdominal hysterectomy was done. Many (42%) of cases spent upto Rs.6000 on surgery.

For decades, professionals and consumers have been intensely interested in determining the appropriate indications for hysterectomy.₇ In Western countries; uterine fibroid and bleeding are the common indications. In our study, excessive menstrual bleeding in pre menopausal age group was the commonest indication (74%) for HT. Present study also revealed that uncontrolled bleeding was the most common reason for hysterectomy (39%). All of them reported relief after surgical intervention.

By and large, population in the present study seemed to have a reasonable faith in government run health facilities for surgery, as 47% respondents got hysterectomy done in government hospitals while 53% utilized the services of private nursing homes.

Surprisingly, in our study, HRT was prescribed in one case only while in western countries and in urban India more of hysterectomy cases are prescribed HRT₅.

Acknowledgement

Correspondence to

Dr Amarjeet Singh, Professor Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh-160012. Phone- (0172)-2755217 E-mail: amarminhas56@rediffmail.com