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Part 1 of 2
by Janice Stensrude
published February 1996 in A Friend Indeed, Vol. XII, No. 9
Janine O'Leary Cobb, editor of A Friend Indeed at the time this article appeared, constructed this two-part series by editing down (by more than half) the popularized three-part version that appeared in Uptown Express under the title "The No-Longer Ubiquitous Uterus:Necessary Losses?" Both the Friend and the Uptown versions were based on an unpublished academic paper completed January 1995. If you are only going to read one version, I would recommend the academic paper, which did not suffer from restraints of size imposed by publishers and has a more complete discussion and fuller listing of source materials.
When I recently undertook a study of oophorectomized women—those who had had ovaries surgically removed—I mentioned my study to family and friends and received some immediate and surprising feedback from two women. Each had lost her uterus and ovaries in separate surgeries, and each had a similar story—an emotional slump following removal of the uterus (and in one case a total loss of sex drive) and physical symptoms characteristic of estrogen deprivation following removal of the ovaries. My interest suddenly turned from ovaries to uterus.
In the books I read, very little was said about the uterus. Most discussion centered on the loss of estrogen due to loss of the ovaries. It appeared that I was not the only one to ignore (with apparently disastrous results) the importance of the uterus.
One physician who underwent a hysterectomy has described her feelings of "chronic sorrow"(1). Chronic sorrow! As I read her words, a sadness stirred in my memory. The next morning, I awoke with a poignantly fresh memory of the terrible loss I felt 23 years ago when I had my hysterectomy. Before the long months of blood loss and sickness that preceded the surgery, I had made a decision to have a tubal ligation. I had made a firm decision that there would be no more children. Why then, did I feel such a deep sense of loss? I finally reasoned that it was the loss of choice that caused my terrible grief.
Then I was bewildered; now I find that my experience was far from unique. Many, many women seek "logical" explanations for feelings of loss, and most find a way to deal with the pain until it subsides. Such depressed feelings focus on childbearing, the essential task of the uterus.
Uterine muscle is the same type of muscle as the heart and has no counterpart in the male body. Does the uterus have memory? life? emotion? Does it have more in common with the heart than a similarity of muscle? Why do we grieve it as a lost child, even when we have all the children we ever intend to have, even when our reproductive life has already ended with menopause?
Most of us learned at an early age that the uterus is the place inside a woman's body where a baby grows for nine months before it enters the world through the birth canal. Until very recently, most people (including most medical professionals) believed this to be the sole function of the uterus. The medical community in particular has stubbornly ignored mounting evidence that the uterus is more than a warm, wet place to hatch new human beings.
The uterus produces substances that affect brain function and reduce the risk of cardiovascular disease. Additionally, it carries on a hormonal conversation with the ovaries, playing an important role in the function of these organs for as long as 25 years past menopause. Evidence of the uterus as a hormone-producing organ was published over twenty years ago but physicians continue to cling to an outdated view of the uterus as "nothing but a big, unresponsive blob"(2). Even today, "prevailing medical wisdom holds that the uterus is a disposable organ that serves no useful purpose once a woman has all the children she wants. What's more, it is regarded as something of a nuisance"(3a).
1. The uterus produces beta endorphins (substances that contribute to feelings of well-being) in the glands of the endometrium (the lining of the uterus). It also influences ovarian cycling, affecting the secretion of endorphins from the brain and pituitary gland.
2. The cervix, the lowermost tip of the uterus, produces quantities of prostaglandins, which have numerous effects on the nervous system and on coronary health.
3. Nerve endings at the cervical tip produce a range of nerve impulse firings during deep rhythmic thrusting in intercourse. Small mammal studies have indicated that this firing pattern may stimulate certain areas of the brain, leading to release of the hormones that affect the reproductive cycle(4a).
If beta endorphins, the joy juices made famous by "runner's high", are produced in a woman's uterus, would it be too unscientific to believe that a woman might experience depressed mood if her uterus is removed?
There are three aspects to uterine participation in sexual acts. The cervix, the "bridge" between the vagina and the uterus, is studded with nerve endings. Some women experience intensely pleasurable feelings as the thrusting penis taps these nerve endings. The second aspect is uterine contractions during orgasm, and the third is lubrication. Though lubrication also originates in the vagina, a significant portion is cervical mucus produced at the tip of the uterus.
The respected sex researchers, William Masters and Virginia Johnson, define three phases in female sexual response each involving the uterus. During the excitement phase, the uterus fills with blood, much the same way as the penis, and elevates in the pelvic cavity. During the plateau phase, the uterus expands to twice its normal size, increasing sexual tension. During the orgasmic phase, the uterus contracts rhythmically and, during the resolution phase, the uterus gradually loses its sexual tension as the blood recedes.
Fourteen years ago, the American Journal of Obstetrics and Gynecology reported that 33% to 46% of hysterectomized women had partial or total loss of sexual function after amputation of the uterus(5). Not the first report nor the last, this study was significant because it was published in a journal that most gynecologists read. If the testimony of hysterectomized women mean nothing; if the work of Masters and Johnson mean nothing; if data from a prestigious journal mean nothing, what will mean something to the physicians who continue to remove uteri as if there were a bounty on them?
Except when dealing with women's problems, doctors are trained never to attribute symptoms to psychological factors unless [they] have ruled out all possible physical causes(3b). Very little is known about why certain symptoms consistently occur following hysterectomy.
... Because we have no medical answers—and no useful help—to offer patients, these complaints often are dismissed as psychological. Indeed, medical students are taught that women who attribute symptoms to hysterectomy must be neurotic, hysterical, or obsessed with their uterus. But ... these problems are very real and have absolutely nothing to do with a woman's mental stability(3c).
The list of effects of hysterectomy is long: fatigue, memory loss, insomnia, vaginal dryness and thinning, loss of firm body tone, hair loss, premature graying, weight gain (despite dieting and exercise), unpleasant vaginal odor, protruding abdomen, constipation, bloating, recurrent vaginal yeast infections, dry eye syndrome, lower resistance to colds and infections, less intense emotions, loss of maternal instinct, hot flashes, headaches, and dizziness.
Here is a summary of the most frequent effects(4b):
1. An alteration in the hormonal environment. Hysterectomy alters circulating levels of estrogen, progesterone, testosterone, androstenedione, luteinizing hormone, follicle-stimulating hormone, and the beta endorphins.
2. Hysterectomy induces a menopause up to five years earlier than normal, even when ovaries are kept. With oophorectomy, postmenopausal women age even more rapidly.
3. Hysterectomy significantly increases risk for depression, which often emerges as much as two years after surgery.
4. Hysterectomy accelerates loss of bone and increases the risk of osteoporosis.
5. The rate of women's heart attack is 0% during premenopause, 33% for mature women having had a surgical menopause, and 12% for mature women experiencing natural menopause. The increase in risk for atherosclerosis (blocked arteries) and coronary heart disease among hysterectomized women is three to seven times that of age-matched women who have not had the surgery.
6. Hysterectomy reduces libido (sex drive), the capacity for sexual arousal, vaginal lubrication, and orgasmic capacity.
7. Hysterectomized women frequently experience both stress incontinence (inability to hold urine when jumping, dancing, or running) and urge incontinence (the need to urinate frequently).
Depression and loss of libido are the two most psychologically devastating effects of hysterectomy. Nora Coffey, founder of HERS, an organization devoted to hysterectomy education(6), remains embittered by her personal experience with hysterectomy, particularly the destruction of the rich and fulfilling sexual relationship that she and her husband enjoyed prior to her surgery. Even with testosterone therapy, which restored her desire, the ability for sexual satisfaction never returned.
In 1994, some 200,000 women in the U.S. alone lost all hope of a rewarding sex life—added to which are their sexual partners who can expect no more than submission to an act of sex.
With so many women suffering such life-altering, devastating effects following loss of the uterus, why do half a million women continue to go under the knife each year, giving up organs that may be essential to their physical, emotional, and sexual well-being?
Geography has considerable bearing on a woman's chances for hysterectomy. Women in the southern and central regions of the United States have a two to three times greater chance of having a hysterectomy than women living in the northeast or on the west coast. The U.S. rate for hysterectomy is twice as high as France—yet the death rate from conditions treated with hysterectomy are no greater in these countries than in the United States.
The largest number of hysterectomies (30%) are performed to treat fibroids, followed by endometriosis (24%), prolapsed uterus (20%), endometrial hyperplasia (6%), menstrual disorders and other reasons (20%). But these figures do not reflect other "hidden," nonmedical reasons for hysterectomy.
Physicians, hospitals, and insurance companies stand to profit from a high hysterectomy rate. Gynecologists are surgeons and they make a living by performing operations. If hysterectomy is the operation a surgeon knows best, it is the one she or he will recommend and perform most often.
In order to maintain status as a good teaching hospital, an institution must be able to offer a rich experience to young interns and residents preparing themselves for a future in the practice of medicine. As the profession is practiced today, a successful gynecologist must be proficient at hysterectomy. If the number of hysterectomies were severely reduced, there would be insufficient hysterectomies to guarantee that each resident would have a hands-on opportunity to learn her or his craft.
Population control/birth control:
Population control on poor and minority women, who were not informed, was openly practiced as recently as 15 years ago. Though it is generally thought that such practice no longer exists, there are some who believe that it continues clandestinely under the guise of medical necessity. With so many physicians continuing to advise their patients that hysterectomy is routine, safe, and not damaging to health, it is likely that sterilization hysterectomies still occur.
Reluctance to accept new information and new treatments in the face of overwhelming evidence, evidence published in respected medical journals and presented at recognized medical conferences, can only be classified as ignorance. Many physicians are not up-to-date with newer treatments that can eliminate the need for hysterectomy. This contention is supported by the fact that the hysterectomy rate within physicians' own families is much higher than in the general population.
Surgical Risks in Hysterectomy
Because hysterectomy is so common, most of us tend to view it as a routine surgery. It is not; the risks are significant. Post-surgical complications are relatively common. One of the more frequent complications is bladder damage and/or the accidental severing of a ureter. In addition, approximately 800 American women die each year from hysterectomy, a rate of one to two women per thousand operations. Half of these deaths are from anesthesia. One woman was told by her surgeon that her radical hysterectomy (due to endometrial cancer) was more life-threatening than open-heart surgery.
Happy and Not So Happy
A woman who had a hysterectomy for endometrial cancer has suffered terrible side effects from the surgery, but she is happy to be alive. A friend who wants a hysterectomy to end her menopausal grief claims her mother and sister are very happy with their hysterectomies.
In 1972, I was very happy with my hysterectomy. The disabling bleeding that had kept me too weak to function normally for four months prior to surgery was finally over. I would never again have to soak stained underwear in bleach. I would never again have to take The Pill that had created a B vitamin deficiency, or use the IUD that wreaked the havoc that resulted in a hysterectomy, or jump out of bed in the heat of passion saying, "Excuse me, dear, while I insert the jelly—let's cool it for about 15 minutes." My sex life was better than ever, and my too-thin frame had swelled to a more voluptuous shape. I had a lot of reasons for being happy with my hysterectomy.
Then things began to go wrong, and I spent the next ten years being patronized and disparaged by doctors as I sought answers.
What I am most unhappy with is doctors who deny symptoms. I diagnosed and treated myself for osteomalacia after a physician insisted I had a pulled muscle, despite my description of deep bone pain that persisted for months. I faced a deep sigh, rolling eyes, and a firm, "It is not caused by your estrogen," when I asked about a sudden growth of hair on my upper lip. It had never occurred to me that it could have been caused by the estrogen; I was just responding to his questions about my state of health. But ten years later when I read "hirsutism" as a possible side effect of Premarin, I realized the doctor had been reacting to an experience repeated with many other women who had linked their hairy upper lips to estrogen therapy. I had fifteen years of having various experiences denied before I gave up and began to do my own research.
Now I know that many times the doctors had the answers, and they would not trust me with the information. Far fetched? In 1976, when the U.S. Food & Drug Administration ruled that estrogen drugs must include a sheet explaining possible side effects, a physician argued against the regulation stating that he could not think of a patient population less able to handle the truth than a bunch of menopausal women.
Menopause and necessary hysterectomy can be very difficult times in a woman's life, and indeed nervous symptoms and periods of crabby behavior can result. Telling someone a symptom doesn't exist when they know it does, does not cure the anxiety of having the symptom. It makes people crazy or it makes them angry—or both.
1. Reider, Dorothy Krasnoff. Hysterectomy & Oophorectomy. In The New Ourselves Growing Older: Women Aging with Knowledge and Power, PB Doress-Worters & DL Siegal (eds.) New York: Simon & Schuster, 1994
2. Edelstein, Barbara, The Woman Doctor's Medical Guide for Women (New York: Wm. Morrow 1982) as quoted in Lee Rothberg, "Hysterectomy: The Shocking Truth," The Woman's Newspaper, 1986
5. Zussman L, Zussman S, Sunley R, Bjornson E. Sexual response after hysterectomy-oophorectomy: Recent studies and reconsideration of psycogenesis. Am J Obs Gyne 1981;140:725-729