Unkindest cut of all... unnecessary hysterectomy

After cesarean section, the most common surgery done on women in India is hysterectomy, which has come to the limelight in recent times. There are various reports highlighting the prevalence of unnecessary cesarean section, tonsillectomy, appendicectomy, cholecystectomy, coronary artery stenting and bypass surgery, and so on. However, the recent public interest litigation (PIL) in the Supreme Court of India has been instrumental in initiating action on the practice of unnecessary hysterectomies in India. In the sugar-growing regions of Beed, Maharashtra, an unusually high number of hysterectomies was noted in 2019, particularly in women involved in sugarcane cutting. It was alleged that the landowners forced the women workers to undergo hysterectomy so that they would not be absent from work during menstruation. Moreover, in 2015, a major racket involving the removal of the uterus in nearly 2200 women belonging to disadvantaged communities in Southern Karnataka came to light, with four hospitals involved in carrying out the procedure and were blacklisted.^[1] In developed countries, hysterectomy is typically conducted in women above 45 years. In India, community-based studies found a rising trend among younger women aged 28–36 years, that is, 10–15 years earlier than the US counterparts. According to the National Family Health Survey (NFHS) done in 2015–2016 in 29 states and seven union territories, the number of hysterectomy was 3.3% of all women, aged between 15 and 49 years; also Andhra Pradesh and Telangana top the list with 8% in this age group (with some rural areas reporting up to 20%), Sikkim with 0.7% and Meghalaya with 0.8%. Seventy percent of these cases were done in private clinics. A high rate of hysterectomy is seen in Andhra Pradesh, Telangana, Madhya Pradesh, Punjab, Bihar, and Delhi. The NFHS also says that the number of hysterectomy is significantly low in Northeast, Himachal Pradesh, Chandigarh, Odisha, and Pondicherry, the reason cited was that the patients utilize more public facilities in these states rather than private hospitals.^[2,3]

Dr. Narendra Gupta, a medical practitioner, based on media reports and researched facts, filed a PIL in the Supreme Court that a widespread pattern of doctors is performing medically unnecessary hysterectomy to reap high insurance fees from the government in States such as Bihar, Rajasthan, and Chhattisgarh. He also claimed that doctors are exploiting women in rural areas, especially from low socioeconomic background and socially disadvantaged communities. Based on his PIL, the Supreme Court directed the Government of India to form a national, state, and district-level hysterectomy monitoring committees and to follow the guidelines adapted by the ministry of health and family welfare (MoHFW). There has to be monthly reporting of all hysterectomy cases, especially for women below the age of 40 years, and if any alternate treatment was considered before resorting to hysterectomy; and for the patients who are <40 years, surgery should be done only after review by two doctors.^[4]

It was argued in the court that the reasons for unnecessary hysterectomy are as follows: Lack of required diagnostic evaluation and failure to try alternate methods of treatment. It is to be noted that diagnostic evaluation such as vaginal sonography, diagnostic laparoscopy, hysteroscopy, computed tomography, and magnetic resonance imaging is available in most hospitals but as far as alternate methods of treatment are concerned, techniques like uterine artery embolization for fibroid, various endometrial ablation procedures and highly advanced laparoscopic procedures for high risk, and difficult cases are available only in select specialized private sectors because the experts in these procedures are very few and not available in most of the medical colleges, leave alone secondary level hospitals, and the cost involved is enormous. Hence, for a woman with heavy menstrual bleeding belonging to a low socioeconomic status, the only option available is medical management and not alternate methods. One of the reasons for the increasing rate of hysterectomy cited in the Supreme Court is that the insurance coverage under various schemes makes the private players earn more money by exploiting the patients.^[4] However, one should be clear that no patient without a distressing or debilitating bleeding condition will walk into any hospital and get a hysterectomy done just because insurance is available. If this is true, the same must be true for appendicectomy, cholecystectomy, coronary stenting, etc.

There is no doubt that there are unscrupulous, greedy, and unethical gynecologists and corporate hospitals who readily exploit the patients; but it also should be kept in mind that the patients should be gullible enough to be exploited by these individuals. The gullible patients belong to one of the following: Those who take irregular treatment from various doctors (physician shopping), patients whose mother or sister died of gynecological cancer, daily wage workers who will lose their earnings if debilitated by bleeding, fear of recurrence or other complications following conservative surgery (e.g., fibroids, uterine prolapse, endometriosis, premalignant lesions of cervix etc.) and those who get misinformation from friends and social media. These patients do not listen to reasoning or counseling, once they fix their mind on hysterectomy. With the opening of new medical colleges and increase in the number of postgraduate seats, there is not much chance for the PGs to assist/do adequate number of hysterectomies, and more and more doctors are opting to undergo training in laparoscopic surgery. The newly passed out PGs and newly certified laparoscopic surgeons venture into their practice by selecting “Normal-sized uterus” until they achieve confidence. Illiteracy, poverty, sociocultural, and religious beliefs hinder our patients from seeking medical assistance until it becomes too late. Only social and economic development will make the patients aware of their health conditions, their right to get information about their disease, and various treatment options available. They should be educated enough to seek appropriate healthcare from the providers and become aware of the immediate and long-term complications of unnecessary removal of the organ which has completed its reproductive function. Till then, this practice will continue.

The Federation of Obstetric and Gynecological Societies of India and Integrated Health and Well-being Council in association with Bayer has initiated the “save the uterus” campaign in 2022.^[5] They have already reached 3800+ practitioners and PG students through education programs to raise awareness about gynecological diseases and modern methods of management through physical and digital meetings. From the government side, steps to enforce the stakeholders to follow the guidelines for hysterectomy and to monitor at the state and district levels have been initiated recently. This will be a big challenge since there are many loopholes in the guidelines and their implementation, which will be readily exploited by the erring hospitals. We have to wait and see until a clear picture emerges from the observations of the state and district-level monitoring committees. Till then, the trend of increasing hysterectomies is likely to continue for years to come, like the trend of cesarean section in our country, where both providers and clients are to be blamed.