MENOPAUSE: THE HYSTERECTOMY TRAP
Hysterectomies are the second most common surgery for women in America, where proliferation in this surgery is more than double the rate in most European countries. It is not even known exactly how many hysterectomies are performed on women each year in the U.S., because there is no organization that keeps national statistics on hysterectomies. In fact, the National Center for Health Statistics does not have a department that deals specifically with gynecological issues. But the generally accepted estimate is that one out of three American women will surrender her womb to the surgeon's knifeusually between the ages of twenty-five and forty-four.
"I was agitated all the time," she recalls, looking back. "I thought I was losing my memory. I had night sweats and blurred vision. Sometimes I'd be so fatigued, coming home from school, my legs would fold underneath me climbing up the stairs."
And then came the all-too-common admission: "I thought, because I'd had a hysterectomy, I wouldn't have a menopause." Virginia never asked her doctor. And her doctor, a woman GP, said nothing to enlighten her. So, how did she manage?
Virginia would get into her car after work, two or three times a week, and drive an hour and a half to Buffalo. There, unrecognized, invisible, she could sit in a shopping mall and cry.
"I was like two people," she recalls with anguish. Back home again, she would get strokes for being a super-coper. Only recently, in Virginia's fifty-second year, her doctor finally did blood tests to measure her hormone levels, and announced: "Virginia, you're finished with menopause."
It was the first time the subject had come up.
If both a woman's ovaries are removed, she will go into instant menopause. It is actually castration. Twice as many women who have a hysterectomy today, compared to twenty years ago, also have their ovaries removed. For a woman with a persistent ovarian tumor, it is common and necessary to have at least one ovary removed. Unless a woman immediately starts hormone replacement therapy and commits to remaining on the medication indefinitely, she will have all the symptoms of menopause, whatever her age. What's more, early surgical removal of the ovaries doubles the risk of osteoporosis. If you lose your ovaries at age thirty, by the time you reach age fifty, your bone age may be seventy. Yet doctors often neglect to warn a woman that the surgery can have such lifelong effects even after the body heals.
I ran into this same high-handed attitude in a heavily utilized menopause clinic in the heart of London. When women complain about side effects from progesterone drugs, this doctor, like many, will often recommend a hysterectomy. He explains that it will free them from having to take the progesterone to protect their uterus. I asked if he would routinely take the ovaries as well?
"In a postmenopausal woman, the ovaries are of no use anyway," he replied dismissively. I expressed alarm. Wasn't this extreme? The doctor was ignoring the fact that the ovaries continue to produce testosterone, which strongly influences a woman's sexual desire and energy.
"To a lot of people that seems like using a sledgehammer to open a nut," he granted. "But for patients who suffer badly, and desperately want to continue their HRTespecially women in their early-to-middle-forties who are faced with this for another ten yearsthey say, 'God, I can't take these side effects anymore, take it all away.'" He boasted that all such women, convinced by him to go ahead with a hysterectomy, "thought it was the best thing since sliced bread."
How much did he question women about their sexual pleasure and comfort, a year after performing these hysterectomies? I inquired.
"I must admit, personally speaking, not a great deal," the surgeon said. "Mrs. Smith comes in, has a hysterectomy, you see her six or eight weeks later, and if she's making a satisfactory recovery, you don't see her again."
"The concept that the ovary burns out is not true," claims one of the experts on the postmenopausal ovary, Dr. Howard Judd at UCLA. Although a woman's ovaries stop producing estrogen, in postmenopause, they continue to produce a significant amount of testosterone. A study that did take the trouble to reconsider the impact on sex life following a hysterectomy found that between 33 and 46 percent of the women whose ovaries had also been removed complained of reduced sexual responsiveness.
Now, what could this woman have done instead? A simple office biopsy of the lining of the uterus could document any evidence of pre-malignant changes. Or, she could have a hysteroscopy, an examination that allows the physician to look inside the cavity of the uterus and see if there is a polyp. If there is still doubt, she could take a three-month course of hormone replacement, to see if the dysfunctional bleeding is resolved.
Some women with fibroid tumors do have clear indicators for hysterectomy: first, rapid growth of the tumor which may be a sign of cancer developing in the fibroid; second, uncontrollable bleeding; third, fibroid size so large that other organs may be compromised; or, finally, intractable pain.
More and more, educated women are beginning to see themselves as selective consumers of health care and refusing to accept any doctor's word as oracular. And when they find out how little the doctors know, or anybody knows, about this oldest of female physical transitions, they are mad as hell.
The TV producer mentioned earlier who suffered embarrassment with hot flashes at a dinner party is a case in point. When she reported her problem to her gynecologist, he said, noticeably bored, "Oh, yeah, fifty years old, you're right on target. Menopause."
"What can I do about it?" inquired the take-charge producer, accustomed to handling an eight-million-dollar budget.
"You just start taking estrogen."
She asked what were the implications of taking hormones.
"Well, you'll have to go for a breast X-ray twice a year instead of once a year. But there's no risk."
"If there's no risk, then why do I have to go twice as often?" she replied, thinking logically. He brushed off her question with a few remarks that sounded like he was reading out of a manual: How to Handle the Over-the-Hill Patient.
"That made me defiant," says the producer. Finally she insisted he tell her if there was anything that would treat the hot flashes. He told her about the old standby called Bellergal. He warned, "But that won't help with irritability, depression, cryingall the rest of it."
"Maybe I won't have any 'rest of it,'" the producer said, her adrenaline pumping full strength. "In the meantime, so I don't have to spend the next ten years in a terry cloth robe, I'll try the Bellergal." She got up to leave.
"You can do that," said the gynecologist, with what she read as an arrogant smirk. "But you'll be back."
The normal preamble to menopause is sometimes treated with a casualness bordering on the criminal. "This uterus looks a little bit tired," a male gynecologist told a forty-year-old North Carolina woman, "guess we'll take her out." It was typical of the attitude among some doctors that the uterus is little more than a nuisance. Since this patient was a housekeeper, without all the fancy scientific words to defend the tired "her," all she could do was "fight to keep my uterus."
At a higher status level, another Southern woman, a fifty-three-year-old graduate student I will call Katherine, ran into a more subtle insensitivity from her male gynecologist and her male internist. Katherine had spent fifty years doing what she was "supposed" to do: fitting her life into the interstices of her children's and husband's lives. Once her children were well launched, Katherine felt a deep need to be "credentialed" as a professional. "But we're out of sync with the family life cycle," she observed. Determined to make up for lost time, she became accustomed to working seventeen hours a day to get her master's degree and apply for a doctoral program.
"Suddenly, at fifty, I could barely function. I couldn't write a paper after four in the afternoon, but all my complaints were vague," she confessed. "Neither doctor would give me hormones. All they know is I'm not supposed to be trying to get my doctorate at fifty-three. Why don't I just go home and calm down?"
If you compare the level of our scientific knowledge about the causes and effects of menopause with the evolution of modern medicine, it is as though bacteria has not been discovered yet and we are still dependent on leeches and roots and shamans to cure what ails us.
Another way of seeing it would be as ovarian fulfillment. One has put in thirty or forty years of ripening eggs and enduring the hormonal mischief of monthly cycles, on the chance that a child is wanted. Enough, say most women in middle age. We're ready to move on now, to find our place in the world, free of the responsibilities of our procreative years. It's time to take risks and pursue passions and allow ourselves adventures perhaps set aside way back at thirteen, when we accepted the cultural script for our gender that ordinarily denied those dreams. It's time to play! And kick up some dust!
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Womens health