Sex and Gender-based Analysis of this topic
Definition
A complete hysterectomy is the removal of both the uterus and cervix and a subpartial hysterectomy is the removal of the uterus while leaving the cervix and upper vagina intact [1]. Both procedures can be done vaginally or abdominally [2]. The hysterectomy rate is the number of hysterectomies performed in health care settings per 100,000 women age 20 and older and the rate is usually age-adjusted. The most recent hysterectomy rate in Canada (2006-2007) was 346 per 100,000 women [3]. Canada’s rate is one of the highest in the world and is double that of Britain, Sweden, the Netherlands and Norway [4]. Canada’s high rate suggests that hysterectomies may be over-utilized in Canada when less invasive alternatives exist and may be more appropriate [4]. There remains much debate surrounding the appropriate indications for performing elective hysterectomies [6].
Sex Issues
Hysterectomies are performed for a wide range of conditions, including fibroids, dysfunctional uterine bleeding, endometriosis, pelvic pain, genital prolapse, malignant and pre-malignant cervical, endometrial, and ovarian cancer [4]. The surgery can result in the relief or reduction of pain, heavy bleeding, and/or discomfort. Drawbacks to hysterectomies include infertility and increased risk of infection. Hysterectomy involving bilateral ovary removal results in premature menopause and associated health problems, such as osteoporosis, possible heart-health problems, insomnia, and hot flushes [6]. Most hysterectomies are elective and are performed to improve the quality of life rather than out of necessity [5].
The hysterectomy rate has steadily decreased from 484 in 1997 to 346 in 2005 [3]. The decrease in hysterectomy rates may be explained in part by the development of alternative procedures such as: endometrial ablation, myomectomy, colporrhaphy, laparoscopic or vaginal suspension, uterine artery embalization, uterine balloon therapy, resection of cul-de-sac obliteration or pharmacological treatments/supplements to name a few [9-11]. A radical trachelectomy is another recent technique used to preserve fertility among women with cervical cancer. The decreasing hysterectomy rate may also reflect women’s changing preference towards less invasive procedures for gynecological conditions, and in response, more careful screening and outpatient management [6].
Gender Issues
Traditional gender roles place importance on women’s fertility and motherhood, which creates an expectation on women to bear children. Hysterectomy results in sterilization and can be trying for many women as infertility is perceived as a loss of womanhood. The loss of the uterus and/or ovaries may also impact how a woman perceives her body and her overall sense of femininity and sexuality. Many women fear a decrease in sexual desire and physical arousal following a hysterectomy, and while this can occur, it is not common. Lubrication and physical arousal may decrease among women who have their ovaries removed but can be restored to normal levels by taking estrogen supplements [7].
Diversity
Hysterectomy rates vary widely across the provinces and territories, with Nunavut having the lowest hysterectomy rate of 179 and PEI having the highest of 558. Hysterectomy rates are high in rural and remote areas, such as in Northern BC, where women are three times more likely to have a hysterectomy than women from southern urban areas [12]. This is due to a lack of opportunities for non-urban doctors to learn alternative and less invasive procedures [4].
Critique
The reporting methods for the hysterectomy rate in 2001-2002 and 2006-2007 include both total and partial hysterectomies, compared to other years which only include rates for total hysterectomies. The hysterectomy rate for these years are likely to be higher than other years due to inclusion of partial hysterectomies, therefore comparison of rates for these years must be made with caution [3]. Data about health conditions (e.g., endometriosis, cancer, fibroids) for which hysterectomies are performed are lacking. This would be useful in estimating the rate of elective hysterectomies so that recommendations can be made to decrease currently high rates.