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Study Finds Different Hysterectomies a Toss-up

No big difference between total and ones that leave cervix intact

WEDNESDAY, Oct. 23, 2002 (HealthDayNews) -- Women who've had both their uterus and cervix surgically removed are generally no better or worse off than those whose hysterectomy left their cervix in place, a new study says.

Researchers in the United Kingdom have found little difference between "total abdominal hysterectomy," in which a woman's uterus and cervix are removed, and "subtotal abdominal hysterectomy," a procedure that leaves the cervix intact.

Even after a year, reports the study appearing in tomorrow's issue of The New England Journal of Medicine, bowel, urinary and sexual function were pretty much the same.

"We did not find any major differences between total and subtotal hysterectomy in terms of the important pelvic organ functions," says Dr. Isaac Manyonda, a gynecologist at St. George's Hospital in London and senior author of the paper. "Those women who have the subtotal procedure do recover quicker, but very occasionally may still have light menses, or suffer a prolapse of the cervix [both very rare]."

"It wasn't too surprising, to tell you the truth," says Dr. Carolyn Runowicz, vice chairwoman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital in New York City. "Even though statistically there were differences, the results were clinically not very different."

According to an accompanying editorial in the same issue of the journal, hysterectomies are, after Caesarean sections, the most frequently performed major operation in the United States. Some 37 percent of women in the United States and 20 percent of women in the United Kingdom have had a hysterectomy by the time they're 60. The procedure is performed for a variety of reasons, ranging from cancer to pelvic pain and irregular uterine bleeding. However, it's much more common to correct quality-of-life issues than for life-threatening illnesses. Though other alternatives such as minimally invasive surgery and hormone manipulation are available, hysterectomy is still seen as the most effective option.

Nevertheless, there are lingering questions about the relative efficacy of total abdominal hysterectomy versus subtotal abdominal hysterectomy. Some experts believe the less comprehensive procedure results in better urinary, bowel and sexual function, a speedier recovery, and fewer complications.

"The great debate over the past two decades has centered on whether subtotal hysterectomy conferred any benefits over total hysterectomy, especially with regards to sexual function," Manyonda says. "Gynecologists have been pilloried in the popular press for apparently destroying women's sex lives by performing the total hysterectomy. Our study provides rigorous and robust data which should now lay to rest this controversy."

In this study, which is the largest, most comprehensive randomized trial of its kind, the researchers looked at 279 women who were randomized into one of two groups. Women in the first group had a total abdominal hysterectomy while women in the second group had a subtotal abdominal hysterectomy. Neither the patients nor the investigators knew which patients were in which group.

Women in the "subtotal" group generally had shorter surgeries, less blood loss and a shorter hospital stay than women in the "total" group, but 6.8 percent experienced cyclical bleeding, 1.5 percent had cervical prolapse (when the cervix protrudes from its normal place), and 2.3 percent had persistent pelvic pain.

Urinary, bowel and sexual function appeared to be similar in both groups at the end of a year.

The study did not last long enough to assess whether subtotal and total hysterectomies had different effects on "vaginal-vault prolapse," when the upper roof of the vagina sags downward.

"The most important take-home message for me is that taking out the cervix won't improve and won't worsen sexual function," Runowicz says. "There's a whole underground group that started a few years ago that believes that leaving the cervix in is better for sexual functioning post-hysterectomy. In this small group of patients for this degree of follow-up, that just wasn't so."

Which procedure is best? As with so much in life, it depends. "If you're in the operating room and the case is not going well and you're having blood loss and it's a difficult surgery, then I would say that I think we better stop at a subtotal," Runowicz says. "Subtotal is the easier of the two and you get out faster."

On the other hand, if the patient is a smoker, has had an abnormal Pap smear in the past or has had more than one sexual partner, Runowicz would suggest a total hysterectomy.

"When everything else is equal, the woman should be given as much information as possible and be empowered to participate in the decision making with regards to the type of hysterectomy she should have," Manyonda says. "In this way satisfaction rates may be greatly enhanced."

What To Do

For a fact sheet on hysterectomy, visit the U.S. Centers for Disease Control and Prevention or the National Women's Health Resource Center.

SOURCES: Isaac Manyonda, M.D., Ph.D., gynecologist, St. George's Hospital, London; Carolyn Runowicz, M.D., vice chairwoman, department of obstetrics and gynecology, St. Luke's-Roosevelt Hospital, New York City; Oct. 24, 2002, The New England Journal of Medicine
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