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Dr. Sharda Jain Secetory General
Dr. Ila Gupta Secreatary
Delhi Gynaecologist Forum
For public / Administrators & Doctors Awareness
TOI Sept. 2010Landmark article
80% of Andhra Village women are minus their uterus
Uterus chopping States
Andhra Pradesh , Madhya Pradesh, Punjab, Bihar, Delhi
Modus Operandi Same as
Female Feticide
22 Sept.2012 appealed to Gynaecologists To be kind to uterus
Why Did he say so about Hysterectomy ?
• Promptly offered following a diagnosis H.M.B.
• Creating fear of cancer in a Small benign tumour
.
There has been unnecessary hysterectomy performed by the doctors in several corners of India. There could be several reasons which might be leading to this rampant practice of hysterectomies amongst health service providers.
. Reasons might be
•lack of knowledge and training on new, less-invasive therapies.• The other reason when doctors are quick to recommend this surgery is cancer prevention. •The knowledge on the individual effects of this operation amongst doctors might be very limited.• However one of the major reasons for recommending hysterectomy is very clearly the greed to make more money
BIG FACT !!
Women AGE early even if ovaries
are retained At
Hysterectomy
All Elders endorse this fact
Dr Duru Shah, former president of FOGSI said
• that modern medicines could fix 95% of woman's menstrual problems without the need for surgery.
• It has been scientifically shown that women who undergo hysterectomy at a young age, reach menopause a few years earlier than those who have their uterus intact."
• This is because during hysterectomy, the blood supply to the ovaries does get marginally disturbed.
It has been shown that hysterectomy (even without oophorectomy) during a woman's reproductive years, increases the risk (triples the risk according to some studies) of heart attack during the remaining reproductive years. If the ovaries are removed as well, the risk of developing heart disease and osteoporosis is further increased,"
• Removal of ovaries also increases the women's risk of death by 40 %
• They also suffer from Depression• ’decreased libido,• heart disease • and osteoporosis
Hysterectomy should not be taken up lightly
KJ Carlson, NEJM 328:856, 1993
DisadvantagesDisadvantages• Anesthesia• Long hospitalization and recovery time• Mortality (USA) 0.6-1/1,000• Major complications 3%• Minor complication 24-43%
Hysterectomy is Not 100% safe
Do You want to guess the
Number of
HYSTERECTOMYdone in India ?
USA 5.9 lac
UK 1.3 lac
Russia 3.12 lac
India 23.2 lac CDC
Numbers of Hysterectomies Per year
1990-2000
Life time riskOf
Uterus Removal
USA 1:3
Women before 60 years had Hysterectomy
U.K. 1:5 Women before 60 years
had Hysterectomy
DUB 20%DUB 20%
FibroidsFibroids 30%30%
Endometriosis/Endometriosis/Adenomyosis 20%Adenomyosis 20%
(Pre) cancer (Pre) cancer 10%10% Chronic pelvic pain 10%Chronic pelvic pain 10%ProlapseProlapse 15%15%
Indications of Hysterectomy Indications of Hysterectomy In USAIn USA
1990 - 2000
90% for benign
problems
Bilateral Salpingo-Oopherectpomy Rate 65%
↓↓↓
45%
Hysterectomy Rate
↓↓ To 1/10th
In western world in last 20 years
Average AGE of Hysterectomy in
USA 46 yrs
(40 – 50 yrs)
Uterus Removal In India 10 to15 yrs. earlier
Who has Caused this Menace in India ?
Gynaecologists&
Surgeons
How western world has ↓↓↓ Hysterectomy Rate?
Big Question
ACOG / Royal College
February, 2000, Vol 95, February, 2000, Vol 95, No. 2, Pages 199-205No. 2, Pages 199-205
The Appropriateness of RecommendationsThe Appropriateness of Recommendationsfor Hysterectomyfor Hysterectomy Michael S. Broder, MD, David E. Kanouse, PhD, Michael S. Broder, MD, David E. Kanouse, PhD, Brian S. Mittman, PhD, and Steven J. Bernstein, MD, MPHBrian S. Mittman, PhD, and Steven J. Bernstein, MD, MPH
76% of the patients who 76% of the patients who were taken up for were taken up for
hysterectomy hysterectomy did not meetdid not meet ACOGACOG
criteria for criteria for hysterectomyhysterectomy
*Obstet Gynecol 2000;95:199-205*Obstet Gynecol 2000;95:199-205
““The most common reasons for which The most common reasons for which hysterectomies were considered hysterectomies were considered
INAPPROPRIATEINAPPROPRIATE were were
• lack of adequate diagnostic evaluationlack of adequate diagnostic evaluation
• failure to try alternative treatmentsfailure to try alternative treatments
before hysterectomy.”before hysterectomy.”
*Obstet *Obstet Gynecol 2000;95:199-205Gynecol 2000;95:199-205
KJ Carlson, NEJM 328:856, 1993
HYSTERECTOMY as Treatment
Should be last resort
• 20-40 yrs – 10 / lac• 40-50 yrs - 36 / lac
Risk of Endometrial Carcinoma
FIBROIDS
More than 1 in 5 30s & 40s suffer from
HEAVY PERIODS(Unmanageable)
Good 80% - Uterus can be saved
PALM - COEIN
FIGO
TVS
Gold Standard
Gold standard for HMB
but not cost effective in India first line diagnostic tool.
Office Hysteroscopy
• Has replaced conventional
D & C under GA • No therapeutic value
Office EB - Diag. ProcedureGold Standard
Treatment
Medical management of DUBMedical management of DUB Effectiveness Effectiveness Side effectsSide effects CostsCosts
Contraceptive PillContraceptive Pill 50%50% + +
ProgestagensProgestagens 20%20% + + + +
DanazolDanazol 100% ( 100% (dose!)dose!) + ++ + ++
GnRH`agonistGnRH`agonist 100% 100% + + ++ + + ++
NSAIDNSAID 30% + 30% +
Antifibronilytic agentsAntifibronilytic agents 50% + ++ 50% + ++
IUD with Progesteron 65%-97%IUD with Progesteron 65%-97% + ++ + ++
20-30% success after 35 years
Is Is Not HysterectomyNot Hysterectomy
THE IDEAL TREATMENTTHE IDEAL TREATMENTFOR HMBFOR HMB
Current Treatment Current Treatment Recommended for HMBRecommended for HMB
Drug therapyDrug therapy
HysterectomyHysterectomy
20%-30% after 35 years
UBTMirena 80%
20%
Mirena (LNG IUS)(5 yrs)
is a
Magic Stick
• Mirena provides most effective medical
treatment with least side effects
• IT CAN REPLACE IN ABOUT 50 % CASES THE NEED FOR ENDOMETRIAL ABLATION OR HYSTERECTOMY
• Especially useful when presently contraception
is required but future fertility is desired
Conclusions about Mirena
• SuccessSuccess is is 8080 to to 90%90%•Repeat procedure / Hysterectomy Repeat procedure / Hysterectomy – –
10 to 20%10 to 20% Amenorrhea, ↓↓ bleeding in over Amenorrhea, ↓↓ bleeding in over 90%90%
GLOBAL ENDO. GLOBAL ENDO. ABLATIONABLATION TECHNIQUES TECHNIQUES
(15-20 years)(15-20 years)
Pooled ResultsUBT
Amenorrhea/ spotting 36%
Eumenorrhea22% Minimal or no
Reduction inMenses 4.0%
Hypomenorrhea 38%
For Treatment of DUB
Uterine Balloon Therapy(Many Types)
GYNECARE* THERMACHOICE*
Performance
> OVER 50,00,000 procedures worldwide
10 minute Solution
for‘Heavy
Periods’
Very Effective
UBT’s Biggest Use
Is In Bad Surgical
Risk cases
Profile of the cases of U.B.T• Peri menopausal HMB - 60 % - Proliferative endometrium - Simple hyperplasia - Complex hyperplasia • Post menopausal bleeding – 20 % - Proliferative / Simple hyperplasia
Poor Surgical Risk patients – 20 %
Let us come forward to stop this menace of uterus removal.
• Think rationally about yourself.• Counsel the patient.• Do not say –if we will not do,
someone else will do.• Vow yourself & Join the
Movement for motivating 10 other gynecologists to do the same.
No way should SURGEONS be
allowed to do hysterectomy in
India ……
Such practices should become
history !!
TAKE HOME MESSAGE• Do not consider uterus a vestigial organ after completion of family• Do not be in haste of removing the uterus without indication• Consider long term suffering of this woman• Find out alternative method first for treatment• Counsel the woman if she insist for removal when it is not essential• Following the guidelines for decision making is ethical way and it is a
gynecologist prerogative
Delhi Gynaecologist Forum Head office
11,Gagan Vihar Near Karkari Morh Flyover Delhi 110051
www.delhigynaecologistforum.com
Thank you