From Overtreatment to Precision: The Overtreated Cervix, the Morcellation Crisis, and the SHAPE Trial
We conized mild dysplasia that would have resolved on its own. We froze lesions we should have excised. We morcellated uteri containing cancers we didn’t know were there.
We performed radical surgery when simple surgery would have been enough.
The history of gynecologic surgery in the late 20th century is a story of escalation. More surgery. More radical surgery. More prophylactic surgery. The instinct was understandable: cancer is terrifying, and aggressive treatment feels like aggressive protection
But aggressive treatment of low-risk disease causes harm without benefit. Conizing a cervix for mild dysplasia removes tissue that was going to heal on its own, and increases the risk of preterm birth in future pregnancies. Cryotherapy destroys tissue without allowing pathological examination, missing diagnoses that matter. Morcellating a fibroid uterus can spread an unsuspected sarcoma. Performing a radical hysterectomy for a small cervical cancer exposes women to urinary and sexual complications that a simple hysterectomy would have avoided.
The shift from maximal to optimal surgery is one of the most important evolutions in gynecology. It requires a fundamentally different mindset: not “what is the most we can do?” but “what is the least we need to do to achieve the same outcome?”
🎯 Free Subscriber Bottom Line: Five surgical practices in gynecology have been reformed or abandoned based on evidence that less aggressive approaches achieve equivalent or better outcomes: routine conization for CIN I, cryotherapy as the standard for cervical dysplasia, uncontained power morcellation for fibroids, radical hysterectomy for all early cervical cancer, and routine incidental appendectomy during gynecologic surgery. The common thread is overtreatment: doing more than the disease required.
Below, paid subscribers get: - CIN I natural history data and why observation replaced excision - Cryotherapy vs LEEP: the specimen matters - The morcellation crisis: FDA safety communication, the sarcoma data, and what changed - SHAPE trial and ConCerv: the de-escalation of cervical cancer surgery - Incidental appendectomy: a procedure without a rationale - The framework for surgical de-escalation.
