The Hysterectomy Default: When Removing the Uterus Was the Answer to Everything
Fibroids? Hysterectomy. Bleeding? Hysterectomy. Pelvic pain? Hysterectomy. The United States performed more hysterectomies per capita than any other developed nation.
The uterus was the most frequently removed organ in American surgery
By the 1990s, approximately 600,000 hysterectomies were performed annually in the United States. One-third of American women had undergone hysterectomy by age 60. The most common indication was uterine fibroids.
The logic seemed straightforward. Fibroids cause bleeding. Bleeding causes anemia. The uterus contains the fibroids. Remove the uterus. Problem solved.
Except that removing a uterus is major surgery with a 4-6 week recovery, significant complication rates, and permanent consequences. And alternatives existed. They were simply not offered.
Myomectomy preserved the uterus. Uterine artery embolization treated the blood supply. GnRH agonists shrank fibroids medically. Endometrial ablation addressed bleeding without removing the organ. But for decades, these alternatives were underutilized because the surgical culture treated hysterectomy as definitive, and definitive was considered best.
When the hysterectomy was performed, the default approach was abdominal: a large incision, longer hospitalization, and slower recovery. Vaginal hysterectomy, which existed and had lower morbidity, was underused. Laparoscopic approaches, developed in the 1990s, took another decade to gain widespread adoption.
And when the uterus came out, the ovaries often came with it. Prophylactic bilateral oophorectomy at the time of hysterectomy was routine in premenopausal women over 40, on the theory that removing the ovaries prevented ovarian cancer. The data eventually showed that premature oophorectomy increased all-cause mortality.
🎯 Free Subscriber Bottom Line: Five surgical practices in gynecology have been abandoned or fundamentally reformed: routine hysterectomy as first-line treatment for fibroids, total abdominal hysterectomy as the default approach, prophylactic bilateral oophorectomy in premenopausal women, uterine suspension for retroversion, and D&C as first-line treatment for abnormal uterine bleeding. Each reflected a surgical culture that favored removal over preservation, open surgery over minimally invasive approaches, and intervention over observation.
Below, paid subscribers get: - The hysterectomy rate data: US vs international comparisons - Parker’s oophorectomy mortality study and its impact on practice - The uterine retroversion myth - D&C: why a diagnostic procedure became a therapeutic default - UAE, myomectomy, and the uterine-sparing revolution - A framework for when hysterectomy is and isn’t appropriate.
