This was a cross-sectional study which included all elective hysterectomies performed for gynaecological indications conducted at the District Hospital of Kodagu Institute of Medical Sciences, Madikeri from January 2018-June 2019. The Institutional Ethical committee clearance was obtained, IEC number “KoIMS/IEC/4/19-20”

Inclusion and Exclusion criteria:

Case records were reviewed to collect information of patient characteristics, surgical indications, clinical histories, histopathological diagnosis and complications, if any.

Cases were divided in 4 categories based on age:

Among all the cases, various indications were reviewed. Histopathology reports were obtained from the Pathology Department. The corresponding patient details, preoperative diagnosis, and type of surgery were obtained from the histopathology request forms from the Medical Records of the Pathology Department. The histopathological findings of the endometrium, myometrium, cervix, ovaries and fallopian tubes were recorded. Findings were tabulated. Then, the data was analysed to know if the hysterectomy was justified.

A total of 238 hysterectomies were performed during 18 months in the District Hospital. Abdominal and vaginal approaches were used.

Types of hysterectomy: Panhysterectomy via abdominal approach was the most common type of hysterectomy (169, 71%) [Table/Fig-1].

Age of the subjects: The ages of the subjects were divided into four categories, 0-20, 21-40, 41-60, >60 years. The mean age of the patients was 46.46 years. The most common age group where hysterectomy occurred was 41-60 years (143, 60.08%) [Table/Fig-2].

Indication of hysterectomy: The most common indication for hysterectomy was found to be Fibroid uterus (152, 63.87%). This was followed by Uterovaginal prolapse (48, 20.17%) [Table/Fig-3].

Summary of the histopathological findings of hysterectomies in the present study are given in [Table/Fig-4,5,6,7,8,9,10,11,12 and 13]. The most common endometrial finding was proliferative endometrium (105, 44.12%). Analysis of the myometrial findings revealed that the most common finding was leiomyoma (alone and with adenomyosis) (152, 63.86%) [Table/Fig-4]. Analysis of the cervical findings was done. It was found that chronic cervicitis (133, 55.88%) was the commonest pathological finding in the cervix [Table/Fig-4].

[Table/Fig-5]:

Smooth muscle cells arranged in bundles and fascicles with whorled pattern H&E Stain (100X).

[Table/Fig-6]:

Haemorrhage with focal glandular and stromal breakdown H&E Stain (100x).

[Table/Fig-7]:

Endometrial glands showing back to back arrangement without atypia, H&E Stain (100X).

[Table/Fig-8]:

Proliferative endometrium, H&E Stain (100X).

[Table/Fig-9]:

Secretory endometrium, H&E Stain (100X).

[Table/Fig-10]:

Polypoidal endocervicitis, H&E Stain (100X).

[Table/Fig-11]:

Normal fallopian tube, H&E Stain (100X).

[Table/Fig-12]:

Fallopian tube lined by flattened plicae hydrosalphinx, H&E Stain (100X).

[Table/Fig-13]:

Normal ovary showing ovarian stroma and corpus albicans, H&E Stain (100X).

Analyses of fibroids: Fibroids were analysed in particular since this was the most common indication in the present study. Two parameters, whether fibroids were single or multiple, and the size of the fibroid were analysed. It was found that out of the total 152 fibroid uteri, 115 (75.65%) of them possessed a single fibroid. 37 (24.34%) of them possessed multiple fibroids [Table/Fig-14]. The analysis of the sizes of the fibroid revealed that most of the fibroids lied in the range of 4.1-6 cm in diameter (54, 35.5%) [Table/Fig-15].

Analysis of the ovary revealed that the ovary was unremarkable in 60 (34.8%) of the cases, followed by corpus albicans 37 (21.5%). All the lesions that were identified were benign. Analysis of the fallopian tubes revealed that in a majority of cases (142, 82.55%) it was within normal limits [Table/Fig-16].

A detailed analysis of the age group 21-40 years was done. As they are in the reproductive age, they experience the full-blown consequences of a hysterectomy, both reproductively and in other aspects. The most commonly performed surgery was still panhysterectomy (59, 88.05%) [Table/Fig-17].

The indications and spectrum of histopathological findings was studied and results were tabulated. Out of the 67 cases, 53 cases in the age group of 21-40 years showed histopathological findings of fibroids, irrespective of the reason operated. It was found that the most common indication was fibroids in this age group (53, 79.10%). The size of the fibroid that most commonly occurred was in the range of 4.1-6 cm (20, 37.73%) [Table/Fig-18,19].

Hysterectomy was the most common operative procedure done after caesarean section in women. Many of these surgeries are done in reproductive age women for nonmalignant indications. Many alternate therapeutic options like levonorgestrel-releasing intrauterine system, endometrial ablation or fibroid embolisation can be tried in many cases before the hysterectomy is considered [11]. In one study, done by Kriplani A et al., Ormeloxifene was an effective and a safe therapeutic option for the medical management of menorrhagia [12].

Hysterectomy is a major surgery which has its own physical, economical, emotional, sexual and medical significance in women [1,2]. Various previous studies were in concordance with the findings found in this study [Table/Fig-20] [3,4,5,6,7,13-17].

In a study by Prusty RK et al., the average prevalence rate of hysterectomy was estimated to be 17/1000 among even married women in the ages of 15-49 years [8]. Out of the very few audits done to compare preoperative diagnosis with histopathological examination of specimens, a study by Tiwana KK et al., pointed out that 7-8% of rural women and 5% of urban women had undergone hysterectomy at an age of 37 years [4].

An audit was conducted on hysterectomies done in district hospital Madikeri, so that common public can be educated with the choice of hysterectomy and helps the medical fraternity in better decision making and assessment of symptoms. In this study in addition to the audit we gave importance to women in reproductive age groups and studied the pattern of indications and histopathological findings in them, as they are the women who face the brunt of unjustified hysterectomies mostly.

Age distribution: The youngest patient was 26 years while the oldest was 79-year-old. The mean age for hysterectomy was 46.46 years of age.

Indication: Most common indication for hysterectomy in our study was leiomyoma uterus, while few other studies showed different results for most common indication for hysterectomy, Verma D et al., utero-vaginal prolapse, Nausheen F et al., dysfunctional bleeding, Sivapragasam V et al., AUB [1,2,14]. This variation in the most common indication for hysterectomy in other studies and can be because of variation in the age group of predominant population in the study [1].

Adenomyosis was most common incidental finding which was frequently missed preoperatively. This is in concordance with a few other studies [4,13].

This was followed by fibroids of size between 4.1-6 cm (54, 35.5%), fibroids of less than 4 cm in diameter (47, 30.9%). 38 fibroids (25%) were >8 cm in diameter. Least number of fibroids was in the 6.1-8 cm range (13, 8.5%) [Table/Fig-15].

It was observed that these 47 (30.9%) cases which had a fibroid of dimension less than 4 cm in diameter and at least few cases with fibroid between the size of 4.1-6 cm could have been managed non-surgically first, before proceeding with hysterectomies. Adenomyosis cases can initially be treated with hormonal therapy, endometrial ablation and the many other nonsurgical options before deciding to perform surgery.

It is alarming that majority of these ovaries and fallopian tubes showed normal benign conditions histopathologically. Except for one case of adenocarcinoma, where panhysterectomy was justified. All these cases were of women in the reproductive age group where retaining the uterus and adnexa is important. An even more intriguing fact was that except for uterovaginal prolapse, many of these women were also subjected to panhysterectomy with bilateral removal of adnexa. Unnecessary removal of ovaries in these patients lead to deficiency of oestrogen, hastens the onset of menopause and patient’s psychosexual health is affected, apart from the vast array of health issues [8].

In such young population in reproductive age group effort should be made to retain adnexal structures when adnexa are normal and indication is benign. 16 cases had fibroid size more than 6.1 cm and histopathology confirmed the indication. 37 patients had fibroids of size less than six cm and 17 cases were with fibroids less than four cm in diameter in greatest dimensions. In these 37 cases, nonsurgical approach could have been attempted first. Therefore, choosing panhysterectomy over other options needs to be debated on as the aftermath is tremendous. Reporting of all hysterectomies should be made mandatory so that the audit results can be used for improvement in the quality of health services.

Controversies: Is it All the Fault of Health Care Providers?

One report in Maharashtra started with a somewhat troublesome question- “why do many women in Maharashtra’s Beed district have no wombs?” - investigated in a report published on April 11 2019 by India’s Business Line newspaper. Contractors of the sugarcane industry never hired women with wombs, forcing thousands of women to undergo hysterectomies. A PIL was filed and the Government of India decided in 2013 to get a national estimate of hysterectomy in women of reproductive age group through the fourth round of the “National Family Health Survey”. The latest National Family Health Survey, from 2015-16, has state-wise data on hysterectomy. But, unfortunately, many instances of coercive hysterectomies linked to livelihoods are still being reported [18]. In India, the research and debate on hysterectomies for benign reproductive health ailments has tended to focus invariably more on health provider, as said in a study by Desai S, which dealt with complex factors operating in the decision of hysterectomies [19].

Studies have showed that hysterectomies have both pros and cons with respect to women’s health. One such study done by Prusty RK et al., stated that “on the one hand, by relieving suffering from gynaecological ailments such as abnormal bleeding and pelvic pain, hysterectomy is found to lead to decreased anxiety and depression among women and thereby improvement in their quality of life, particularly 6 to 12 months after the surgery. Apart from this, research also shows several adverse effects of hysterectomy such as urinary incontinence, sexual dysfunction, late medical problems such as backache, weakness and early onset menopause [8].

Oophorectomy in reproductive age women can have various complications associated with hormonal imbalance like increased risk of osteoporosis, coronary heart disease and thus poses excess mortality risk [8]. There is need for education among poor rural women about dangers of hysterectomies and alternative management strategies [2].

Taboo against menstruation, poverty, illiteracy, socioeconomic factors, poorly developed medical infrastructure and some degree of possible malpractice by health care providers have together added to the complexity of performing a hysterectomy [19].

India’s health system currently caters to a limited range of health services for women, largely related to pregnancy, delivery, family planning, and postpartum care. There is thus a need for improvements in management of chronic gynaecological complaints in advanced way and stop using hysterectomies as a one stand option for chronic gynaecological complaints.

Limitation of this study was that, since the study was cross-sectional in nature, follow-up of women and the consequences could not be studied and further study needs to be done focussing on follow-up.

The indications for hysterectomies were frequently for benign conditions, yet the rate of panhysterectomy was higher. Menace of unnecessary hysterectomy is a complex problem which is a result of multiple deficiencies in healthcare, socioeconomic, individual loopholes. Though, it is an effective treatment option for various gynaecological problems it should be used judiciously after careful evaluation of the necessity. Regular audits to confirm the indications by histopathological support are a necessity.

Although hysterectomy is a good procedure in justified cases, in many benign cases, use of advanced alternate management can save the woman from the trouble of going under the knife and the many postoperative complications associated with the procedure.