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A survey of hysterectomies in young patients in Eastern Uttar Pradesh: are the wombs being removed unnecessarily?

Background : There are reports of unnecessary hysterectomies in young patients in some parts of Eastern Uttar Pradesh and adjoining regions. This study was conducted to know the indications of hysterectomies done at less than 35 years of age. Methods : This study was conducted in the outpatient Department of Gynaecology and Obstetrics, Sir Sundar Hospital, Institute of Medical Sciences, Banaras Hindu University Varanasi over a period of one year. Hysterectomised patients with age less than 35 years were included in the study. After getting an informed consent, a detailed history was taken, patient’s past medical record was reviewed and their socio-demographic profiles, indication for hysterectomy and any surgical complications were recorded. Statistical analysis of data was done using SPSS and results were recorded as mean and percentage. Results: One hundred patients were included in the study over a period of one year. Mean age of the study population was 28 years. The 32% patient were below 25 years of age, 44% were between 25 to 30 years of age whereas 24% were in the age group of 30 to 35 years. Unevaluated Vaginal discharge (28%) and pain in pelvic region (25%) were the main indication for hysterectomy. Menstrual abnormalities (13%), asymptomatic uterine fibroid (12%), small functional ovarian cyst (10%) and abnormal colposcopic images (12%) were other indications. Conclusions : There is a high prevalence of unnecessary hysterectomies in eastern part of Uttar Pradesh, India. Such practice must be discouraged and stopped. Public awareness, adherence to medical ethics and strict action against those involved in medical malpractice would be helpful in decreasing the number of unnecessary hysterectomies in the young women.


INTRODUCTION
Uterus is an important organ for females, but once family is complete some women think that now uterus has no work. This is the main reason that hysterectomies are done even for trivial and may be unrelated complaints. Due to underdeveloped government health sector and the mushrooming of unregulated, profit oriented and often greedy private sector clinics, women are being exploited and subjected to inappropriate treatment. 1 Rising number of hysterectomies especially among young women have been reported in press from many states of India. 2 In India private sector provides 80% of the outpatient care and 40% of inpatient care. 3 In eastern part of Uttar-Pradesh there are large number of small-scale private hospitals which are owned by paramedical person or medical officers. They call specialists mainly surgeons, BAMS doctors and sometimes gynaecologists for gynaecologic surgeries. These patients did not have operative notes, histopathology report and indication for performing hysterectomy. Bhaumik reported that doctors in private hospitals in India are pressurized to carry out unnecessary tests and procedures to meet revenue targets. 3 In the present era, medically unwarranted hysterectomy is the burning issue. 4 Hysterectomy is a major surgery and can be associated with a number of complications. Hysterectomies are sometimes performed for trivial and irrational indications. Women are often forced by their families for hysterectomy because they believe that periods disturb their routine work. Aim of this study is to highlight this problem and decrease this trend by drawing the attention of the regulatory authorities and increasing public awareness.

METHOD
This study was conducted in the department of gynaecology and obstetrics at Sir Sunder Lal hospital, Institute of medical sciences, Banaras Hindu university Varanasi for a period of one year from November 2016 to October 2017. The study was conducted on patients presenting to out-patient department of this hospital.

Inclusion criteria
All hysterectomised patients younger than 35 years were included in the study.

Exclusion criteria
Patients with hysterectomies done for obstetrical causes like ruptured uterus, placental abnormalities, atonic postpartum hemorrage, broad ligament haematoma, invasive mole, ectopic pregnancy were excluded from the study.
The 100 patients satisfied the study criteria and were included in the study. Informed consent was obtained from all patients. A questionnaire was made and patient's medical history was reviewed with special focus on complaints for which hysterectomy was done, their duration, hospital where it was done, patient's sociodemographic profile and educational status. Economic status was classified using Kuppuswamy scale. Previous medical records of the patient were reviewed for patients presenting complaints, imaging studies, indication for hysterectomy, perioperative complications, operative notes and histopathology. Data was recorded on preformed Performa in tabulated form and analysed systematically. Results were expressed as mean and percentages.

RESULTS
The observations and results of the study are summarized in the following section. Table 1 and 2 show the age distribution and sociodemographic profile of the study population. The mean age of the study population was 28±7 years. The 44% patients were in the age group of 25 to 30 years, whereas 32% and 24% patients were in the age group of 25-30 years and 20-25 years respectively. Majority (70%) of the patients belonged to low socioeconomic status as per the Kuppuswamy scale and 76% of them resided in the rural areas. Only 5% of the patients belonged to upper socioeconomic group. 25% of the patients had middle income status. The 24% of the study population were residing in the urban areas. The spectrum of the educational status of the study population is shown in Table 4. The 5% of the patients were illiterate and postgraduate each. 26% of the patients were under matric, 20% matriculate were as 30% and 14% were educated up to 12 th standard and graduation level respectively. The indications for hysterectomy in the study population are shown in Table 4. Vaginal discharge (28%) and pain in the pelvic region (25%) were the most common indication for hysterectomy in the present study. Other indications for hysterectomy included menstrual abnormalities (13%), abnormal colposcopic findings (12%) and asymptomatic fibroid (12%). Complications (Table 5) encountered during and after the surgical procedure were pain abdomen (20%), sepsis (4%), secondary haemorrhage (3%) vesicovaginal fistula (3%) and ureteric injuries (2%). The 96% (Table 7) of the surgeries were done in the private hospitals (Table  6). Only 5% of the patient had got ultrasonography done by a qualified radiologist where as 95% of the patients the can were not done by a qualified radiologist. Pap smear (2%), cervical biopsy (2%) and colposcopy (15%) were done in ver limited number of patients. The documentation of the surgical procedure is show in Table 8. In majority (85%) of the patients the name of the surgeon was not documented.
Surgical details, pre operative records, proper discharge record and histopathology report were not provided to the patient in 96%, 90%, 95% and 955 respectively.

DISCUSSION
There are increasing reports of hysterectomies in young patients in India especially in peripheral parts where awareness in the common masses is lacking. The average rate of hysterectomies in India as per the national family and health survey is 3.2%. There is a significant variation between different states. 5 Rural background, low education status of the patient and surgery done in the private sector account for majority of these cases. 5 Another study from Karnataka found that nearly 50% of women who had undergone hysterectomy were less than 35 years of age, and many were coerced into the surgery at exorbitant rates with the threat of cancer. 6 In Gujarat and Andhra Pradesh the reported rate of hysterectomies per 1000 women years 20.7% and 17% respectively. 7,8 A right to information petition in Rajasthan revealed that majority of surgeries conducted in three private hospitals were hysterectomies, many of which were performed in women under the age of 30, with the youngest being 18 years old. 9 While many of these are paid by out-of-pocket expenditure, it was observed that practitioners misuse government insurance schemes as well. 8 Many of such surgeries are done in absence of actual indication of the surgery. In the present study included only those patients who were younger than 35 years and 76% of them were younger than 30 years. In a study by Kameshwari et al 60% of patients had hysterectomy before the age of 30 years. 10 The 70% of the patients in this study belong to low socioeconomic status and 76% were from rural areas. In our study 4% patients were operated in government hospitals and 96% in private hospital. This is also similar to the study done by Kameshwari et al. 10 The commonest indication of hysterectomy in the present study was per vaginal discharge (28%) followed by pelvic pain (25%) and menstrual disturbances (13%). Histopathology report was available in only 5% cases. Our findings were consistent with the study done by Xavier et al. 6 These indications were very vague and hysterectomies were done for complaints which could either be managed conservatively or were unrelated to uterus like chronic pelvic pain. Excessive menstrual bleeding is often cited as the indication for removal of uterus, which is difficult to assess objectively and may be amenable to other nonsurgical modalities of treatment like hormonal pills, intrauterine devices (IUD) or newer techniques like endometrial ablation. Ideally hysterectomy should be performed only when patient does not respond to the conservative management. There are multiple reports of unnecessary hysterectomies performed in several parts of the country. Evidence from recent studies and surveys indicated that doctors in private hospitals and clinics recommend and perform hysterectomies on women, when it is not indicated. 2 Most (96%) hysterectomies in our study were done in the private hospitals. Those who were done in government hospitals had clear indication, proper operative notes and histopathology report. This practice will destroy the trust of doctor patient relationship. It has been seen that illiterate women are more vulnerable targets. 11,12 Poor training, lack of knowledge of the latest less-invasive therapies and greed for money can all lead to this practice of unnecessary hysterectomies. To decrease this trend awareness must spread in the general population about non-surgical options for the treatment of these complaints and also about the ill health effects of removing uterus and ovaries at the young age. There should be an audit of the surgical procedures done in every hospital. Professionals involved in medical malpractice should be punished.

CONCLUSION
The practice of unnecessary hysterectomies is common in rural parts of eastern Uttar Pradesh and adjoining areas. In young patients' hysterectomy should be done only when other conservative treatment options have failed.
Awareness programmes and medical camps should be organized to educate the general population. Only qualified doctors should be allowed to do hysterectomies. Young patients should take a second opinion when they are advised for hysterectomy by any medical person.