Unnecessary Hysterectomies Among Premenopausal Women in Developed and Developing Countries: A Critical Review of Steps Taken to Improve Women's Health

Women or their relatives must discuss all alternative treatment options before adopting extreme choices such as hysterectomies for fibroid, abnormal uterine bleeding, prolapse, chronic lower back pain, pelvic inflammatory disease, abnormal uterine lining thickening (endometrial hyperplasia), and premalignant, malignant uterine, and cervical tumors. Many nonsurgical, low-cost interventions are recommended to improve the health of women in the reproductive age group. The cost of menstrual care and hygiene in some contractual sets is also a triggering factor with the aim of more work hours for women in such settings. Private institutions are misusing health insurance money for personal gains by misguiding women from poor social and economic backgrounds such as scheduled castes, scheduled tribes, and backward communities.

Search methodology Embase, PubMed, Cumulative Index of Nursing and Allied Health Literature, SINOMED, Cochrane Library, Ovid MEDLINE, and Web of Science databases were rigorously searched and reviewed from 1974 and updated until June 2023 by two authors. Research and reviews published in English during the last more than 50 years were considered in this review. In earlier years, less emphasis was framed regarding women's health and indications for hysterectomy, but in due course of time, more guidelines and emphasis are framed to improve the health of women of the reproductive age group. Various complications due to unnecessary hysterectomies, such as sexuality, pain, psychological well-being, early onset menopause, etc., and their controversial views and empirical data are debated. Particular emphasis is placed on the design, sample, measurement difficulties, and several nonsurgical approaches to hysterectomy, their early detection, and the role of nongovernmental organizations, health departments, and law enforcers critically compared using keywords such as "health education," "socio-psychological health," "fibroids," "pre-menopausal women," and "hysterectomy" (("health education" [Title/Abstract]) OR ("health education" [MeSH Terms]), ("Socio-psychological health" [Title/Abstract])) OR (("Socio-psychological health" [MeSH Terms]), ("Fibroids" [MeSH Terms]), AND ("Pre-menopausal women" [Title/Abstract])) OR ("Pre-menopausal women" [MeSH Terms]) (Figure 1 ). Results In the 1974 research by Richards, 70% of patients who underwent hysterectomies experienced postoperative depression, and almost as many also experienced hot flashes, urinary problems, and acute fatigue. The majority of these symptoms are due to oophorectomy [ 1 ]. In 1989, a study showed that individuals undergoing hysterectomy had considerably higher psychological morbidity (60%) [ 2 ]. In 1993, 42 hospitals in Pennsylvania provided data for a study on 4,660 patients, indicating that doctors in various institutions had distinct philosophies regarding practicing medicine. Many hospitals have fewer validating signs for large volumes of hysterectomies where obstetrics and gynecology programs are being run [ 3 ]. During a 2001 review of 63 insurance claims and semi-structured interviews with 12 providers by members of the Self Employed Women's Association, an Indian Central Bureau of Health Intelligence scheme, in Gujarat, operating rooms were found to lack separate handwashing facilities or proper lighting, and there were no qualified nursing staff. Hysterectomies were also conducted on demand, and removed organs were not submitted for histology even when symptoms and indications point to an illness [ 4 ]. In the United States, between 1994 and 1999, 52% of all hysterectomies were performed in women under 44 years. Three diagnoses accounted for 73% of all hysterectomies: uterine leiomyoma, endometriosis, and uterine prolapse. Bilateral oophorectomies performed concurrently with laparoscopically assisted vaginal hysterectomies dramatically increased from 20.4% in 1994 to 42.5% in 1999 [ 5 ]. In 2005, authors discovered that 10%-20% of patients with hysterectomy for benign causes experience adverse psychosocial consequences such as decreased sexual desire, altered body image, and worsened depressive symptoms [ 6 ]. The psychological effects of a recent hysterectomy for non-malignant diseases were investigated prospectively in 68 women [ 7 ]. Forty-four young women who had undergone hysterectomies for various reasons, such as fear of cancer, failure of medical treatments, difficulties coping with reproductive health concerns, and terror instilled by doctors, were interviewed in-depth in 2010 with the conviction that surgery was the best option [ 8 ]. A longitudinal prospective cohort study addressing ovarian failure due to hysterectomy for benign diseases and annual follow-up with serum follicle-stimulating hormone levels in all women less than or equal to 46 concluded that early ovarian failure developed in those women having unilateral oophorectomy or vaginal hysterectomy [ 9 ]. A systematic review and meta-analyses measured the relationships between the age of menarche, education level, parity, and hysterectomy for uterine fibroids and endometriosis. In contrast to urban women who utilize the public sector more frequently, rural women use the private sector [ 10 ]. According to a 2011 research by the non-governmental organization Life-Health Reinforcement Group, Andhra Pradesh has one of the lowest median ages for women having hysterectomies internationally at 29 years due to the state's high prevalence of hysterectomies [ 11 ]. Research conducted in Gujarat by the Self Employed Women's Association, a group that aids rural women, discovered that women who underwent hysterectomies were under 35 years old [ 12 ]. According to a 2013 study, numerous groups in Indian society are violating people for poverty and illiteracy, especially rural women. The need for insurance, gender bias, and unethical behavior in the medical industry were all highlighted by these unneeded hysterectomies in the Indian area of Medak [ 13 ]. Women with less education and poor working conditions have common risk factors for poor health outcomes and diabetes and cardiovascular disease. A survey in India in 2011 among 2,214 rural and 1,641 urban women from the low-income category in Ahmedabad showed that more rural (9.8%) than urban (5.3%) women had hysterectomies among the insured category, which is more than the uninsured category [ 14 ]. In 2014, in Maharashtra, interviews with 44 women younger than 45 who had undergone hysterectomies revealed that the factors that led them to accept hysterectomy were fear of cancer, disappointment with medical outcomes, and the challenges of living with reproductive health issues. Private hospitals performed the majority of these hysterectomies to earn quick money [ 15 ]. Audit measures are essential to ensure judicious hysterectomies [ 16 , 17 ]. Doctors frequently promote hysterectomy as a preferable therapeutic choice for reproductive health issues; nevertheless, research suggests that this procedure has a detrimental impact on women's physical health and compromises their ability to work [ 18 ]. Health education at gynecological clinics before opting for a hysterectomy will help maintain their self-esteem and good body image [ 19 ]. Health campaigners and civil society organizations have urged that hysterectomies be included during the fourth cycle of the National Family Health Survey and that the data gathered be utilized to develop recommendations for performing uterine removal procedures [ 20 ]. In India, we need to address the flaws in healthcare governance at the community level by empowering women regarding their health and perception [ 21 ]. In Gujarat, India, a study in 2017 suggested that health policy initiatives must increase reach to women's reproductive as well as sexual healthcare, education, research, and audits to encourage women to make excellent decisions throughout the life cycle [ 22 ]. The emergence of ulipristal acetate as a medical etiological therapy has significantly modified clinical indications as a less invasive surgical method and reduced potential hazards and pointless procedures [ 23 ]. More education and information on the possible adverse effects of hysterectomy with additional alternatives can help women make more educated decisions [ 24 ]. The Comparing Options for Management: Patient-centered REsults for Uterine Fibroids (COMPARE-UF) registry in 2018 compared various uterine fibroids treatments (hysterectomy, myomectomy, endometrial ablation, radiofrequency fibroid ablation, uterine artery embolization, magnetic resonance imaging-guided focused ultrasound, or implantation of a progestin-releasing intrauterine device) regarding long-lasting symptom alleviation, risk of recurrence, medical consequences, improved quality of life and sexuality, age at menopause, and fertility and pregnancy outcomes so that patients and their doctors may better comprehend the benefits and drawbacks of various treatment choices and make more educated decisions [ 25 ]. Myomectomy continues to be the gold standard treatment for fibroids, and many women have improved their quality of life [ 26 ]. Public health programs must pay greater attention to teaching women about reproductive health and try to spread it through local language media, radio, and television [ 27 ]. We now have a variety of alternatives to traditional surgery, including medical and less-invasive procedural management, with good evidence showing that gonadotropin hormone-releasing hormone agonists and progesterone receptor modulators reduce fibroid volume and improve the quality of life of women with fibroids who intend to get pregnant in the future. The United Arab Emirates has also demonstrated reduced uterine fibroid volume with better quality of life [ 28 ]. Based on the National Family Health Survey 4 univariate, bivariate, and multivariate analyses done in 2020, the frequency of hysterectomies has increased women's reproductive, sociopsychological, and physical health sufferings. Women need to be persuaded to choose high-quality prophylactic measures and alternative therapies to avoid unindicated hysterectomies [ 28 , 29 ]. In India, community-based studies and media critiques propose a surge in young women adopting hysterectomies in a shorter period, which has led to accusations of bad manners and heated discussions about its potential to harm younger women's health. It is highly challenging to change medical practice once a procedure has established the "standard of care." Furthermore, it is impossible to overlook the attractive reimbursement for surgery that medical professionals and institutions receive (particularly for robot-assisted surgeries). Another critical element is the lack of informed consent before hysterectomy. The consent forms for gynecological surgery are frequently open-ended, allowing doctors to remove any organ without pathology. Gynecological societies assert these treatments so nobody can criticize them for such endorsements. Common observations in the literature are shown in Table 1 . NGOs, nongovernmental organizations This table is created by the author(s). The average age at which hysterectomies were performed was 28.5 years, according to a study carried out in the state of Andhra Pradesh. Most private medical facilities fraudulently get exorbitant insurance premiums from the government under various health insurance programs in return. Rural India had higher rates of hysterectomy (3.4% versus 2.7%) [ 29 ]. In India, three out of every 100 women between the ages of 15 and 49 had undergone a hysterectomy, according to the results of the National Family Health Survey 5 study [ 30 ]. In national regions with higher hysterectomy rates, surveillance, audits, and advocating the prudent use of health insurance can be quite beneficial (Figure 2 ) [ 11 ]. GnRHa, gonadotropin-releasing hormone agonists; sPRMs, selective progesterone receptor modulators This figure is created by the author(s). Gonadotropin-releasing hormone agonists are usually advised for managing fibroids. They reduce estrogen levels, reducing symptoms associated with uterine fibroids such as heavy monthly flow and pelvic pain. Pinhole nonsurgical techniques are uterine fibroid embolization and uterine artery embolization (preserves fibroid or other sections of the uterus). Surgeons use imaging guidance to insert tiny catheters (thin tubes) into blood vessels leading up to the uterus, which houses the fibroids to deliver minute particles that obstruct circulation, causing the fibroid to cease growing and shrivel before being absorbed or killed by the body. Uterine fibroid embolization has a 95% success rate in decreasing fibroids and alleviating patient symptoms such as discomfort and heavy monthly flow. Radiofrequency ablation is an outpatient nonsurgical therapy for uterine fibroids with high-energy waves. Dangers include infection, bleeding, and scarring. Menopause may be achieved with ulipristal acetate therapy early while protecting the patient's quality of life in the least expensive economic and social manner in the younger age group [ 26 ]. The chief justice of India proposed hysterectomies for women under 40 only with the approval of two trained doctors. Medical audits for all unnecessary hysterectomies based on patient profiles and reasons for hysterectomies, the use of alternative and effective medical treatment before hysterectomies, ethical issues relating to surgical options, justification of surgical options, complications of the surgery, whether these surgeries are covered under health insurance schemes, blood transfusion for correcting anemia, cost of surgery, etc. should be made more effectively at district and state levels to protect women from adopting such course of treatment and putting them under distressful medical health issues such as depression and social disgrace. The Supreme Court also suggested the creation of national-, state-, and district-level hysterectomy monitoring committees, as well as the establishment of a grievance site, to address the issue [ 31 , 32 ]. Discussion According to statistics from the National Family Health Survey 5, 3% of women between the ages of 15 and 49 have had a hysterectomy. The greatest prevalence of hysterectomy among women aged 15-49 is seen in Andhra Pradesh (9%), followed by Telangana (8%), Sikkim (0.8%), and Meghalaya (0.7%). With a rate of 4.2%, which was also higher than the national average, the southern region of India had the highest incidence of hysterectomy, followed by the eastern region (3.8%). Only 1.2% of it is in the northeast [ 33 ]. Before deciding on a hysterectomy, women must know about their reproductive health and the potential adverse effects of surgery, especially those in their early reproductive years. Their situation could improve if they are aware of nonsurgical treatment choices, and they may be able to live healthier lives for medical conditions that do not necessitate hysterectomies. To accomplish these goals, which should also reach distant areas in different sections of the nation, various resources, the mass media, public health educators, and social groups must collaborate. The most recent ruling acknowledges India's soaring hysterectomy rates among young women compared to patterns seen in affluent nations. It recognizes the violation of fundamental rights and claims that unneeded hysterectomies violate Article 21 of the Constitution's right to life and health [ 34 ]. With Rs. 5 lakh annual health coverage per family, covering 12 crore families under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, the long-term impacts of this very promising scheme must be observed to see how it would curb this danger (preventing needless hysterectomies) from society via prudent usage [ 35 ]. The factors affecting outcomes are shown in Figure 3 . NGOs, nongovernmental organizations This figure is created by the author(s). Doctors in remote areas of the country try to create fear among premenopausal women because of their less education and social shyness. They fall prey to their hands for choosing unindicated hysterectomy and subsequently suffer from various ill effects such as early menopause, early aging, psychosocial distress, cardiovascular symptoms, and decreased bone marrow density; it also sometimes affects their sexual life. Prolapse due to malnutrition and hard labor is one of the reasons for such uncalled hysterectomies. Government-sponsored insurance programs Rashtriya Swasthya Bima Yojana and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana provide free treatment to families below the poverty line or other equivalent beneficiaries. The main aim of such health insurance is to reach all beneficiaries in remote areas of the country by empaneling health institutions with all health facilities with a noble motive to achieve a healthy nation. Qualified doctors are not available at many government health institutions in these remote or tribal areas, resulting in private health institutions playing a role in providing such services in these areas. There is a problem with accountability and government control in certain healthcare institutions, resulting in poor file-keeping and a lack of auditable data. Effective solutions face obstacles such as the requirement for records of all hysterectomies, external audits of bodies, and surveys of public, private, and camp environments. Establishing rules and procedures, standardizing health examinations, and utilizing online or short message service-based notifications and discharge forms could also be helpful. Informed consent from patients must convey a complete understanding of the benefits, drawbacks, and options available (Figure 4 ). This figure is created by the author(s). Preventing unnecessary hysterectomies comes with several challenges, including limited availability of two gynecologist opinions before hysterectomies under 40 years of age, regulating surgeries in younger women with benign medical indications, limiting hysterectomies to lifesaving procedures, monitoring private sector practices before using government-sponsored health insurance schemes, utilizing more of the government sector to avoid unindicated hysterectomies, and supporting noninvasive procedure through campaigns such as the Federation of Obstetric and Gynaecological Societies of India's "Save the uterus" initiative launched in 2019 [ 36 ]. In recent years, the number of hysterectomies for benign gynecological diseases has decreased in Australia, the United States, and Sweden. Australia saw a 25% decrease from 2002 to 2014, the United States decreased by 54.2% from 2002 to 2012, and Sweden decreased from 232 per 100,000 person-years in 1999 to around 210 per 100,000 person-years in 2003 [ 37 ]. A summary table of the studies included in the review is shown in Table 2 . GHQ, General Health Questionnaire; LH, luteinizing hormone; SEWA, Self Employed Women's Association

The availability of proper health knowledge, regular awareness through mass media, and local leaders' active participation by health system professionals is a need of the time. For women from underserved groups and cultures to get better medical advice about their issues and choose alternatives to hysterectomy, we need to strengthen the public health system. More trained and dedicated health staff and doctors are required to cover remote, underprivileged areas. Considering this burning issue on women's health, the recently worthy Supreme Court of India has lately directed all states through the Government of India health department to formulate a policy to track all hysterectomies and the reasons for their occurrence, particularly in premenopausal age groups, and define the role of gynecologists before hysterectomies. Collecting data from public and private institutions is always challenging, as they retain records poorly. Stricter laws can only make these institutions responsible for retaining such records for future reference and evaluation.