SANTA FE, N.M. — U.S. clinicians ought to tell hysterectomy candidates they have the option of leaving the cervix intact—and should give full information about the controversial alternative so patients can make informed choices, Craig A. Winkel, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.
There is a broad disconnect between what women read about supracervical hysterectomy on the Internet and the hard data in the scientific literature, according to Dr. Winkel of Georgetown University School of Nursing, Washington. Claims of better preservation of sexual, bladder, and bowel function with supracervical hysterectomy are contradicted by randomized, controlled trials, he said.
Adding to the confusion, nearly two-thirds of area physicians surveyed by his group at Georgetown said they neither offer their patients a choice nor counsel them about supracervical hysterectomy as an option, he said. Fear of cervical cancer apparently was not a factor; 81% of the physicians said the risk was negligible (Obstet. Gynecol. 2003;102:301-5).
“All women who are hysterectomy candidates should be counseled and given the choice. The data say it is easier for you to do the supracervical [procedure], and you may reduce the complications,” Dr. Winkel said, advocating full disclosure, although he noted that more trials are needed before the evidence can be considered conclusive.
Supracervical hysterectomy is widely done in Europe and was standard practice in the United States until the mid-1940s, according to Dr. Winkel, in a review of the data to date. He said interest in this country has been revived by a recommendation from the American College of Obstetricians and Gynecologists calling for a 30% reduction in abdominal hysterectomies.
In 1983, a retrospective study reported that coital frequency, orgasm, and libido all decreased while dyspareunia increased in women asked to compare their sexual functioning before and after removal of the cervix (Acta. Obstet. Gynecol. Scand. 1983;62:141-5). Dr. Winkel quoted the investigator as theorizing that leaving the cervix intact better preserves Frankenhäuser's ganglion of autonomic nerves.
According to Dr. Winkel, an anatomy study subsequently ruled out this theory, noting that simple hysterectomy causes “minimal disruption of nerves or ganglia” (Cancer 2000;89:834-41).
Since then, Dr. Winkel said two randomized controlled trials (N. Engl. J. Med. 2002; 347:1318-25 and BJOG 2003;110:1088-98) and a prospective study (BMJ 2003;327:774-8) have shown no difference in sexual satisfaction. The study published in the New England Journal of Medicine included 279 patients.
The impact of supracervical hysterectomy on morbidity is less clear, however. Complications were significantly less during and after discharge with supracervical hysterectomy, compared with total hysterectomy in the New England Journal of Medicine study. Cyclic vaginal bleeding and cervical prolapse were reported at 12 months in 7% and 2%, respectively, of supracervical patients, but none who had undergone total hysterectomy. Conversely, persistent pain was higher in the total hysterectomy group (6.4%) than in the supracervical hysterectomy group (2.8%).
Dr. Winkel also cited a prospective trial that found fewer complications, (Obstet. Gynecol. 2003;102:453-62) compared with total hysterectomy, and an observational study concluding that classic intrafascial supracervical hysterectomy has a lower complication rate than laparoscopic hysterectomy (J. Am. Assoc. Gynecol. Laparosc. 1998;3:253-60). A third study, however, found increases in cyclic bleeding, dyspareunia, and trachelectomy with laparoscopic supracervical hysterectomy (BJOG 2001;108:1017-20).
“Supracervical hysterectomy is easier than removing the cervix. The data suggest supracervical hysterectomy may be safer.”