Ontario's hysterectomy rates too high

In northern areas, fewer gynecologists and longer distance to CME key

By Jenny Manzer

TORONTO – Better physician training and more patient education are needed to reduce Ontario's high rate of discretionary hysterectomies, a new report suggests.
   The Ontario Women's Health Council produced the report, "Achieving Best Practices in the Use of Hysterectomy." They found women are having the procedure "too frequently" as first-line treatment for benign uterine conditions such as fibroids or abnormal uterine bleeding.
   Less invasive alternatives exist—such as ablation therapy, medical management or myomectomy—if women had access to them, the report said.
   While Ontario's hysterectomy rate has declined significantly over the past 20 years to 476 per 100,000 in 1998, the figures show a great disparity in rates across the province.
   For example, Toronto's hysterectomy rate was 327 per 100,000. In Sudbury and to the north, it was 743 per 100,000.
   About 22% of Canadian women age 35 and older have had a hysterectomy.
   The report said many women in the north seemed to regard having a hysterectomy as inevitable, and weren't aware of alternatives.
   "It was almost an expected event in women's lives. They would say, 'You know, my mother, grandmother, my sisters, my aunts, they've all had it out—it's time,' " said Dr. Donna Stewart, head of the panel that submitted the report.
   Women in rural and northern areas often have to travel long distances for care and experience long waits for appointments.
   Faced with these circumstances, women in remote areas may consider hysterectomy their only viable option, she said.
   "What we heard from the women up there was it sometimes takes six to 12 months for their first appointment with a gynecologist, and if they're hemorrhaging during that time, obviously by the time they finally get in there . . . they want a quick fix, and they want to be sure it's going to work. And certainly hysterectomy does that," she said, adding other therapies, such as ablation, don't always work the first time.
   Report co-author Dr. Janice Willett, chairwoman of the Ontario Medical Association's section on obstetrics and gynecology, said the lack of patient information and physician shortages must be addressed.
   The panel's research showed wherever there was an extreme shortage of gynecologists, the hysterectomy rate was higher, she said.
   "I'm in a community where it's not just (a problem of) access to gynecologists. It's access now to family doctors. We have so many unattached patients," said Dr. Willett, speaking from Sault Ste. Marie, where she practises.
   The report's recommendations focused on educating women about conditions such as abnormal bleeding and fibroids, and making programs more available to get rural doctors up to speed on newer techniques.
   "Women need to be better informed about their health problems so they can ask questions about procedures and treatment options. Whatever the health problems, women should ask questions, read widely about their conditions and discuss possible options with their health providers," said Dr. Stewart.
   "Women we spoke to in the course of our research for this report told us quite clearly they wanted more information and to be involved in the decision-making process about their own health."
   As part of the panel's research, about 200 family doctors in the north were surveyed.
   Doctors there said it's difficult for them to leave their practices for continuing medical education, and they don't have access to good clinical guidelines, said Dr. Stewart, adding more must be done to help them get this information.
   The report supported designating funding to make hysteroscopic and ablation procedures more widely available by offering them at outpatient centres and ambulatory surgical facilities.
   "Access and expertise," said Dr. Stewart. "If you do a lot of these things, you get good at it."
   The report said it is usually desirable with discretionary hysterectomies to leave healthy ovaries intact. Yet 72% of discretionary hysterectomies in the province were total hysterectomies, with or without removal of the ovaries.
   Only about 40% of hysterectomies done in Ontario are vaginal as opposed to abdominal, the report said.
   "That's hard to understand" said Dr. Stewart, as vaginal hysterectomies have a lower complication rate and shorter recovery time.
   Vaginal hysterectomies also take longer and require more expertise, so the report recommended physicians be compensated more to perform them.
   Recent figures show Canadian doctors perform twice as many hysterectomies as their peers in Sweden, the United Kingdom and the Netherlands.
   Canada's overall hysterectomy rate of 476 per 100,000 is dwarfed only by the U.S. rate of 550 per 100,000, the highest in the Western world.
   "The good news is the rates have dropped over the last 15 years. The not-so-good news is that we're still in the number two position in the world," said Dr. Stewart.