Lecture 1

How to decrease Hysterectomy
Rate in India?
Dr. Sharda Jain

“Save
Uterus
Campaign”
Lecture Series
(1 to 4 )
How to decrease
Hysterectomy Rate
in India?
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar
Save
PARTNERS
•Delhi Gynae Forum
•Faridabad
obs/Gynae Society
•Gurgaon
obs/Gynae Society
•Gaziabad obs/Gynae
Societ
•Noida...
TOI Sept. 2010
Landmark article
80% of Andhra Village women are minus
their uterus
Uterus chopping States
Andhara Pradesh , Madhya
Pradesh,Punjab
Bihar, Delhi
Modus Operandi Same as

Female Foeticide
22 Sept.2012 appealed to Gynaecologists
To be kind to uterus
Why Did he say so about
Hysterectomy ?
• Second most frequent
surgical procedure in
women of reproductive
age group
• 90% ...
BIG FACT !!
Women AGE early even if
ovaries
are retained
At
Hysterectomy

All Elders endorse this fact
Hysterectomy is
Not 100% safe
Disadvantages
• Performed under general or regional
anesthesia
• Long hospitalization and re...
Do You want to guess
the
Number
of
HYSTERECTOMY
done in India ?
Numbers of
Hysterectomies Per year
USA

5.9 lac

UK

1.3 lac

Russia

3.12 lac

India

23.2 lac
CDC
1990-2000

Life time risk
Of
Uterus Removal
U.K.
1:5
Women before 60 years
had Hysterectomy
USA
1:3
Women before 60 years
had Hysterectomy
Indications of Hysterectomy
Indications of Hysterectomy
In USA
In USA
Prolapse 15%

(Pre) cancer
10%

Chronic pelvic pain ...
Hysterectomy Rate

↓↓
th
To 1/10

(20 years)

In western world
Causes of Hysterectomy
in USA now
5 per 1000
%

•
•
•
•
•
•

Uterine leiomyoma
Endometriosis
Uterine Prolapse
Cancer
Endom...
Bilateral

Salpingo- Oopherectpomy Rate

65%
↓↓↓

45%
Uterus Retained (Bad PID)
Average AGE of Hysterectomy in

USA
46 yrs
(40 – 50 yrs)

Uterus Removal In India

10 to15 yrs. earlier
Menace of Uterus Removal is on
GOVT enquiry in Many states
Who has Caused this
Menace in India ?
Gynaecologists
&

Surgeons
Big Question
How western world has
↓↓↓ Hysterectomy Rate?
ACOG / Royal College
February, 2000, Vol 95,
No. 2, Pages 199-205

The Appropriateness of Recommendations
for Hysterectomy
Michael S. Broder, M...
The Appropriateness of
Recommendations for Hysterectomy*
Michael S. Broder, MD, David E. Kanouse,
PhD,
Brian S. Mittman, P...
“The most common reasons for which
hysterectomies were considered
inappropriate were
• lack of adequate diagnostic evaluat...
HYSTERECTOMY
as Treatment
Should be last resort

KJ Carlson, NEJM 328:856,
1993
Risk of Endometrial
Carcinoma

• 20-40 yrs – 10 / lac
• 40-50 yrs - 36 / lac
More than

1 in 5

30s & 40s suffer from
HEAVY PERIODS
(Unmanageable)
FIGO

PALM

-

COEIN
TVS
Gold Standard
Office Hysteroscopy

Gold standard for HMB but not cost effective
as first line diagnostic tool.
Office EB - Diag.
Procedure
Gold Standard
• Has replaced conventional

D & C under GA
• No therapeutic value
Treatment
THE IDEAL TREATMENT
FOR HMB
Is Not

Hysterectomy
Current Treatment
Recommended for HMB
Drug therapy
20%-30% after
35 years

Global Endo.
Ablation/
Mirena

Hysterectomy
Medical management of DUB
Effectiveness

Side effects Costs

Contraceptive Pill

50%

+

Progestagens

20%

++

Danazol

1...
Mirena (LNG IUS)
(5 yrs)
is a

Magic Stick
Conclusions about Mirena
• Mirena provides most effective medical
treatment with least side effects
• It can replace in ab...
We have largest Number of
cases
of MIRENA
in Delhi & NCR
(2013 upto 30th June)
GLOBAL ENDO.
ABLATION TECHNIQUES
(10-15 years)

•

Success is 80 to 90%

•Repeat procedure / Hysterectomy –

10 to 20%

Am...
Uterine Balloon Therapy

(Many Types)
For Treatment of DUB
Very Effective

10 minute
Solution
for
‘Heavy
Periods’
We Have Largest No. of Cases
of UBT in India
Our cases : till March 2013

N - ↑ 1300
(24 months F/U completed – Over 1000
...
UBT’s
Biggest Use
Is In
Bad Surgical
Risk cases
Let us come forward to stop this
menace of uterus removal.
° Think rationally yourself.
° Vow yourself &
° Join the Moveme...
No way should
SURGEONS be
allowed to do
hysterectomy in
India ……
Such practices
should become
history !!
Thanks
How to decrease hysterectomy in  rate in india,dr. sharda jain lecture 1
How to decrease hysterectomy in  rate in india,dr. sharda jain lecture 1
How to decrease hysterectomy in  rate in india,dr. sharda jain lecture 1
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  • WHY SHOULD’NT A HYSTERECTOMY BE AVOIDED IF THE BENEFIT CAN BE PROVIDED TO A GOOD NO, OF PATIENTS BY A SAFER ALTERNATIVE TT MODALITY COZ HYSTERECTOMY DOES CARRY RISKS OF ANAESTHESIA ETC
  • As u can see from thslide that 20 % of all hystrec are done for dub alone so if we take that chunk out of the pie and treat a lot of these patients with newer modalities you can understand the impact IT WOULD HAVE on the morbidity and financial implications.
  • The rcog issued evidence based clinical guidelines in 1998 on initial management of menorrhagia and were subsequently updated.
  • THERE HAVE BEEN SEVERAL STUDIES PUBLISHED IN VARIOUS JOURNALS QUESTIONING THE APPROPRIATENESS OF HYSTERECTOMY
  • Why would hysterectomies be performed inappropriately BECAUSE OF
  • WHY SHOULD’NT A HYSTERECTOMY BE AVOIDED IF THE BENEFIT CAN BE PROVIDED TO A GOOD NO, OF PATIENTS BY A SAFER ALTERNATIVE TT MODALITY COZ HYSTERECTOMY DOES CARRY RISKS OF ANAESTHESIA ETC
  • THE SECOND SESSION WILL HAVE A DETAILED PRESENTATION BY DR SHARDA JAIN AS WELL AS THE PATIENTS OWN EXPEREINCES REGARDING THE UTERINE BALLOON THERAPY
  • How to decrease hysterectomy in rate in india,dr. sharda jain lecture 1

    1. 1. Lecture 1 How to decrease Hysterectomy Rate in India? Dr. Sharda Jain “Save Uterus Campaign” Lecture Series (1 to 4 )
    2. 2. How to decrease Hysterectomy Rate in India? Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar
    3. 3. Save PARTNERS •Delhi Gynae Forum •Faridabad obs/Gynae Society •Gurgaon obs/Gynae Society •Gaziabad obs/Gynae Societ •Noida obs/Gynae Society •Muradabad obs/Gynae Society Uterus Campaign CROSSING All Boundaries in GYNAECOLOGICAL Care to SAVE UTERUS THEMES • How to decrease Hysterectomy rate In India • Global Endometrial ablation • Uterine Balloon Therapy • Mirena • Minimizing Complications in Hysteroscopic Surgeries •Simplifying Medical Treatment of DUB
    4. 4. TOI Sept. 2010 Landmark article 80% of Andhra Village women are minus their uterus
    5. 5. Uterus chopping States Andhara Pradesh , Madhya Pradesh,Punjab Bihar, Delhi Modus Operandi Same as Female Foeticide
    6. 6. 22 Sept.2012 appealed to Gynaecologists To be kind to uterus
    7. 7. Why Did he say so about Hysterectomy ? • Second most frequent surgical procedure in women of reproductive age group • 90% for benign reasons • Promptly offered following a diagnosis. • Hysterectomy should not be taken up lightly.
    8. 8. BIG FACT !! Women AGE early even if ovaries are retained At Hysterectomy All Elders endorse this fact
    9. 9. Hysterectomy is Not 100% safe Disadvantages • Performed under general or regional anesthesia • Long hospitalization and recovery time • Mortality 0.6-1/1,000 • Major complications 3% • Morbidity 24-43% • Psychological 25-35% • Long period of convalescence KJ Carlson, NEJM 328:856, 1993
    10. 10. Do You want to guess the Number of HYSTERECTOMY done in India ?
    11. 11. Numbers of Hysterectomies Per year USA 5.9 lac UK 1.3 lac Russia 3.12 lac India 23.2 lac CDC
    12. 12. 1990-2000 Life time risk Of Uterus Removal
    13. 13. U.K. 1:5 Women before 60 years had Hysterectomy
    14. 14. USA 1:3 Women before 60 years had Hysterectomy
    15. 15. Indications of Hysterectomy Indications of Hysterectomy In USA In USA Prolapse 15% (Pre) cancer 10% Chronic pelvic pain 10% Fibroids 30% Endometriosis/ Adenomyosis 20% DUB 20% 1990 - 2000
    16. 16. Hysterectomy Rate ↓↓ th To 1/10 (20 years) In western world
    17. 17. Causes of Hysterectomy in USA now 5 per 1000 % • • • • • • Uterine leiomyoma Endometriosis Uterine Prolapse Cancer Endometrium hyperplasia Misc. (Includes CERVICAL DYSPHASIA) Obstat Gvnecol 2008;34.e1-e7 40.7 17.7 14.5 9.2 2.7 15.2
    18. 18. Bilateral Salpingo- Oopherectpomy Rate 65% ↓↓↓ 45% Uterus Retained (Bad PID)
    19. 19. Average AGE of Hysterectomy in USA 46 yrs (40 – 50 yrs) Uterus Removal In India 10 to15 yrs. earlier
    20. 20. Menace of Uterus Removal is on
    21. 21. GOVT enquiry in Many states
    22. 22. Who has Caused this Menace in India ? Gynaecologists & Surgeons
    23. 23. Big Question How western world has ↓↓↓ Hysterectomy Rate? ACOG / Royal College
    24. 24. February, 2000, Vol 95, No. 2, Pages 199-205 The Appropriateness of Recommendations for Hysterectomy Michael S. Broder, MD, David E. Kanouse, PhD, Brian S. Mittman, PhD, and Steven J. Bernstein, MD, MPH
    25. 25. The Appropriateness of Recommendations for Hysterectomy* Michael S. Broder, MD, David E. Kanouse, PhD, Brian S. Mittman, PhD, and Steven J. Bernstein MD, MPH 76% of the patients who were taken up for hysterectomy did not meet ACOG criteria for hysterectomy *Obstet Gynecol 2000;95:199-205
    26. 26. “The most common reasons for which hysterectomies were considered inappropriate were • lack of adequate diagnostic evaluation • failure to try alternative treatments before hysterectomy.” *Obstet Gynecol 2000;95:199-205
    27. 27. HYSTERECTOMY as Treatment Should be last resort KJ Carlson, NEJM 328:856, 1993
    28. 28. Risk of Endometrial Carcinoma • 20-40 yrs – 10 / lac • 40-50 yrs - 36 / lac
    29. 29. More than 1 in 5 30s & 40s suffer from HEAVY PERIODS (Unmanageable)
    30. 30. FIGO PALM - COEIN
    31. 31. TVS Gold Standard
    32. 32. Office Hysteroscopy Gold standard for HMB but not cost effective as first line diagnostic tool.
    33. 33. Office EB - Diag. Procedure Gold Standard • Has replaced conventional D & C under GA • No therapeutic value
    34. 34. Treatment
    35. 35. THE IDEAL TREATMENT FOR HMB Is Not Hysterectomy
    36. 36. Current Treatment Recommended for HMB Drug therapy 20%-30% after 35 years Global Endo. Ablation/ Mirena Hysterectomy
    37. 37. Medical management of DUB Effectiveness Side effects Costs Contraceptive Pill 50% + Progestagens 20% ++ Danazol 100% (dose!) GnRH`agonist + ++ 100% ++ ++ NSAID 30% + Antifibronilytic agents 50% + ++ IUD with Progesteron 65%-97% + ++ 20-30% success after 35 years
    38. 38. Mirena (LNG IUS) (5 yrs) is a Magic Stick
    39. 39. Conclusions about Mirena • Mirena provides most effective medical treatment with least side effects • It can replace in about 50 % cases the need for endometrial ablation or hysterectomy • Especially useful when presently contraception is required but future fertility is desired
    40. 40. We have largest Number of cases of MIRENA in Delhi & NCR (2013 upto 30th June)
    41. 41. GLOBAL ENDO. ABLATION TECHNIQUES (10-15 years) • Success is 80 to 90% •Repeat procedure / Hysterectomy – 10 to 20% Amenorrhea, ↓↓ bleeding in over 90%
    42. 42. Uterine Balloon Therapy (Many Types) For Treatment of DUB
    43. 43. Very Effective 10 minute Solution for ‘Heavy Periods’
    44. 44. We Have Largest No. of Cases of UBT in India Our cases : till March 2013 N - ↑ 1300 (24 months F/U completed – Over 1000 cases)
    45. 45. UBT’s Biggest Use Is In Bad Surgical Risk cases
    46. 46. Let us come forward to stop this menace of uterus removal. ° Think rationally yourself. ° Vow yourself & ° Join the Movement for motivating 10 other gynaecologists to do the same
    47. 47. No way should SURGEONS be allowed to do hysterectomy in India …… Such practices should become history !!
    48. 48. Thanks

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