Happy Thursday!

I’ve just returned from the JP Morgan Conference, where private equity firms, investment banks, venture capitalists, biopharma companies, startups, and more gathered to discuss healthcare trends and investment opportunities. It was incredible to see women’s health finally getting the well-deserved attention it deserves. With healthcare so often treated as a business, we must ensure that women’s health remains a top priority on the agenda.

In this issue, I’m kicking off a series of articles on informed consent in women’s health—starting with a deep dive into hysterectomies. Also, don’t miss the latest updates on bone health and the FDA’s recent decision to ban food dye Red 3.

Have other topics you’d like me to cover? Respond to this email.

Warmly,
Georgie

“Holy Cow, I’m Going to Ask More Questions Now”: A Guide to Hysterectomy, Informed Consent, and Your Health

Imagine walking into a doctor’s office to address debilitating pelvic pain or endless heavy periods. After a few minutes of conversation, you hear the word “hysterectomy.” Relief might wash over you—finally, a solution. Or panic—what does this mean for my body? But one emotion is almost universal among women undergoing hysterectomy: confusion.

Rachel Gross, in The New York Times, highlighted “There are few procedures in which patients routinely go under the knife without understanding their full range of options -- or leave the operating room not knowing exactly which of their organs remain.”【1】As an example, An international team led by Dr. William H. Parker (on the adjunct faculty at the John Wayne cancer institute at St John's health centre in Santa Monica, California) and researchers from Harvard medical school analysed incident rates and deaths from coronary heart disease, stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture and pulmonary embolism as well as death from all causes.【2】

In this blog, we’ll unpack the complexities of hysterectomy—what it is, why informed consent is critical, and how you can advocate for yourself to take control of your health.

Why Hysterectomy? Common Reasons and Trends

Hysterectomy is one of the most frequently performed surgeries in the United States, primarily used to treat significant gynecological issues. The most common indications include:

• Symptomatic Uterine Fibroids (51.4%)

• Abnormal Uterine Bleeding (41.7%)

• Endometriosis (30%)

• Pelvic Organ Prolapse (18.2%)

Minimally invasive techniques, such as vaginal and laparoscopic hysterectomies, are often preferred due to shorter recovery times and reduced hospital stays compared to open abdominal surgery. Between 1998 and 2010, the number of abdominal hysterectomies decreased from 65% to 54%, while robot-assisted laparoscopic hysterectomies surged from 0.9% in 2008 to 8.2% by 2010. However, vaginal hysterectomy—the approach associated with the best outcomes and cost-effectiveness—has seen a consistent decline, from 25% in 1998 to 17% in 2010【3】【5】【6】.

What Is a Hysterectomy? Types of Surgeries and Procedures Explained

A hysterectomy removes the uterus and, depending on the type, may also involve the cervix, fallopian tubes, and ovaries. Here’s a quick breakdown:

• Total Hysterectomy: Uterus and cervix removed.

• Supracervical Hysterectomy: Uterus removed, cervix remains.

• Radical Hysterectomy: Uterus, cervix, and surrounding tissues removed, often for cancer.

• Hysterectomy with Oophorectomy: Removal of the ovaries, often paired with fallopian tube removal (salpingo-oophorectomy)【3】【4】【6】.

Why Ovaries Matter: Hormone Therapy After Oophorectomy

The ovaries produce hormones like estrogen and progesterone, which are vital for bone health, heart health, and overall well-being. Removing the ovaries (oophorectomy) can result in surgical menopause, leading to:

• Hot flashes and night sweats.

• Increased risk of osteoporosis and heart disease.

• Vaginal dryness and changes in sexual function【3】【6】【8】.

Hormone therapy (HT) is essential to mitigate these effects. Dr. Jocelyn Wallace emphasizes, “Women often don’t realize how removing the ovaries can drastically shift their body’s hormonal landscape, and hormone therapy can play a key role in recovery and quality of life”【8】.

Key questions to ask:

• Will you remove my ovaries? If so, why?

• What are the risks of surgical menopause?

• Is hormone therapy recommended for me, and what are the risks and benefits?

Hysterectomy Guidelines: Why Training, Reimbursement, and Referrals Matter

Hysterectomy is one of the most common surgeries performed on women, but up to 70% of procedures don’t meet expert criteria for appropriateness【5】【6】.

Updated ACOG guidelines prioritize minimally invasive procedures when feasible. However, training, experience, and reimbursement pathways often influence surgical decisions. For example:

• Training, experience, and technical difficulty are often cited as barriers to performing a laparoscopic hysterectomy. However, none of these factors should be considered an absolute contraindication to a minimally invasive approach.

• An OB-GYN may choose an abdominal hysterectomy instead of referring the patient to a minimally invasive surgeon, driven by financial incentives or lack of advanced training in minimally invasive techniques.

• Facilities may prioritize procedures that align with their reimbursement models, even if those procedures are not the most patient-centered【3】【5】【6】.

This makes it crucial to discuss all options with your doctor and ask whether referral to a minimally invasive specialist is appropriate.

Pelvic Physical Therapy: The Missing Piece of Hysterectomy Recovery

Pelvic PT is not included in standard hysterectomy guidelines, leaving many women unaware of its transformative potential. Pelvic PT is the missing piece according to Dr. Wallace. “It's not standard of care yet to do it from a preventative or proactive place. I absolutely think that it should be.”  She points out that, sadly, it’s up to patients to ask. Dr. Wallace reinforces that it can rebuild the strength and support lost during surgery, addressing back pain, incontinence, and even sexual dysfunction【8】.

Benefits of pelvic PT include:

• Preparing the pelvic floor pre-surgery to prevent complications.

• Rebuilding muscle strength and improving recovery post-surgery【8】.

If pelvic PT isn’t offered by your surgeon, request a referral—it can make a significant difference in your recovery.

What Is Informed Consent for Hysterectomy?

Informed consent isn’t just a signed form—it’s a conversation. True informed consent should include:

• A thorough discussion of all surgical options.

• Risks and benefits, including hormonal and structural changes.

• Exploration of non-surgical alternatives【7】【8】【9】.

Ask your doctor:

1. What type of hysterectomy do you recommend, and why?

2. Will you remove my ovaries, and if so, how will surgical menopause be managed?

3. Are there minimally invasive options for my case?

4. What long-term effects should I anticipate (e.g., hormonal changes, pelvic floor support)?

5. Will you refer me to a pelvic physical therapist?

Questions to Ask About Minimally Invasive Surgery

Many women don’t realize that minimally invasive surgeons and OB-GYNs differ in training and expertise. Minimally invasive specialists use advanced techniques to reduce recovery time and complications, but they’re not always the default recommendation【3】【6】【7】.

Key questions include:

• Is a minimally invasive approach possible for me?

• What experience do you have with minimally invasive hysterectomies?

• Are there reimbursement factors influencing this recommendation?

Take Charge of Your Post-Hysterectomy Recovery

Post-hysterectomy, many women report significant quality-of-life improvements. However, Dr. Wallace emphasizes that we tend to undersell ourselves on what’s possible. Yes, patients might feel relief from fibroids or pain, but they don’t have to accept back pain or incontinence as their new normal【8】.

With pelvic PT, hormone therapy, and proper care, you can thrive post-surgery.

Conclusion: Your Body, Your Choices

Hysterectomy isn’t just about removing an organ—it’s about empowering women to make informed, life-changing decisions. Rachel Gross poignantly observed that too many women discover the fine print only after the surgery. Let this be your rallying cry to demand answers, advocate for yourself, and ensure that your health decisions are fully informed【1】【7】【9】.

Your body. Your choices. Let’s make them count.

Sources:

1. Gross, Rachel. The New York Times. "Women Often Face Hysterectomies Without Full Knowledge of Their Options." December 2024.

2. Reedy, Betsy. The Guardian, US study: Women who have ovaries removed face increased risk of death. April 2009.

3. American College of Obstetricians and Gynecologists (ACOG). Choosing the Route of Hysterectomy for Benign Disease. Clinical Guidelines. October 2024.

4. Rodriguez, Zoe. "Hysterectomy with Dr. Zoe Rodriguez." Transcript from Fempower Health Podcast. December 2024.

5. Broder, Michael S., Kanouse, David E., Mittman, Brian S., and Bernstein, Steven J. The Appropriateness of Recommendations for Hysterectomy. RAND Corporation. February 2000.

6. Gor, Hetal B., MD, FACOG, and Rivlin, Michel E., MD. Hysterectomy Guidelines Summary. Medscape. October 16, 2024.

7. American Medical Association. AMA Code of Medical Ethics: Informed Consent. Accessed December 2024.

8. Wallace, Jocelyn, PT, DPT. "Preparation Before and After Hysterectomy." Transcript from Fempower Health Podcast. December 2024.

9. American College of Obstetricians and Gynecologists (ACOG). "7 Things You Didn’t Know About Hysterectomy." ACOG Publication. December 2024.