Hysterectomy, the surgical removal of the uterus, has garnered unprecedented attention in recent years. Over a decade ago, a series of news reports and factfinding missions identified rural pockets where young women were undergoing hysterectomy in small, private hospitals. The women’s young age suggested that most surgeries were medically unnecessary. Private doctors and insurance schemes came under the scanner, as did other motivations. More recently, news from Beed, Maharashtra, on uterus removal amongst sugarcane workers, hit the international media.

Alongside journalistic coverage, a considerable evidence base of quantitative and qualitative research has emerged in the academic literature over the past several years.

In response, government insurance schemes introduced restrictions on how hysterectomy could be reimbursed, in hopes of curbing profit incentives. Policymakers also developed comprehensive guidelines on monitoring and regulations to control unnecessary hysterectomy. The guidance includes treatment for gynaecological morbidity to avoid hysterectomy and outlines the importance of interventions such as audits and community engagement. The Supreme Court recently addressed and disposed of a public interest litigation on the issue, underscoring that hysterectomy is indeed a matter of women’s rights. The response notes the steps taken towards adhering with the centre’s guidelines, setting up a grievance portal and establishing district, state and national monitoring committees to prevent unnecessary hysterectomy, particularly in women younger than 40 years.

[W]omen lose their uterus at least a decade earlier than is medically indicated. This appears to be unique to India.

Hysterectomy is a major procedure that can have serious implications for women’s health, especially if conducted amongst young women. Why has hysterectomy emerged as specific issue in the first place and what does it means for women’s broader sexual and reproductive health in India? 

Puzzling patterns

Hysterectomy is mainly used to treat major gynaecological issues such as large fibroids or cancer. When needed, it is typically conducted amongst women in mid-life, around menopause. When the first fact-finding data on hysterectomy emerged from community-based settings, the young age of women undergoing hysterectomy made it clear that a problem was brewing – but the extent was unknown.

In 2015, the National Family Health Survey started collecting data on hysterectomy across women up to age 49 in India. It is the only national demographic survey globally that tracks the procedure amongst women in their reproductive years.

Unpacking why, where and amongst whom hysterectomy is conducted has been a persistent puzzle. At first glance, the average proportion of women who have had hysterectomy is not alarming. Just about 10% of women currently between 40–49 (the age group at the highest risk) have undergone the procedure.

Yet a closer look at patterns reveals worrying trends.

To start, the average masks a wide range across states. At one extreme, one in five women in Andhra Pradesh and Telangana will have no uterus by age 50 – levels similar to parts of North America or Australia. In other states, mostly in the North East, the corresponding figure is one in 20, which suggests that women who need the surgery may lack access. In between, there is no clear pattern to the scattering of higher and lower prevalence states. For example, hysterectomy is relatively high in Bihar, but considerably lower in neighbouring Uttar Pradesh and Jharkhand.

Unlike other health indicators like maternal or infant mortality, hysterectomy patterns across India aren’t easily explained by usual factors, such as a state’s health system performance or wealth level.

Doctors recommend that hysterectomy should be conducted in women with medical indications who are above 45 years, with exceptions for serious indications such as cancer. National data, however, indicate that women typically undergo hysterectomy in their mid-30s, known as early hysterectomy. In other words, women lose their uterus at least a decade earlier than is medically indicated.

This appears to be unique to India, at least based on data available from other countries. If the ovaries are removed with the uterus, then women effectively enter menopause in their 30s. Anecdotal data suggest that removal of ovaries is quite common, but this is not yet systematically documented.

About two-thirds of hysterectomies are conducted in the private sector. Initial reports assumed health insurance was driving high rates in Andhra Pradesh and Telangana, where over 80% of people are covered by insurance. Yet health insurance coverage is equally high in Rajasthan or Chhattisgarh, with lower hysterectomy rates. Higher rates could reflect higher access to facilities, yet Kerala and Tamil Nadu, amongst the highest in health system performance, do not have high rates of hysterectomy. Unlike other health indicators like maternal or infant mortality, hysterectomy patterns across India are not easily explained by usual factors, such as a state’s health system performance or wealth level.

Across states, we do know that hysterectomy is more common amongst rural women, and women with minimal formal education. Urban or more educated women have much lower chances of an early hysterectomy. Vulnerability is further compounded by social inequities. While occupation, caste and class play out differently, across contexts women with fewer resources have consistently higher chances of having their uterus removed, and at a young age.

Complex web of causes

Why are young, rural women offered hysterectomy in the first place?

Women report they undergo the surgery largely to treat excessive menstrual bleeding – a common symptom of gynaecological ailments. For women who work long hours at home or in manual labour, severe bleeding and pain are a major disruption to daily life. Menstrual disorders and other gynaecological ailments affect women through their life, and many issues become more troublesome with age.

Once women have had their children, issues become more noticeable or even worse. Where health care is easily accessible, hormonal treatment is a common first step to control bleeding. Other women may undergo specific, targeted procedures, such as removing a painful cyst or fibroid. Yet where distances to gynaecologists are long, funds are limited, and symptoms are unbearable, this calculation changes.

On the supply side, surgeons equipped to address women’s symptoms over time are more widely available than gynaecologists. Uterus removal can be a source of profits in the private sector, or a source of surgical skill-building for others.

For women, relief from longstanding pain can be an incentive to undergo a major procedure. The less invasive options available to urban women, such as hormones or incremental surgeries prevent hysterectomy—but require repeated trips to doctors, recurring costs and time, unlike a one-time surgery.

Then there are strongly held beliefs. No uterus means no more periods. Menstruation, especially heavy bleeding, interferes with manual labour, household responsibilities and day-to-day life, especially if menstrual blood is seen as taboo or polluting. Or, some believe that the womb is not really 'necessary' after it has performed its childbearing function.

On the supply side, surgeons are widely available compared to gynaecologists who are trained and equipped to address women’s symptoms over time.

No singular story explains early hysterectomy or its patterning across the country. As an editorial in the British Medical Journal reflected, “to study the indications for hysterectomy is to study the interface of medicine with society.” It is a complex combination of health systems, societal and economic factors which makes hysterectomy difficult to explain – and as a corollary, difficult to address head-on.

The recent guidelines are important steps for concerted action. Efforts with communities – doctors, women and support structures – will prove equally important in curtailing violations of women’s health security. Most importantly, women need alternative options to treat the symptoms that brought them to doctors in the first place. This challenge, offering non-invasive treatment that is widely available and accessible, is perhaps the most critical.

Punctuated health journeys

Hysterectomy amongst young women is a direct reflection of the nature of health services available to women. Advances in maternal health demonstrate that alternatives to hysterectomy are indeed possible. But only a small proportion of women have access to them.

With few exceptions, evidence and policy on women’s health are dominated by reproduction. Menstruation, contraception, pregnancy and childbirth are where health programmes for women begin and – to a large extent, end.

These interventions deserve great priority, especially in states struggling to reduce maternal deaths. Yet women outside of a narrow age group are left behind.

Menstrual health interventions focus on adolescent girls and sanitary napkins, not the excessive bleeding faced by many women in their 30s. Innovations in contraception aim to increase the time between births, but not the hormonal shifts later in life that contribute to gynaecological issues. Access to life-saving surgery for delivery – the caesarean section – continues to expand across the country (to the point of serious concerns regarding over-use). Yet there has not been similar expansion in non-invasive treatment for menstrual disorders.

Reproductive health services offer three surgical options to women in a short span of time. At childbirth, on average, one in five deliveries is by caesarean section. Like hysterectomy, this varies significantly with large pockets of problematically high rates. Eight states have districts where more than one in two births is by caesarean section. After childbirth, women typically focus on childcare and the next pregnancy.

Once families are complete, the next possible surgery is sterilisation. A little under 40 percent of women have undergone tubal ligation, which is by far the leading choice of contraception compared to non-surgical methods like pills or IUDs widely used in other countries. About a decade later, a sub-set of women loses her uterus through hysterectomy to treat gynaecological ailments, propelling them closer to menopause by their mid-30s.

Advances in maternal health demonstrate that alternatives to hysterectomy are indeed possible—but only a small proportion of women have access.

These patterns are not uniform. Some states have low rates of caesarean sections but high sterilisation numbers, or vice versa. Some are low on all fronts, suggesting that women who need surgical procedures cannot access them. In a handful of states, some women may undergo all three surgeries in a short span of time.

The variation can be explained: these procedures are conducted by different doctors, in public and private hospitals, and for different reasons. Caesarean sections and hysterectomy incur out-of-pocket costs, while sterilisation is largely conducted in the public sector.

In between these three surgical punctuation points, the health system recedes for most women. To illustrate, only 2% of women have had a cervical cancer screening test. Less than two in five seek care for symptoms of infections, such as discharge. And strikingly, we have no recent national data on the proportion of women in India who suffer from menstrual disorders.

Other research indicates that treatment is limited. Alongside tracking the use of surgery, the lack of options available to women is equally important. Some doctors argue that until viable alternatives are widely available, hysterectomy will continue to serve as an extreme replacement for basic, primary-level gynaecological care.

Women deserve an expanded lens

For women who do undergo hysterectomy, the financial costs can be tremendous, especially in the private sector.

Households may sell assets or incur debts to finance the procedure. Any major surgery carries risks of infection, as well as extended recovery time. We do not know enough in India, but studies from other parts of the world indicate that young women who remove their uterus or ovaries have a range of health complications as a result. Oestrogen, the hormone supplied by the ovaries, plays a critical role in women’s bodies. Women without a uterus, even if the ovaries are kept, start to experience declines in oestrogen, which in turn can lead to a range of issues linked to the heart and the musculoskeletal and nervous systems.

Recent, though not conclusive, national data from India’s ageing survey indicate that hysterectomy is associated with increased risk of hypertension, high cholesterol, diabetes, and bone and joint disease. Socially and mentally, women have reported a range of side effects, including depression, feeling socially ostracised, effects on sexuality and fatigue.

What happens to women post menopause in India is largely unknown and barely studied. We know even less about women who enter menopause a decade too early.

Menstruation, pregnancy, gynaecological morbidity and non-communicable diseases are all interconnected, and cannot be sliced into different phases of the womb’s functionality.

Via hysterectomy, we have seen a unique convergence of media, research, policy and legal interest in women’s health over the past decade. The narrow focus on one surgery has spurred action.

Yet to truly address the roots of unnecessary hysterectomy, women’s health requires a broader lens.

Women need options for gynaecological treatment beyond pregnancy; women require responsive health services through the life course. The reproductive life span, however punctuated by surgeries, is directly linked to women’s well-being for the rest of their lives. Menstruation, pregnancy, gynaecological morbidity and non-communicable diseases are all interconnected, and cannot be sliced into different phases of the womb’s functionality.

Seeing hysterectomy within the journey of women’s health will undoubtedly require a response beyond one surgery. It will mean meeting women’s changing needs through the life course.

Sapna Desai is a women’s health specialist based in New Delhi. She currently leads a three-state initiative to examine hysterectomy and its effects on women’s health.