In her case that meant not only losing her uterus, which is standard in all such operations, but also her ovaries.
Sundar, a housewife in the village of Parsapally, in the Medak district of the southern Indian state of Andhra Pradesh,was 29 at the time.
She soon discovered that after losing her ovaries she was contending with the effects of early menopause.
"Removal of ovaries is the biological equivalent of castration and results in the immediate and sudden onset of menopause, in contrast to natural menopause which is a gradual process," said Dr. S.V. Kameswari, a leading gynecologist in Andhra Pradesh, in a recent phone interview.
Women with premature menopause can suffer a steep loss of estrogen, which causes hormonal imbalances and increases the risks of depression, heart disease, osteoporosis, diabetes, hypertension and breast cancer.
Kameswari is also the director of the health services unit of a Hyderabad-based nongovernmental organization called Life-Health Reinforcement Group, which studied 171 women who had undergone a hysterectomy from a cluster of villages in one block of Medak district. Sundar was one of the participants.
Their 2011 study found that the average age of the women who had opted for a hysterectomy was 28.
In general, most Indian women stop menstruating and enter menopause between the ages of 45 and 55, according to Kameswari's study.
The proportion of women aged 30-49 who are menopausal in Andhra Pradesh is 31 percent, far above the national average of around 18 percent and the highest in India, according to the second National Family Health Survey, a government health survey published in 1998-1999.
Fertility Rate Push
Andhra Pradesh is the fifth most populous state in the country. The female literacy rate of 50 percent, according to the 2001 Census, is lower than the national average of 54 percent. Although its fertility rate (1.8) is lower than the national average of 2.4, the state is aiming to lower it even further to 1.5, according to health department reports.
As part of this goal, health advocates say the state's push for female sterilizations as a mean of family planning and fertility control has been an important contributor to the high rate of early menopause.
Eighty-two percent of the women who opted for hysterectomies had undergone a family planning operation prior to it, found a 2009 study by the Andhra Pradesh Mahila Samatha Society, an autonomous institution under the state government.
Dr. A. Padma, a member of the society who helped conduct the study, said in a phone interview that unhygienic conditions in government facilities where tubectomies were performed were one of the main reasons women were later assigned to hysterectomies.
"Our study showed that women suffered from abdominal pain and other gynecological ailments after tubectomies," Padma said. "Hysterectomies were recommended as the only way to rid these women of their complaints. Eighty percent of the women undergoing hysterectomies were between the ages of 20 and 40."
About 69 percent of 200 women who had undergone a hysterectomy between 2009-2011 in the state didn't even know whether their ovaries were removed or not, said Dr. Kiranmai Gottapu, who was working at the Alluri Sitaramaraju Academy of Medical Sciences, Andhra Pradesh, when her study was conducted.
"We found that when a hysterectomy was done before 40 years, women were at greater risk of premature menopause and its complications. Although many alternate options of medical management and conservative surgeries are available, hysterectomy is still commonly performed," she said in a phone interview.
Hysterectomies have been driven by sterilizations for a long time, said Dr. Veena Shatrugna, former president and now executive member of the Anveshi Research Center for Women's Studies, based in the state's capital city of Hyderabad.
Of the 65 percent of those in the state who used family planning measures, female sterilization was the top method, used by 60 percent of people, according to the latest district level health survey, 2007-2008. Male sterilization was a poor second at 3.9 percent.
Bodies Still Vulnerable
In the rush to meet family planning targets, Shatrugna said, women are often sterilized immediately after giving birth, when their bodies are still vulnerable.
"Medically speaking, operations like these are to be carried out when all her parameters are normal," she said. "But then family planning doesn't care about the health of women. It's all about cutting the tubes. So at the second level, when they have problems arising from side effects of sterilizations, doctors suggest women finish the problem by removing the uterus. So menopause also occurs at an early age."
The state's introduction in 2007 of an insurance program for families below the poverty line that compensated doctors for conducting hysterectomies appears to have intensified the problem among low-income marginalized women.
In 2011 the state government--after studies found that a majority of the surgeries conducted in private hospitals approved by the health department were unnecessary--revised its guidelines and banned participating private hospitals from conducting hysterectomies and claiming the insurance money.
But women are still being actively pushed towards unneeded hysterectomies, said Kameswari."There are not enough women doctors in rural medical facilities who can give proper advice," she said. "So, private rural medical practitioners in the villages take advantage of these women's ignorance and reluctance to access proper health services for reasons that include availability, distance, cost and quality."
She added that women who undergo early hysterectomies often have little or no education, don't understand the surgery or its side effects and are pushed toward it by gynecological complaints stemming from conditions such as early marriage, poor nutrition and spousal relations.
"Instead of treating these morbidities ethically, unscrupulous doctors recommend hysterectomy, which is unnecessary," said Kameswari. "They are rarely counseled about the consequences of the surgery . . . They don't know if their ovaries will also be removed along with the uterus, or that menopause will be an immediate consequence. We don't recommend the removal of ovaries as it increases the woman's overall risk of death by 40 percent."
Some husbands have also pushed wives to have a hysterectomy, said Kameswari. "They opine that women are susceptible to illness and it was better to opt for a 'permanent solution.' The only way to change their minds is greater gender sensitivity and awareness on this issue."
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