A WOMB OF ONE'S OWN

Caroline Richmond denounces the doctors

who perform hysterectomies on women without asking their permission

LAST MONTH, Mr Reginald Dixon, a consultant gynaecologist at Kingsmill Hos- pital in Nottinghamshire, was committed for trial on a charge of procuring an abor- tion. The woman concerned, 35-year-old Barbara Whiten, claims she had been told that she was infertile and was unaware of her pregnancy when she consented to a hysterectomy. She subsequently went to the police. More than that I cannot say because the matter is sub judice.

But I can say that Mrs Whiten is one of several women who have recently com- plained to the police about 'routine' gynae- cological treatment. Winnie Sowerby, a Yorkshire lady of 75, complained to Wake- field police after she awoke from an anaes- thetic to discover that her womb had been removed. She had gone in as a day patient to have a pessary, inserted to correct a pro- lapse, checked. The police asked her to come back to them when the 'Richmond case' had been decided. The case in ques- tion was me.

I had gone into St Thomas's Hospital for a new operation called endometrial resec- tion. It consists of removing, through the cervix, the cells that line the womb and bleed during heavy menstruation. Per- formed with either a laser or a cautery, it cures heavy periods. The success rate varies with the skill of the operator, and St Thomas's has a surgeon, Oliver Chapatte, who is said to be particularly competent at it. I was counselled at St Thomas's that they have an 80-90 per cent success rate; the remaining patients report no benefit. There is risk of perforating the womb. This can usually be repaired but, at worst, might need emergency removal. The registrar and senior registrar both warned me of this, adding that it had never happened at St Thomas's. I was carefully assessed, includ- ing having a biopsy taken, to exclude the possibility of cancer. They noted that I had a bulky womb, but said this is common in women over 40.

On 26 April 1992, the eve of the opera- tion, I went into St Thomas's. I signed a consent form for endometrial resection. In fact the operation was not to be performed by Mr Chapatte but by the consultant, the society gynaecologist Ian Fergusson. I met him briefly on the ward round before the operation. He told a medical student that I was a suitable candidate for endometrial resection and pointed out that I was still, at 51, producing eggs. In the event, by his own admission, he did not attempt the endome- trial resection.

I came round to find myself in unexpect- ed pain, with a bandage across my abdomen; later, a house surgeon told me brusquely that Mr Fergusson had 'given' me a hysterectomy because 'it was the best thing for me'. I spent the night racked with grief and anger. Next morning Mr Fergus- son was elsewhere. The ward round was taken by the registrar, who divested himself of his retinue of students before telling me that I had also been castrated.

Later that morning Mr Fergusson arrived, smiling benignly, and said that on examining me he had felt a lump that, as it was not recorded in my notes, could have been a new, aggressive tumour, so he had cut my abdomen open. He then saw I had fibroids and removed my womb; he removed my ovaries to save me the possi- bility of cancer. But the pathology report showed that there were no fibroids, only a different and equally benign condition called adenomyosis.

After Mr Fergusson finished talking I dis- charged myself, fearful of what they might do next. Two weeks later, on the separate advice of two doctor friends, I reported the matter to the police as an assault. They car- ried out an extensive investigation, taking over 20 statements and later arresting Mr Fergusson. The Director of Public Prosecu- tions eventually decided not to bring charges on the ground that there was insuf- ficient evidence to secure a conviction.

The DPP made a similar decision in the case of Vanessa King, who went into the Luton and Dunstable Hospital to have her womb and one ovary removed. Since she had one healthy ovary and wanted to keep it, Mrs King endorsed her consent form with the words 'do not remove left ovary'. Nathaniel Adu, the locum consultant gynaecologist who operated on her, did remove it. The police investigated but no charges were brought. Mr Adu is due to explain his behaviour to the General Med- ical Council this autumn. He has said he removed the ovary because of possible cancer risks.

In a few months, John Studd, a consul- tant gynaecologist with a large private prac- tice, is due to appear in the High Court, where he is being sued by Mrs Jacquie Bartley for removing her ovaries without consent. Mrs Bartley had undergone a hys- terectomy and claims she did not know that her ovaries had been taken out until she received Mr Studd's bill. Removing ovaries brings on a sudden surgical menopause and increases the rate of developing heart dis- ease and osteoporosis (brittle-bone dis- ease). Mr Studd is defending the action and is understood to have an independent opinion backing his judgment.

In my case, St Thomas's have said noth- ing that might be to the discredit of one of their consultants. Instead they have tried to • discredit me by telling a major newspaper journalist that I was a dubious character and that investigation of my background would yield some interesting information.

A fortnight after my operation, about the same time as I went to the police, St Thomas's pulled off a public relations coup that backfired on them. A whole page fea- ture ('Every mother's hero') in the Daily Mail described their fund-raising appeal for premature babies and their wonderful gynaecologist Ian Fergusson, 'friend of the Duchess of York'. As a result, the CID, who were investigating my complaint, told the police protection squad responsible for looking after the Duchess of York that Fer- gusson was under investigation.

The story then got on to the front page of the Independent on Sunday one day in 1992. And, before you open your wallet, please note that some of the money given to the St Thomas's Baby Fund has, in the past, been used to assess different forms of hormone therapy given to women who have undergone 'prophylactic' (unneces- sary) castration at the hospital. (The results of the research were published in the British Medical Journal in July 1992.) When asked about this, Helen Otten, a spokesperson for the fund, stressed that such a project was 'totally outside the cur- rent remit of the St Thomas's Baby Fund and certainly would not be approved now'.

The Guy's and St Thomas's Hospital Trust's own chairman, Tim Matthews, told the Press Association that an internal enquiry had been carried out into my case, and 'we believe that Mr Fergusson made the best clinical judgment. The hospital has always supported him and will contin- ue to do so.' Two years later, when I tried to get a copy of the investigation's report, I was assured by Helen Lawrence, assis- tant to Lord Hayhoe, chairman of the Trust, that no enquiry had taken place: 'As you will be aware, the hospital co-operat- ed fully with the police investigation into the allegation of assault and did not find it necessary to conduct a separate enquiry.' I asked my MP, David Mellor, if he could tease out this inconsistency. He wrote to Lord Hayhoe (`Dear Barney'), who replied (Tear David'): 'I can assure' you that there has been no "cover up".' Whenever an MP's letter is received in my office an acknowledgement is immediately sent to say that "an investigation is being held". Mrs Lawrence informs me that the "inves- tigation" on this occasion established that the allegations of assault, made to the police, were being looked into by them and in these circumstances it was agreed that further action within the hospital was inappropriate.' St Thomas's most recent statement, less than a month ago, is that they are adamant that its staff behaved quite properly and followed normal proce- dures. But if they have not held an enquiry, how can they be sure whether or not their staff behaved properly?

In my opinion, there should be an enquiry if there has not already been one, and its results should be made public.

I am considering bringing a private prosecution, and have received donations totalling £1,600 towards the cost, but could need up to £30,000. Even then I will be up against the wealth of the Medical Defence Union, who can afford to pay the most expensive and aggressive lawyers; and if I lost I might have to meet their costs, which would cost me my home. But whatever happens to me, there is a wider issue which needs addressing, and which is of importance to all women.

Surge9ns become surgeons because they like operating, but gynaecologists are now threatened with the loss of much of their surgical work. The mainstays are the oper- ations of hysterectomy and Oophorectomy, and dilation of the cervix and curettage of the womb lining — D & C for short. In 1992 an editorial in the British Medical Journal pointed out that the latter opera- tion, which is performed for painful or heavy menstruation, has no therapeutic value — and its diagnostic value, for find- ing abnormal cells in the womb lining, is inferior to hysteroscopy, where a cell sam- ple is taken in an outpatient clinic.

Hysterectomies, almost a routine opera- tion for women in middle life, are, in my view, rarely essential. Most gynaecological surgeons like performing hysterectomies, which is the only major operation in their repertoire, and in some districts perform a huge number — hence the fame of 'womb- less Woking'. Heavy bleeding can now be treated by a new procedure, endometrial ablation, where only the lining cells are destroyed; the procedure can be done as day surgery. Many women are opting for this, if given the chance. Health economists are pressing for fewer hysterectomies, as something like 50 per cent of all wombs removed are completely normal or have only minor problems such as small fibroids. Many operations•are performed on women approaching the menopause, when their fibroids would shrink naturally.

Many gynaecology departments cam- paign to have an extra consultant appointed to their department to ease the workload, but, when the new appointee arrives, the pace of work remains the same because more operations are performed — and the threshold for performing a hysterectomy gets even lower. Hysterectomy is also used as a would-be panacea for women who complain of aches and pains but have no demonstrable disease.

Gynaecology has evolved in the last decade, changing from being a purely sur- gical speciality to one that is increasingly medical. New drug treatments, often using sophisticated hormones and anti-hor- mones, offer non-surgical remedies for fibroids and for endometriosis, a condition in which womb-lining cells invade other parts of the abdomen, where they bleed. However, gynaecologists have been slow to take up these new non-surgical methods.

If gynaecologists are to perform fewer 'clearance' operations, how else can they use their time? They can learn more about, and make more use of, the new drugs that treat fibroids and endometriosis. They can do more conservative surgery, such as endometrial ablation and myomectomy (removal of fibroids but leaving the womb). They can reduce the fraught waiting times for terminatipn of pregnancy. And they can spend more time helping the infertile, who at present get a raw deal under the NHS.

My hysterectomy, performed on the NHS, probably cost around £1,600. It was one of over 70,000 NHS hysterectomies, most of which are inessential. The potential saving of money and human suffering are obvious. It's too late for me, however.

Caroline Richmond is European correspon- dent and a contributing editor to the Canadi- an Medical Association Journal.