HYSTERECTOMY RATE SPARKS A QUIET FURY.

Byline: Natalie Angier The New York Times

Hippocrates thought the uterus wandered and so drove women to hysteria, but in that belief he was the mad one. If anything, the womb is the body's Atlas, bearing the weight not only of the human future but of bitter social and medical disputes.

The abortion debate can be viewed as a question of who owns the womb - woman or embryo. The most common surgical procedure in the United States is the much-criticized Caesarean section. And the second most common operation is another, more radical storming of the uterus, the hysterectomy.

The debate over hysterectomies is one of quiet fury. Nobody bombs surgical suites in protest, but for years critics have assailed what they call the hysterectomy industry.

They have campaigned vigorously against the prevalence of the practice, appearing on television and writing articles and books with names like ``The Hysterectomy Hoax'' and ``No More Hysterectomies.''

They have complained that doctors are too quick to take out the uterus at the least sign of trouble, particularly with middle-aged women for whom the organ is supposedly past its purpose anyway. They have blamed greed by doctors and hospitals, pointing out that hysterectomies constitute a $3 billion-a-year business. They have accused surgeons of laziness, of liking hysterectomies because the procedure is relatively easy.

Each year, about 560,000 women in the United States undergo hysterectomies, a rate that is among the world's highest.

Now medical experts and women alike are struggling to understand why such a major operation continues to be almost routine. They say too many doctors cling to the hysterectomy as the first-line solution to any gynecological problem of middle-age patients and can be patronizing or dismissive when a woman asks about alternative treatments.

Medical monolith

In 1992, at the age of 45, Sandra Gandsman developed benign uterine growths called fibroids and started bleeding heavily. Seeking medical help, she encountered a medical monolith.

``I went to more gynecologists in the city of Philadelphia than most women see in a lifetime,'' Gandsman said. ``Every solitary one, and I mean without exception, wanted to do a hysterectomy. I couldn't find one who would talk about alternatives.''

Eventually, Gandsman, a health care marketing executive, found a doctor willing to simply remove the fibroids alone.

At the same time, some in the field insist that rather than being bamboozled or railroaded into having surgery they do not want, many women decide on a hysterectomy only after rejecting the alternatives and after seeing their symptoms become incapacitating.

``A number of recent studies of how women feel after hysterectomy have found that women are much more likely to find their life improved by hysterectomy than not,'' said Dr. Joanna M. Cain of the Pennsylvania State University Medical School in Hershey, Pa. ``We tend to look at this as an issue of there being too many unnecessary hysterectomies, but that may be in part because we don't validate the pain and suffering some of these women go through.''

Some experts predict that the number of hysterectomies will decline in the near future, perhaps dramatically, as baby boomer women pass the peak hysterectomy years of ages 40 to 50. Moreover, several new alternatives to hysterectomy are starting to gain attention in clinical trials. In addition, as managed care takes over the medical industry, hysterectomies may no longer be automatically covered, for they are often considered elective procedures.

A common procedure

Whatever happens tomorrow, hysterectomies are a staple of gynecological surgery. By the age of 60, one in three American women will have had her uterus removed. In Italy, by comparison, the figure is one in six women, while in France, it is only one in 18.

The reasons for having a hysterectomy vary widely and are accorded varying degrees of legitimacy. Few would argue against a hysterectomy in cases of cancer of the uterus, cervix or ovaries, but such instances account for only 10 percent of the total. The most frequent impetus for having a hysterectomy is the presence of fibroids, benign growths of the uterine muscle that, depending on their location, can cause considerable pain and bleeding.

Other common reasons are sustained heavy bleeding, hormonal imbalances, endometriosis - the abnormal and sometimes painful growth of uterine lining tissue outside the uterus - and pelvic discomfort that cannot be explained.

Critics of the widespread use of hysterectomies emphasize not only the dangers of major surgery, but the role of the uterus in a woman's lifelong physical, mental and sexual health. The womb, the shape and size of a small upside-down pear, has been regarded primarily as an incubator, a muscular and distensible baby sac that can become, in the words of one gynecologist, a ``nuisance'' after childbearing.

Yet some researchers insist that the uterus is an integral part of the body's endocrine system and that it continues to perform essential functions even after menopause. Not only does it respond to hormones - as everybody who has menstruated is well aware - it creates a few compounds of its own. Among these are beta-endorphins, the body's innate painkillers, and a type of prostaglandin called prostacyclin, which inhibits blood clotting. The loss of this source of prostacyclin could help explain why women who have had hysterectomies are prone to cardiovascular problems.

``There have been studies in the last couple of years showing that women can develop hypertension after a hysterectomy, even when their ovaries are preserved,'' said Dr. Herbert A. Goldfarb, director of gynecology at Montclair Community Hospital in New Jersey and author of ``The No-Hysterectomy Option'' (John Wiley), which is coming out in a new edition this spring.

Women need warning

Nora W. Coffey - director of Hysterectomy Education Resources and Services, a nonprofit counseling and information organization in Bala-Cynwyd, Pa., that she started after her own hysterectomy at age 36 - contends that the effects of a hysterectomy are profound and that women must be warned of them in detail before undergoing the operation.

``The most frequent problems that women report are loss of energy and stamina, loss of physical and sexual sensations, diminished maternal feelings,'' Coffey said.

There are consequences of the anatomical change as well. ``Without a uterus, you lose bladder support,'' she said. ``It's very common to have urinary problems like leakage and increased urinary frequency. And the bowel moves down to take up the place where the uterus has been, so over time it can become very difficult to have a bowel movement.''

Dr. Sam Kirschner, a psychologist in Philadelphia who has counseled many women with hysterectomies, said that some became depressed and lost their sexual appetite without realizing the surgery might have something to do with it. For a number of women, the rhythmic contractions of the uterus and cervix during orgasm are an important part of their pleasure, and the loss of that capacity can leave them with a sense of lessened sexuality.