Uterus (womb) as an organ is pivotal not only to giving birth, but also to the overall well-being of women and their physical, emotional, and sexual health.

1.  Chairperson Elect ICOG –Indian College of OB/GY
 National Corresponding Editor-Journal of OB/GY of India JOGI
 National Corresponding Secretary Association of Medical Women, India
 Founder Patron & President –ISOPARB Vidarbha Chapter 2019-21
 Chairperson-IMS Education Committee 2021-23
 President-Association of Medical Women, Nagpur AMWN 2021-24
 Nagpur Ratan Award @ hands of Union Minister Shri Nitinji Gadkari
 Received Bharat excellence Award for women’s health
 Received Mehroo Dara Hansotia Best Committee Award for her work as
Chairperson HIV/AIDS Committee, FOGSI 2007-2009
 Received appreciation letter from Maharashtra Government for her work in the
field of SAVE THE GIRL CHILD
 Senior Vice President FOGSI 2012
 President Menopause Society, Nagpur 2016-18
 President Nagpur OB/GY Society 2005-06
 Delivered 11 orations and 450 guest lectures
 Publications-Thirty National & Eleven International
 Sensitized 2 lakh boys and girls on adolescent health issues
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra

2. SAVE THE UTERUS
Dr Laxmi Shrikhande

5. Saving the uterus: why it is need of the hour in India
• Uterus (womb) as an organ is pivotal not only to giving birth, but also
to the overall well-being of women and their physical, emotional, and
sexual health.

6. Most common indications for hysterectomy
Is the most common surgery in women after caesarean delivery in India
The most common indications for hysterectomy in India are -
 Fibroids (45%),
 HMB (31%),
 Cervical dysplasia (3%),
 Pelvic inflammatory Disease, and
 Endometrial hyperplasia
 Prolapsed uterus and cervical cancer are other conditions that may
necessitate hysterectomy.

8. Study published on 02-Aug-2019
The findings of this study reveal that six in every 100 women aged
30–49 have had a hysterectomy in India.
The prevalence is about 11 per 100 women in the age group 45–49
years.

9. UP, Telangana, Bihar

10. Road Map in India
 Women, mostly from poor socio-economic backgrounds, are often
coaxed into hysterectomy with the fear of cancer.
 In many instances, it is inappropriately recommended as the first line
of treatment for minor gynaecological issues that may not directly be
related to the uterus, such as lower abdominal pain, back ache or
white discharge.
 Early marriage, closely spaced childbearing and early hysterectomy is
a road map followed by many Indian women during their
reproductive years.

11. Infamous case-36% of Beed
 Rural women lack access to proper medical advice
around menstruation and are often restricted to
manual labour on farms.
 These are often controlled by unscrupulous
contractors who place a huge strain on these
women’s bodies through hard labour, leading to
health problems.
 Local doctors recommend hysterectomy to alleviate
many of these conditions even in young women,
when alternative therapies could have saved the
uterus.

12. Hysterectomy is not without its side effects
• Hysterectomised women see their ovarian reserve go down, which in
turn causes skin dryness and decreased sexual desire.

13. Hysterectomy is not without its side effects
 The surgery is often accompanied by removal of ovaries to reduce the
risk of ovarian cancer.
 There may be vaginal burning, increased urinary frequency and early
onset of menopause.
 Women who have undergone hysterectomy tend to have increased
incidence of heart disease and may also show symptoms of
osteoporosis at an early age.

15. Ways to save uterus
 In recent years, the Western world has seen a reduction in the
number of hysterectomies, with healthcare practitioners actively
favouring more conservative approaches.
 Many alternative methods of treatment to hysterectomy today
exist, including oral remedies, hormonal injections for excessive
menstrual bleeding, and removal of just the fibroid and not the
entire uterus.
 Indian women, especially those living in small towns and villages,
have poor knowledge of their reproductive health.

16. Need of the hour
Public health initiatives should create this awareness through people-
to-people contact and mass media.
Regular cervical cancer screening will also help reduce the incidence
of hysterectomy.
There is a dire need of counselling services for women regarding their
reproductive health, the importance of uterus and the medical
conditions that necessitate hysterectomy.
With the advances in medical science, hysterectomy should be the
last resort for a woman, not the first.

17. FIGO Classification system (PALM-COEIN)

18. Treatment of AUB of Nonstructural Cause (COEIN)
Hormonal
 Cyclic or continuous oral progestogen
 Combined estrogen and progestogen
 Injectable progestogen
 LNG-IUS
 Other options
Non-hormonal
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Antifibrinolytics
• Purified Diosmin: Bioflavonoids
• Ormeloxifene

19. Treatment of AUB of Nonstructural Cause (COEIN)
Medical management should be the initial treatment for most patients, if
clinically appropriat e.g. IV conjugated equine estrogen, multi-dose
regimens of OCs or oral progestins, and tranexamic acid
Need for surgical treatment is based on the clinical stability of the patient,
the severity of bleeding, contraindications to medical management, the
patient’s lack of response to medical management, and the underlying
medical condition of the patient
Choice of surgical modality should be based on the aforementioned factors
plus the patient’s desire for future fertility

20. Inadequate Evaluation and fair trial to medical
management Hysterectomy

21. Treatment of AUB of Structural Cause (PALM)

22. Polyp
Hysteroscopic polypectomy is an effective and safe
option for the diagnosis and treatment, with rapid
recovery and early return to activities
Small polyps (<0.5 cm)
Can be removed in the ambulator
setting using 5-Fr mechanical
instruments (sharp scissors and/or
grasping forceps) primarily for cost
reasons.
Larger polyps (>0.5 cm) can be
removed en bloc (by resection of the
base of the implantation injury with a
monopolar or bipolar electrode) or,
alternatively, sectioned into fragments
Clin Obstet Gynaecol 2015;29(07):908–919

23. Adenomyosis
• Studies show that symptoms can be
controlled with suppressive therapies similar
to those used for AUB without structural
change, such as combined contraceptives &
progestogens
Gynecol Endocrinol 2016;32(09):696–700

24. Leiomyoma
 Pharmacological treatment can be used in the presence of symptoms
 Surgical approach should be considered if there is no response to the
medical treatment
 Surgical approach will depend on the number, location, and size of
the leiomyoma, as well as on the future desire for conception

26. Indications of Endometrial Sampling
 AUB: >40 years
 Peri menopausal
- Clinical history not suggestive but ET>12mm
- Clinical history suggestive of unopposed estrogen exposure
even when ET 5-12 mm ( RCOG 1999: COG 2005 )
 AUB: >35 years (ACOG 2004)

27. Endometrial Hyperplasia without Atypia

28. Risk of Ca Endometrium
 The cumulative 20-year progression risk among women with endometrial
hyperplasia without atypia is less than 5%. Most cases will regress.
 Women should be informed that treatment with progestogen has a higher
regression rate than observation alone.
 The regression rate ranges from 74.2% to 81% for observation alone
compared with 89% to 96% for progestogen treatment.
 Importantly, reversible risk factors, such as obesity &HRT, should be
identified and corrected if possible.
Lacey JV Jr, Sherman ME, Rush BB, et al. Absolute risk of endometrial carcinoma during 20-year follow-up among women with endometrial hyperplasia.
J Clin Oncol 2010; 28:788-92.
Terakawa N, Kigawa J, Taketani Y, et al. The behavior ofendometrial hyperplasia: a prospective study. Endometrial Hyperplasia Study Group.
J Obstet Gynaecol Res 1997; 23:223-30.
Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral progestogens vs levonorgestrel-releasing intrauterine system for
endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2010; 203:547.e1-10.

30. Surgical treatment
 In view of the high regression rate with progestogen, hysterectomy is not
offered as the first-line treatment.
 It is only indicated in those who show
 no regression after 12 months of treatment,
 who progress to atypical hyperplasia,
 relapse after treatment completion, or
 have persistent abnormal bleeding, and
 those who decline to comply with treatment and surveillance.

31. Surveillance
 According to the RCOG/BSGE guidelines, endometrial surveillance
for endometrial hyperplasia without atypia should be performed
every 6 months.
 In women at higher risk of relapse such as those with body mass
index of ≥35 kg/m2 or those who are treated with oral
progestogens, long-term follow-up with annual endometrial
sampling is required after two consecutive negative endometrial
biopsies.

32. Endometrial Hyperplasia with Atypia

33. Atypical Hyperplasia
 The risk of progression to malignancy is 30% with a risk of concomitant cancer
(40-50%) for atypical hyperplasia.
 Thus, total hysterectomy is offered as the first-line treatment.
 If hysterectomy is to be performed in postmenopausal women, total
hysterectomy with bilateral salpingo-oophorectomy is recommended, whereas
for premenopausal women, total hysterectomy with bilateral salpingectomy is
recommended.
 The decision to perform bilateral salpingo-oophorectomy should be taken on an
individual basis in pre menopausal women.
Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients.
Cancer 1985; 56:403-12.
Palmer JE, Perunovic B, Tidy JA. Endometrial hyperplasia. Obstet Gynecol 2008; 10:211-6.

35. Patient education
 Patients need to be educated that most often chronic therapy is
mandatory to prevent further episodes.
 Reassure patients that most bleeding stops with the appropriate
hormonal therapy.
 Explain the physiologic reason for the anovulatory bleeding
pattern.

36. Patient education
 Perhaps the best measure of successful treatment is a good
menstrual calendar. Encourage patients to keep a calendar to
record daily bleeding patterns.
 This will serve to document severity of blood loss and impact on
daily activities.

37. Take Home Message
Uterus is not a vestigial organ once family is complete
Removing uterus should be last option and not the first one
Hysterectomy on demand should not be entertained
Do evidenced based counselling-don’t create phobia for uterine
cancer
Decision to do hysterectomy is in the domain of gynaecologist and
not the surgeons

39. The more you give, the more you
will get.
Then life will become a sheer dance
of love.
H. H. Sri. Sri. Ravishankar
The Art of Living
Thank you