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A Piece of My Mind
May 7, 2019

History Taking in the Anatomy Lab

Author Affiliations
  • 1Georgetown University School of Medicine, Washington, DC
JAMA. 2019;321(17):1669. doi:10.1001/jama.2019.4741

In medical terminology, the words history and physical almost always appear together in that order. As a physician, you do not engage a patient in the intimate pas de deux of a neurological examination until you’ve gathered the details of his or her debilitating headaches. You do not begin palpating the abdomen for some hidden point of tenderness until you’ve heard the details of the pain from start to finish.

But there is one time in our medical careers when we are instructed to perform the most thorough physical examination possible without learning so much as the patient’s name. We cannot ask her how many cigarettes she smoked per day; instead we can only look for discoloration and damage to her lungs and make assumptions. We note the absence of a uterus and wonder if a hysterectomy was performed after a harrowing birth or to prevent the spread of an insidious cancer weaving through her womb. All we are given is an anatomy table number, an age, and a cause of death. We work our way through the medical school rite of passage that is anatomy lab—inspecting, searching, and feeling every muscle, bone, and organ—and we write our patients’ histories ourselves.

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    2 Comments for this article
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    Absence of Uterus
    Diane Browning, BBA | Patient
    Regarding the statement "We note the absence of a uterus and wonder if a hysterectomy was performed after a harrowing birth or to prevent the spread of an insidious cancer weaving through her womb." Chances are much greater that it was neither since less than 8% of hysterectomies are done for a cancer diagnosis (1) and peripartum hysterectomy is rare. (2) Hence, ~90% of hysterectomies are "elective." 

    There would likely be far fewer hysterectomies if women were aware of the ensuing problems and increased health risks such as heart disease (3,4), metabolic morbidity (5), bladder (6,7) and bowel (8)
    problems, pelvic organ fistula (9,10), sexual dysfunction (from loss of uterine contractions and reduced sensation due to severed nerves and blood vessels), and some cancers (renal cell (11), rectal (12), thyroid (13,14). Impaired ovarian (endocrine) function (15) is also common which further increases risk of heart disease as well as many other problems. Despite the average woman’s 1.3% lifetime risk of ovarian cancer (SEER), the oophorectomy rate was 73% of the hysterectomy rate in 2006. (16) Removal of one or both ovaries, even after menopause, pre-disposes women to lifelong health problems (17,18,19,20,21,22). The ovaries produce health promoting hormones a woman's whole life if she is intact with testosterone levels increasing in the post-menopausal years. (23) Even hysterectomized women who still have their ovaries have significantly lower levels of testosterone than intact women. Exogenous hormones cannot replace those that the body produces on its own in just the right amounts and as needed. These risks are all poor trade-offs for a surgery that is rarely necessary. Yet, nearly 40% of U.S. women aged 45-54 reported having had a hysterectomy (24) and 45% end up having one. (25) 

    REFERENECE
    1 Stewart EA, Shuster LT, Rocca WA. Reassessing hysterectomy. Minn Med. 2012;95(3):36–39.
    2 Machado LS. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3(8):358–361. doi:10.4297/najms.2011.358
    3 Centerwall BS. Premenopausal hysterectomy and cardiovascular disease. Am J Obstet Gynecol. 1981 Jan;139(1):58-61.
    4 Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study. Menopause. 2018;25(5):483–492. doi:10.1097/GME.0000000000001043
    5 Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study.
    6 Brown JS1, Seeley DG, Fong J, Black DM, Ensrud KE, Grady D. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol. 1996 May;87(5 Pt 1):715-21.
    7 Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol. 2006;194(2):339–345. doi:10.1016/j.ajog.2005.07.051
    8 Forsgren C1, Zetterström J, Lopez A, Nordenstam J, Anzen B, Altman D. Effects of hysterectomy on bowel function: a three-year, prospective cohort study. Dis Colon Rectum. 2007 Aug;50(8):1139-45.
    9 Forsgren C1, Lundholm C, Johansson AL, Cnattingius S, Altman D. Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet Gynecol. 2009 Sep;114(3):594-9. doi: 10.1097/AOG.0b013e3181b2a1df.
    10 Altman D1, Forsgren C, Hjern F, Lundholm C, Cnattingius S, Johansson AL. Influence of hysterectomy on fistula formation in women with diverticulitis. Br J Surg. 2010 Feb;97(2):251-7. doi: 10.1002/bjs.6855.
    11 Altman D, Yin L, Johansson A, Lundholm C, Grönberg H. Risk of Renal Cell Carcinoma After Hysterectomy. Arch Intern Med. 2010;170(22):2011–2016. doi:10.1001/archinternmed.2010.425
    12 Luoto R1, Auvinen A, Pukkala E, Hakama M. Hysterectomy and subsequent risk of cancer. Int J Epidemiol. 1997 Jun;26(3):476-83.
    13 Luoto R1, Auvinen A, Pukkala E, Hakama M. Hysterectomy and subsequent risk of cancer.
    14 Luo J, Hendryx M, Manson JE, Liang X, Margolis KL. Hysterectomy, Oophorectomy, and Risk of Thyroid Cancer. J Clin Endocrinol Metab. 2016;101(10):3812–3819. doi:10.1210/jc.2016-2011
    15 Farquhar CM1, Sadler L, Harvey SA, Stewart AW. The association of hysterectomy and menopause: a prospective cohort study. BJOG. 2005 Jul;112(7):956-62.
    16 Stewart EA, Shuster LT, Rocca WA. Reassessing hysterectomy.
    17 Parker WH1, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol. 2005 Aug;106(2):219-26.
    18 Shoupe D1, Parker WH, Broder MS, Liu Z, Farquhar C, Berek JS. Elective oophorectomy for benign gynecological disorders. Menopause. 2007 May-Jun;14(3 Pt 2):580-5.
    19 Rocca WA, Gazzuola-Rocca L, Smith CY, et al. Accelerated Accumulation of Multimorbidity After Bilateral Oophorectomy: A Population-Based Cohort Study. Mayo Clin Proc. 2016;91(11):1577–1589. doi:10.1016/j.mayocp.2016.08.002
    20 Rocca WA1, Bower JH, Maraganore DM, Ahlskog JE, Grossardt BR, de Andrade M, Melton LJ 3rd. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007 Sep 11;69(11):1074-83. Epub 2007 Aug 29.
    21 Phung TK1, Waltoft BL, Laursen TM, Settnes A, Kessing LV, Mortensen PB, Waldemar G. Hysterectomy, oophorectomy and risk of dementia: a nationwide historical cohort study. Dement Geriatr Cogn Disord. 2010;30(1):43-50. doi: 10.1159/000314681. Epub 2010 Jul 30.
    22 Rocca WA1, Bower JH, Maraganore DM, Ahlskog JE, Grossardt BR, de Andrade M, Melton LJ 3rd. Increased risk of parkinsonism in women who underwent oophorectomy before menopause. Neurology. 2008 Jan 15;70(3):200-9. Epub 2007 Aug 29.
    23 Gail A. Laughlin, Elizabeth Barrett-Connor, Donna Kritz-Silverstein, Denise von Mühlen, Hysterectomy, Oophorectomy, and Endogenous Sex Hormone Levels in Older Women: The Rancho Bernardo Study, The Journal of Clinical Endocrinology & Metabolism, Volume 85, Issue 2, 1 February 2000, Pages 645–651, https://doi.org/10.1210/jcem.85.2.6405
    24 U.S. Department of Health and Human Services, Health Resources and Services Administration. Women’s Health USA 2008, Page 52
    25 Stewart EA, Shuster LT, Rocca WA. Reassessing hysterectomy.
    CONFLICT OF INTEREST: None Reported
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    BRILLIANT!
    Christine Wallace, RN, NPP | Retired
    Because I am donating my brain for ALZ research, and the remaining cadaver for use in an anatomy lab, I am thrilled to read this article! The Obituary Writing Program started by this author is enormously creative. And now the program has evolved for the students to learn about the people they'll be dissecting....makes me wonder why this hasn't been done sooner. Kudos to Bethany Kette.

    I have just read the comment by Diane Browning and feel obliged to comment. I, for one, had a radical hysterectomy as treatment for adenocarcinoma of the uterus, showing one
    should not assume anything. So, actually learning the cadaver's history, both medical and personal, seems a very useful learning tool.
    CONFLICT OF INTEREST: None Reported
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