There are fashions in medicine which determine which are the taboo subjects, those not to be talked about-and which are the acceptable illnesses and treatments - those everyone seems to be interested in and which can be discussed without undue embarrassment or anxiety on the part of the patient or her friends. Although c, the second most common operation performed on women in this country, definitely belongs to the second group, medical fashions have a way of changing.

There was a time, for example, when children's tonsils were removed routinely at the first sign of an inflamed or irritated throat; now attitudes have altered and tonsillectomy is far less commonly performed. A similar change may well be due in the fashion for hysterectomy.

This is not to suggest that all hysterectomies are unnecessary - there are many cases where surgical intervention is the only treatment-but there is growing concern about the degree of post-operative depression after hysterectomy and, consequently, a search for different approaches to conditions at present normally treated surgically.

Of the various reasons for performing a hysterectomy, the most common is the presence of fibroids (benign growths) in the uterus. These can be removed leaving the uterus intact, but if the patient is past child-bearing age or does not wish to have any more children they are more commonly treated by removing the whole uterus and, sometimes, the ovaries and Fallopian tubes as well. The advantage from the doctor's point of view is that hysterectomy is the more straightforward method of treatment; the advantage from the patient's that this once-and-for-all operation will rule out the possibility of recurrence, or, indeed, of any associated problem. Other reasons for removal of the uterus include suspected cancer and post-menopausal bleeding, both of which definitely call for surgical treatment, and the existence of prolapse (dropping of the uterus). The necessity of surgery varies with the degree of prolapse-in less severe cases, a repair operation can be carried out or a ring fitted in the vagina.

There is one rather more controversial condition for which treatment by hysterectomy is currently being called into question. This is menorrhagia, defined as heavy and irregular menstrual bleeding, and it is not uncommon. About seven per cent of women between the ages of fifteen and fifty are thought to consult their doctors with this problem at some time during their lives. On consultation, questions on the patient's general health and the frequency and severity of the bleeding are usually followed by an internal examination and cervical smear test in order to cheek for any organic cause, such as fibroids or cervical erosion (minor damage to the neck of the womb). Sometimes there will be no obvious physical cause. In this case, the doctor may try hormone treatment to regularise menstruation, or may suggest surgery. Some patients may first undergo a D & C (diletation and curettage) as part of a preliminary investigation and evaluation prior to surgery; others may have hysterectomy recommended to them as the initial treatment. The major reasons for advising hysterectomy are, first, that it may reveal some so far undetected problem and, secondly, that the removal of the uterus will also remove the primary symptom-namely excessive menstrual bleeding.

This approach of treating the symptoms rather than the person is a very limited one. Because of its association with sex and childbirth, any abnormality of the uterus - and particularly one which culminates in its removal-can be very traumatic. In addition, straightforward medical diagnosis of menorrhagia is extremely difficult. One recent study of women complaining of menorrhagia compared the actual amount of blood lost during menstruation with the women's own assessments and revealed that in many cases the perception of blood lost bore little relation to the actual amount of bleeding. The women who complained of excessive bleeding but were in fact within normal limits have their counterparts in women whose bleeding is well above average and yet consider their periods to be quite normal.

It is now well known and widely accepted that emotional and psychological factors, such as anxiety, stress and depression, can have a significant and measurable affect on physical health and this is particularly true of menorrhagia. A group of GPs in London pioneering a two-year study, in which the patients' emotional and psychological problems were considered along with their physical ones, has shown that in many cases the menorrhagia was associated with sexual problems and domestic conflicts and that detailed and sympathetic discussion between doctor and patient often resulted in an alleviation of the symptoms.

This is encouraging news-not only because it avoids an unnecessary operation but also because it may help to prevent the post-operative depression that can sometimes accompany hysterectomy.

Although there is still a certain amount of controversy within the medical world about the relationship between hysterectomy and depression, a number of authoritative studies have produced evidence of a link between the two. One recent investigation published in the British Journal of Psychiatry concluded that women who had experienced depression before the operation had a higher chance of developing depressive illness after it, while an earlier study, published in The Lancet, came to a similar conclusion and identified two further high-risk groups. These were women who had the operation before the age of forty and those whose hysterectomy subsequently revealed that there had been no abnormality in the uterus. This is particularly interesting in view of the finding on menorrhagia because it suggests that if those women whose menorrhagia is linked with depression and has no organic cause do actually undergo hysterectomy they will be especially likely to develop post-operative depression.

Although depression tends to be the major and most worrying component of what has been described as the post-hysterectomy syndrome, other symptoms that may occur after the operation include headaches (one survey found that twenty-one out of forty-seven hysterectomy patients complained of headaches compared with seven out of forty-nine in a control group) and hot flushes. These may occur even when the ovaries have not been removed.

There is always a danger that, when a doctor highlights the problems associated with a medical procedure, patients may become unduly alarmed about it even when it may be the most appropriate method of treatment-as hysterectomy usually is for fibroids and prolapse, for example. But it is also important that patients should realise that emotional and psychological factors do sometimes have a significant bearing on their perception of the problem, on the intensity of their symptoms and on their attitudes towards treatment both before and afterwards. Awareness of these factors should help everyone-not just women facing the prospect of hysterectomy to work together with their doctors to find the best and most acceptable solution to their problems.

"BECAUSE OF ITS ASSOCIATION WITH SEX AND CHILDBIRTH, ANY ABNORMALITY OF THE UTERUS - AND PARTICULARLY ONE WHICH CULMINATES IN ITS REMOVAL - CAN BE VERY TRAUMATIC . . ."