In years past, a woman's uterus was treated much like last year's dress - discarded once it was considered no longer useful for childbearing.

Hysterectomies, the surgical removal of the uterus or womb, were common in years past.About one-third of women in the United States have had a hysterectomy by age 60; their average age at the time of surgery is 43.

But attitudes - those of patients and doctors - are changing.

More informed women, previously fearful of questioning a physician's authority, are asking more questions and seeking greater sensitivity from doctors. Some are requesting second opinions.

"Utah doctors are performing fewer hysterectomies than they did five years ago, primarily because many women, especially those in their 40s, are today more apt to ask, `What other options do I have?' " said Dr. Vicki L. Macy, an obstetrician/gynecol-ogist in private practice in Salt Lake City.

Macy's motto: Preserve the uterus and ovaries whenever possible. Women have many options, a hysterectomy being only the final one.

Macy said women who have been advised to have the surgery should be given information about the cardiovascular, oncologic and sexual implications of a hysterectomy before deciding if the benefits outweigh the risks.

According to Macy, the legitimate medical reasons for hysterectomy are:

- Severe endometriosis resulting in excruciating pain or bleeding.

- Leiomyomas or fibroids (tumors made of muscle and fibrous tissue) of the uterus with increasing size or bleeding.

- Unusual bleeding that is hormone-related.

- Early malignant cancerous changes or changes that may lead to cancer of the uterus or cervix.

- Pelvic relaxation, or sagging and/or protruding of the pelvic organs. This results when the muscles and ligaments that support the organs become weakened by repeated stretching during childbirth.

While these can be valid reasons for a hysterectomy, Macy says each needs to be considered on a case-by-case basis.

If fibroid tumors are small, asymptomatic and not growing rapidly, they can be checked at 3- or 6-month intervals. Larger fibroids can be treated by a new medication, Lupron, which shrinks and lessens blood supply to tumors.

"This medication can be used for three months prior to removal of the fibroids in a surgery called a myomectomy that leaves the uterus in place," Macy said. "This is generally recommended for young women who wish to preserve child bearing capacity."

The specialist said a woman with unusual bleeding should have tests to confirm the bleeding is not from precancerous or cancerous conditions. Then she would be a candidate for hormone therapy to control the bleeding.

The symptoms of pelvic relaxation often advance with age. The best option for advanced forms of the condition is surgery.

Early endometriosis can be treated with hormones, lasers or conservative surgery. Again, hysterectomy is the last resort, according to Macy.

Early precancerous changes of the lining of the uterus can be treated in some cases with intensive hormone therapy. In other cases, surgery is truly the best option.

Because of the risks associated with hysterectomy _ including death, pain and expense _ Macy stressed it shouldn't be the first choice.

A recent study, she said, has also shown an increased rate of cardiovascular disease in premenopausal women who have had a hysterectomy, even when one or both ovaries are preserved.

"We don't even know what the cause of that is yet and it needs to be collaborated with other studies," she said. But some researchers say it indicates a possible hormonal function of the uterus.

Women, Macy said, also need to realize that rare post-surgical adhesions can cause pain and discomfort and can diminish sexual response.

Another controversy surrounding hysterectomies is whether to remove healthy ovaries at the time of hysterectomy to prevent ovarian cancer. The cancer, which occurs in about 1 percent of women, has a low survival rate because it is difficult to detect in its early stages by pelvic exam.

"Gynecological oncologists typically say that any woman over age 40 needs to have her ovaries taken out because there is a possibility of cancer. Until 5 to 7 years ago, that was the dogma," Macy said. "Now hopefully that's changing so the decision can be made on an individual basis, taking into account all factors including the woman's preference.

"Women should be aware that when ovaries are preserved, about 5 to 10 percent of the time they will need to be removed later for a variety of reasons."

But Macy said ovaries produce some substances that are beneficial to a woman's body even after the onset of menopause.

"Women need to prepare themselves emotionally and intellectually for a hysterectomy. If this step is neglected, their personal sexual image may suffer or they may experience some post-surgical depression," she said.

Macy advises seeking a second opinion if a woman has questions. "Realize that the decision for surgery must be based on each individual case, considering all factors germane to that particular case."