The decision to have a hysterectomy is never an easy one. Healthy reproductive organs are central to a female's womanhood beginning with her first period at puberty, through pregnancy and childbirth, and ending with menopause. Yet, it is the second most common surgery performed on reproductive-aged women after delivery by cesarean section. More than a half a million of these surgeries are performed in the US every year, which begs the question - how could they all be necessary?
The (In)Dispensable Uterus
There was a time when doctors didn't think much about removing a woman's uterus, fallopian tubes, ovaries, cervix and parts of the vagina, particularly if a woman had already produced children or was beyond childbearing age. Hysterectomies were standard treatments for everything from anxiety (known back then as hysteria) to abnormal bleeding.
We now know that making the decision to have a hysterectomy should never be taken lightly. It not only closes the door to childbirth, it has other potential repercussions, beyond the risks posed by any surgery - bleeding, infection, reactions to anesthesia and injury to nearby organs, nerves and tissue. A hysterectomy can also cause the vaginal dryness, mood swings and hot flashes of menopause if the ovaries are also removed; impact sexual pleasure, particularly uterine orgasm; produce bladder and intestinal changes; and provoke emotional distress and depression.
A hysterectomy may be the only choice if a woman has cancer of the uterus, ovary, cervix, or endometrium. But most hysterectomies are performed for non-cancerous conditions - such as fibroids, endometriosis, and uterine prolapse. Up to 80% of women have fibroids by the time they reach age 40. Fibroids can prevent a pregnancy from taking hold, and cause enough bleeding to cause severe blood loss and anemia. While most are less then a few centimeters in diameter, they can also grow to a size of a grapefruit that can elbow organs in the abdomen to cause urinary frequency and changes in bowel habits.
While hysterectomy can alleviate the pain, pressure and bleeding caused by conditions of the uterus, and many women are pleased with the result afterwards, the pros and cons of surgery must always be carefully weighed. And there are many cases when surgery might be completely unnecessary.
So how should women and their doctors decide? It is a complex judgment call. Much will depend on why a hysterectomy is being considered, the type of hysterectomy offered, a woman's goal for treatment and her willingness to tolerate side effects or symptoms. It may also depend on where you live, as doctors practicing in certain geographical regions are more hysterectomy-centric.
Considering Hysterectomy Carefully
The uterus is pear-shaped organ nestled in the pelvis flanked by 2 fallopian tubes and ovaries. It is the focus of the reproductive system. During fertile reproductive years every month the lining engorges with a nutritious blood supply with the expectation of receiving and implanting a fertilized egg. If that doesn't occur, it sheds the lining during menstruation and repeats the process as long as the necessary hormones are adequate. If all the hormones are aligned and the attachment surface is a good one, a pregnancy can occur. The uterus grows to accommodate the fetus and placenta and contracts during labor of childbirth.
Occasionally, something happens that changes the integrity of this hardy muscular organ that causes everything from annoying abdominal cramps to more serious symptoms such as severe pelvic pain, bleeding, pregnancy loss, or bladder and gastrointestinal symptoms.
Conditions affecting the uterus include
- Cancer - endometrial, uterine, ovarian, cervical or vaginal cancer
- Fibroids or polyps (fibromyomas, leiomyomas or myomas) - one or many benign growths ranging in size that sit in or outside of the uterus
- Endometriosis - when endometrial tissue grows on the outside of the uterus
- Prolapsed uterus - when ligaments holding the uterus fail and it slips out of the vagina
- Adenomyosis - when endometrial tissue lining the uterus grows into the muscle wall
- Endometrial hyperplasia - abnormal thickening of the endometrial lining
- Chronic pelvic pain - sometimes no cause can be found
- Dysfunctional uterine bleeding (DUB) - excessive or irregular bleeding
- Uncontrolled bleeding after childbirth or uterine surgery
If your doctor proposes hysterectomy there are a few questions you should ask.
- Why are you recommending hysterectomy?
- What type of hysterectomy do you propose and why?
- Partial - removal of the uterus keeping the cervix
- Total - the entire uterus and cervix
- Radical - removal of uterus, cervix, ovaries and fallopian tubes
- Abdominal hysterectomy - removal of the uterus through an incision on the lower abdomen
- Vaginal hysterectomy - removal of the uterus through the vagina
- Laparoscopic hysterectomy (keyhole surgery) - the uterus is visualized using a flexible lighted microscope (laparoscope) threaded through the belly button while other instruments inserted into a few small incisions removes the uterus
- What are the pros and cons of the type of hysterectomy you want to perform?
- Are there any alternatives to hysterectomy?
- Is watchful waiting an option (fibroids will shrink during menopause)?
A second opinion is a good idea, particularly whenever surgery that cannot be reversed is recommended. And being an informed patient can help you to avoid unnecessary surgery.
It may not be essential to surrender to hysterectomy after all.
Taking the Alternative Route
Hysterectomy rates in the US have been steadily declining partly because there are more alternatives to surgery available that keep reproductive organs intact. Still, some doctors are not yet convinced that these uterus-sparing treatments work well enough to trump traditional removal, while others don't have the clinical expertise or experience to perform newer techniques.
Not all techniques work on every condition and not every woman is a good candidate. And while a newer technique preserves the uterus, it may still affect a woman's ability to achieve pregnancy in the future.
Here are some alternative techniques to consider in lieu of hysterectomy.
- Radiofrequency ablation - This technique delivers intense heat to destroy thickened or abnormal tissue inside the uterus. An electrode inserted into fibroid tumors or thickened areas melts tissue away.
- High-frequency ultrasound - This method uses high-frequency ultrasound to destroy small fibroid tumors.
- Myomectomy - A surgical procedure used to treat uterine fibroids. The uterus remains intact and only the fibroids are removed.
- Intrauterine device (IUD) - Inserting an IUD within the uterus (similar to the birth-control device) laced with the hormone progesterone can reduce endometrial wall thickening and control excessive menstrual bleeding.
- Loop electrosurgical excision procedure (LEEP) - A conservative procedure that preserves the uterus while removing abnormal cells in women with cervical cancer.
- Hormonal therapy - Hormone pills, similar to birth control pills, or hormone injections can reduce pain, and excessive or irregular bleeding.
- Anti-estrogen therapy - Hormone blockers given until natural menopause occurs can keep ovaries from producing estrogen, which can shrink fibroids.
- Uterine artery embolization (UAE) - Usually performed by an interventional radiologist, this procedure cuts off the blood supply feeding fibroids. A catheter is threaded through a blood vessel in the groin to the area of the uterus. Eventually tissue fed by the zapped blood vessel dies and is reabsorbed.
- Dilatation and vaginal curettage (D&C) - A procedure that resurfaces the uterine lining and may help to control excessive bleeding temporarily.
- Pain Medications - Some non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, not only reduce painful cramps but can calm heavy bleeding.
- Herbal and dietary supplements - Certain dietary supplements and teas may help relieve menstrual cramps and regulate blood flow. Cramp bark, derived from the viburnum plant can quell cramping; valerian root has a sedating effect that can relax the uterus; pycnogenol can reduce swelling and pain; and red raspberry leaf tea (rubus) can help keep the uterus muscle toned.