The Future of Hysterectomy

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Dr. Hugo Verhoeven:  “It’s April 19th and I’m reporting from the 9th Annual meeting of the International Society for Gynecologic Endoscopy at the Gold Coast in Queensland. My name is Hugo Verhoeven, I am a member of the Editorial Board of OBGYN.net, and I have the great honor of talking to Professor Carl Wood, Congress Chairman of this important meeting. The topic that I would like to discuss with you today, Professor Wood, is hysterectomy - are there any more indications today? My first question is about heavy bleeding in a young patient. The normal procedure until now was performing a D&C, doing another D&C, doing hormonal treatment, and if that didn’t work to perform a hysterectomy. It is my impression that hysterectomy will be the treatment of choice in the older patient who does not want to get pregnant but we’ve now learned at this meeting that there are alternatives for these patients. This alternative is called : ablation of the endometrium. What are the indications and the risks of this technique ?”

ProfessorCarl Wood:  “The curette has been proven ineffective as a treatment as a reduction in bleeding only occurs for one period and not subsequent to this. A curette can still be done as a diagnostic procedure to determine the cause of the heavy bleeding. Its use as a diagnostic procedure has been replaced to a large extent by endometrial sampling with a fine plastic tube passed inside the uterine cavity as an outpatient procedure. The cells from this procedure can assist in diagnosis of abnormalities. Vaginal ultrasound and hysteroscopy are the most useful procedures in making a diagnosis of the cause of the bleeding.
Endometrial resection (ablation) which removes the lining of the uterus is a day procedure with a much lower risk of complications and mortality than a hysterectomy. It has a success rate of 75-85% and can be repeated if the heavy bleeding recurs. The frequency of recurrent bleeding subsequent to initial success is 10-15% over 4 years. Women who have recurrence of the bleeding after an initial endometrial ablation may prefer to have a hysterectomy as this assures 100% success. Some women will prefer hysterectomy as an initial procedure instead of endometrial ablation accepting its increased costs, time in hospital and risks because they wish to be certain of cure, or they may have an increased risk of cancer of the uterus if they are markedly overweight, have a family history of uterine cancer, diabetes or polycystic ovaries.”

Dr. Hugo Verhoeven:  “What is the frequency of this procedure? How many women underwent hysterectomy, as we heard now, without any reason?”

ProfessorCarl Wood:  “One of the main reasons, I think, that it is not universally performed, is that, as I said, in the early days there was a bad experience because of the high failure rate. The operation got bad publicity, doctors lost interest in learning how to do it properly and, therefore, patients weren’t aware that there was another alternative to hysterectomy. Doctors, of course, are reluctant to recommend a procedure that they themselves are not proficient at and may be a source of lost revenue. They’re not going to be telling patients about a procedure that they can’t do and tell the patient this is the best thing for you. Over the years, most of the patients that I have operated on have in fact been referred from friends. For example," I had this operation and it’s wonderful; I was in hospital for six or eight hours, and I was back at work within two days". So it’s a word of mouth referral system as opposed to a general practitioner to consultant.”

Dr. Hugo Verhoeven:  “There’s a lot of educational work not only from the side of the patient but also for the doctors to do. So from the many different techniques there are available, what is your method of choice at this moment?”

ProfessorCarl Wood:  “Gynecologists may not consider all of the alternatives to surgery. There have been a large number of randomized controlled studies showing some drugs have been overlooked. Tranexamic acid, which is not a hormone, is well tolerated and more effective than any other drug except progesterone impregnated intrauterine device. It can be used long term for some years and the drug is given for the first few days of heavy bleeding each month. Progestogens are also popular for women with heavy bleeding but have often been used incorrectly only offering a drug for several days a week before the period. Properly controlled studies have clearly shown that used this way it is not very effective, or completely ineffective. However, this drug is effective if used for 20 days in a cyclical regime every month from day 5 to 25. The oral contraceptive pill also will reduce bleeding by 30-40%. A group of drugs called anti-prostaglandins, including Ponstan and Naprosyn will also result in a 30-40% reduction in bleeding. This is less effective than the average reduction of blood loss of tranexamic acid which is 60-70%. The gynecologist training often emphasizes surgical aspects of gynecology to the neglect of medical treatment. I only perform a hysterectomy for heavy periods or fibroids when simpler treatments are ineffective. Both drug therapy and endometrial ablation are my first treatments offered.

Another aspect of menorrhagia is that one third of women that complain of heavy periods have a measured loss which is normal. They may have difficulty controlling their bleeding because of lack of knowledge about how to use tampons, pads and other measures. After reassurance that they are not ill or anemic, they may be able to cope better and avoid surgical treatment. Another condition which is the second most common reason for hysterectomy in many countries is the presence of fibroids. The treatment of fibroids is changing considerably and in my own home city of Melbourne, I was surprised how many were being offered hysterectomies for fibroids when they didn’t need it. Because of this, we formed a clinic called the Melbourne Fibroid Clinic. In the first 200 women seen in 18 months, 105 had already been offered hysterectomy for the treatment of their fibroids. I gathered a group of specialists, two surgeons skilled in removing fibroids with laparoscopic surgery, including myomectomy, myolysis and laparoscopic uterine artery ligation, and two radiologists who perform uterine artery embolization. Their own previous experience was treating brain aneurysms. One lady also joined us who was an expert in the use of drugs to try and control the growth of fibroids which has been the basis of her Ph.D. The end result of treating the first 200 women was that only 20 ended up having a hysterectomy, so we have been able to save 150 women having a hysterectomy by offering satisfactory less extensive medical and surgical treatments.”

Dr. Hugo Verhoeven:  “That means 90%!”

ProfessorCarl Wood:  “The conservative procedures include a variety of ways of shrinking the fibroids. Uterine artery embolization involves injecting small particles into the blood vessels supplying the fibroids. The laparoscope is also used to ligate uterine artery or smaller blood vessels supplying the fibroid which shrinks them. Dr Golfarb pioneered a method of using an electrosurgical needle placed directly into the fibroids to coagulate them and subsequently shrink them. I found this most suitable for women in their forties as the large areas of scar tissue which may remain in the uterus may adversely affect fertility, or during a subsequent pregnancy increase the risk of uterine rupture. Removal of the fibroids, myomectomy, can often be done through the laparoscope except for very large fibroids where a longer incision in the abdomen may be necessary. This is particularly relevant to women wishing to have children as suturing a large hole in the uterus needs to be done to secure a strong incision which would allow expansion of the uterus during pregnancy and security of the uterus in labor.”

Dr. Hugo Verhoeven:  “Until now we did not talk at all about medication : medical treatment of fibroids. We learned that there are many possibilities. What is your medicament of choice at this moment for treating fibroids?”

ProfessorCarl Wood:  “Medicine can be used in two ways; either to shrink the fibroids before menopause as the fibroids will naturally shrink after menopause, which avoids surgery, or shrink the fibroids prior to surgery to make the surgery easier with less blood loss and possible conversion from a long incision to laparoscopic surgery. The drugs most commonly used are GnRH analogues that stop estrogen production from the ovary. Fibroid growth is dependent upon estrogen so the growth of the fibroid can be inhibited and allow shrinkage of the fibroid. They cannot be used for more than 6 months as there is some calcium loss from the bones during drug usage which is restricted to 6 months. Short term use may be convenient near the menopause. There is also some evidence that the oral contraceptive pill may reduce fibroid growth. Other drugs which are anti-estrogens have side effects so that prolonged use is not feasible. A new group of estrogens that occupy the chemical sites in the fibroid and prevent the natural estrogens produced by the women acting on the fibroid can result in slowing of the growth. Trials of these new drugs are now underway.”

Dr. Hugo Verhoeven:  “Is there a place for endometrial ablation in young women with heavy bleeding, fibroids and infertility ?”

ProfessorCarl Wood:  “I once removed a core of the endometrial lining in a women who had recurrent heavy bleeding with blood transfusions and failure to respond to drug therapy. She did become pregnant but had a premature birth at 24 weeks and the baby did not survive. No one else has attempted this procedure, but once the exact area required to maintain a healthy placenta and fetal growth is known, then a modified form of endometrial ablation may be achievable and consistent with a successful pregnancy.”

Dr. Hugo Verhoeven:  “So at this moment, everything should be tried to avoid surgery in young patients.” 

ProfessorCarl Wood:  “At this moment, I think you are right, surgery should be avoided. A doctor tried to remove a part of the top of the uterus to try to stop the bleeding but that was a disaster. She didn’t get pregnant because she got adhesions from the surgery, and so in younger woman we really have to keep them going as long as possible with medication, like GnRH-Analogues. You can for instance give to the patients three months treatment with Synarel or another GnRH-Analogue, then you interrupt the treatment for some six or nine months. I have a patient, who’s doing that each year, and we’re keeping a close eye on her. It seems to control the bleeding. An additional problem arises if the bleeding is caused by fibroids. Then medical treatment can be difficult. Only resection of the fibroid will be successful, as all other techniques could provoke formation of fibrotic tissue, being a reason for rupture of the uterus during pregnancy."

Dr. Hugo Verhoeven:  “So if we have a good alternative to hysterectomy for patients with heavy bleeding and for fibroids, why are so many women hysterectomized and what can we do to improve the frequency of non-hysterectomy treatment in these patients? It seems to me that this is a worldwide problem even in highly civilized countries like Australia, United States, and Europe. Why is that?”

ProfessorCarl Wood: “Highly civilized countries like Australia, the United States, and some European countries have higher hysterectomy rates than the poorer nations. There are several things we need to do, number one is to educate the patient. The second thing is to educate the gynecologists about the alternative methods. If they cannot perform these alternatives, we should persuade them to refer the patients to other centers. Financial aspects are important as a hysterectomy brings more money, a reason for advising the patient to accept this treatment. For many gynecologists, one of the reasons for performing hysterectomy is that are sure you have cured the patient, 100%. New techniques require more skill with a higher failure rate. At this present time we try to have better training programs for all gynecologists and once the senior gynecologists in the teaching hospitals in the private sector set the example, the others can no longer afford to do unnecessary hysterectomies. So educate the consumer, educate the gynecologist. We need, at least in the big cities, something like a fibroid clinic, where we have several experts. In these centers, all important information can be given to the patient. She can decide herself what she wants. It is not the doctor who says : you must have this kind of treatment or another. Patients can decide themselves. The majority of our patients do not want to have hysterectomy, they want alternative procedures, as I said before, at least 80 % of them."

Dr. Hugo Verhoeven: “Well, who prefers invasive and mutilating surgery if there are alternatives?”

ProfessorCarl Wood: “I certainly don’t.”

Dr. Hugo Verhoeven: “Thank you very much for this interview.”