Hysterectomy and Alternatives

Hysterectomy is the removal of the uterus. This can be done through either an abdominal or a vaginal incision, and either with or without removal of the ovaries. Almost 600,000 hysterectomies are performed each year in the U.S. This makes hysterectomy the second most common major surgical procedure performed in this country, with the first most common being cesarean section.

The uterus, or "womb", is a hollow, muscular organ located within a woman’s pelvis. During pregnancy the baby develops within the uterus, and at the delivery it is the contractions of the uterus that results in the birth of the baby. When a woman is not pregnant, the lining of the uterus is shed each month during her menstrual cycle.

There are many reasons why a woman might need a hysterectomy. As stated in Te Linde’s textbook of Operative Gynecology: "Without question, a properly indicated and properly performed hysterectomy can be of enormous benefit to properly informed patients with significant gynecologic symptoms or disease."

The most common indication for hysterectomy is fibroids. These are benign tumors that grow on or within the uterus. Most of the time no treatment is needed, but sometimes there is so much discomfort that surgery is required. Other reasons for hysterectomy include: endometriosis, prolapse (which occurs when the uterus "drops down" too far), cancer, and problems with heavy bleeding or pain.

For the most part hysterectomy is a safe procedure. Although as with any surgery there are risks involved. Risks can include blood loss, infection, allergic reaction, damage to the intestine or bladder, blood clots in the legs or lungs, and possibly even death (although this is very rare, happening in less than one out of every 1,000 surgeries). Although there is a low probability of any of these things occurring, it is good to know that alternative treatments are sometimes available.

In particular, when the reason for the hysterectomy is for problems with heavy bleeding, alternatives include treatment with hormones (such as progesterone) which can sometimes stop the bleeding. Also, a procedure called "endometrial ablation" is an option for some women. This can usually be done as an outpatient procedure, and it consists of using electricity to burn away the lining of the uterus. This is done using a hysteroscope, a telescope-like instrument that is placed through the natural opening in the cervix (the lower portion of the uterus), and no incisions are needed. Results are good, although some women will still need to proceed with hysterectomy at some point in the future.

Recently, a device called the "intrauterine thermal balloon" has been FDA approved for the treatment of irregular bleeding. The procedure consists of placing a plastic balloon into the uterus through the cervix. The balloon is then filled with sterile water and heated to very high temperatures which destroys the lining of the uterus. Preliminary studies suggest it may be as effective as endometrial ablation. The most attractive point of this procedure is that it can be performed in the doctors office. However, not many doctors have this device yet, and more experience treating patients in this fashion is probably needed before it can be widely recommended.

When the indication for hysterectomy is fibroid tumors, a procedure called "myomectomy" can be considered. With myomectomy, the tumors are removed while the uterus is left in place. Often this will require an abdominal incision, although sometimes the procedure can be accomplished with either laparoscopy ("belly-button surgery"), or hysteroscopy. Myomectomy is best suited for women who still desire to have children, however, be aware there is a risk that these tumors could grow back.

Hysterectomies have relieved suffering for millions of women. However, it is important for patients to realize that in some situations, there are alternatives. Discuss this with your gynecologist who will help you to decide which procedure is right for you.

References:

Bibliography

1. "Preliminary clinical experience with a thermal balloon endometrial ablation method to treat menorrhagia," A. Singer, et al, Obstetrics and Gynecology, 1994; 83:732-4.

2. Understanding Hysterectomy, ACOG Patient Education #AP008, May 1995.

3. Te Linde’s Operative Gynecology, Eighth Edition, Rock, J.R., and Thompson, J.D., Lippincott-Raven, Philadelphia, 1997.

4. Novak’s Gynecology, Twelfth Edition, Jonathan S. Berek, MD, Williams &Wilkins, Baltimore, 1996.