Alternatives to Hysterectomy
Despite a decades-old debate over its medical necessity, hysterectomy is still the most common non-obstetrical major surgery performed on women in the United States. By the time a woman reaches age 60, the chances are about 1 in 3 that she will have had her uterus removed, and possibly her ovaries as well, in order to remedy some gynecological condition, such as fibroids, uterine cancer, endometriosis, or troublesome uterine bleeding. The prevalence of the procedure has fallen about 20% in the last quarter century, thanks in part to the growing availability and awareness of alternative fibroid treatment options. However, the rate of hysterectomy varies by geographic region, as well as by a woman’s age, level of education, and insurance coverage. Nonetheless, studies suggest that when appropriate, hysterectomy can substantially improve a woman’s quality of life. Hysterectomy removes either the entire uterus (total, or simple, hysterectomy) or the uterus above the cervix (supracervical hysterectomy). Either type may include a salpingo-oophorectomy, meaning that the ovaries and fallopian tubes are removed as well. Any hysterectomy means the end of childbearing, and the removal of the ovaries and fallopian tubes causes the onset of menopause and loss of ovarian estrogen and androgen.
The long-term effects of ovary removal include an increased risk of osteoporosis and heart disease, hot flashes, vaginal dryness, decline in muscle mass, and decreased sexual desire. Some studies suggest that even when the ovaries are preserved, women who have had a hysterectomy may experience earlier menopause.
Before undergoing a hysterectomy, a woman needs to give considerable thought to its psychological as well as medical ramifications. What would the loss of the uterus or ovaries, or both, mean? Would an alternative treatment be better? For the most part, hysterectomy is necessary only for life-threatening conditions, such as cancer, uncontrollable bleeding, or an obstetrical emergency, or for severe uterine prolapse. In many other circumstances, hysterectomy is not the only option, nor should it necessarily be the first one considered.
THE MOST COMMON INDICATION:
Fibroids Benign tumors, or fibroids, are the reason for about one-third of all hysterectomies. Fibroids, also called leiomyomas or myomas, are rubbery nodules that begin as irregular cells in the muscular layers of the uterus. They develop slowly into bundles of smooth muscle and fibrous tissue that may grow to the size of a walnut or an orange. Fibroids affect 25% of women in their 30s and 40s, and they are diagnosed in African-American women two to three times more often than in Caucasian women. Although most fibroids cause no symptoms and require no treatment, some women with the condition experience excessive bleeding and discomfort in the pelvic area. When fibroids cause bleeding, they usually cause clots. The size and location of fibroids determine how much trouble they cause. Large fibroids can distend the abdomen and push against the bowel or bladder, causing constipation or frequent urination. A fibroid can interfere with pregnancy, or it may press against the pelvic nerves, causing chronic leg or pelvic pain. Most commonly, fibroids are responsible for menorrhagia, or heavy menstrual bleeding.
Although the ultimate cause of fibroids is not known, they are related to rising estrogen levels. For example, both pregnancy and hormone replacement therapy can spur fibroid growth. Fibroids are seldom found in young women who have not begun to menstruate, and they often shrink in postmenopausal women. Alterations in DNA may also have something to do with fibroid development.
Drug Therapy
Medical management is usually the first approach to fibroids. This may include nonsteroidal anti-inflammatory drugs (NSAIDs) or drugs such as birth control pills or progestins to manipulate hormone levels. One commonly used type of medication is a gonadotropin-releasing hormone (GnRH) agonist. Drugs like leuprolide (Lupron), goserelin (Zoladex), and nafarelin (Synarel) turn off estrogen and progesterone, shrinking fibroids, but also stopping menstruation and triggering menopausal symptoms. Because of their side effects, which include decreased bone density, GnRH agonists can be given for only a few months, and fibroids often return to their previous size. Long-term treatment with GnRH can also be expensive. This approach may be a good choice for women who are close to menopause and thus will need to use the drug for only a short while. GnRH agonists may also be prescribed to shrink fibroids before surgery (see sidebar below: “A Word About GnRH Agonists”).
Myomectomy
There are several approaches to the surgical fibroid removal. The standard procedure, which is performed under general anesthesia, involves removing each fibroid individually through an abdominal incision. A myomectomy to remove fibroids within the uterine cavity may be done through the vagina under local or general anesthesia, using a fiberoptic device called a hysteroscope. The hysteroscope enters the uterus through the cervix.
A myomectomy may also be done laparoscopically. A laparoscope is a device that allows the surgeon to view the patient’s pelvic organs. It is inserted into the abdomen through one of several small incisions, along with additional instruments needed to remove the fibroid(s) and repair the uterine wall. Myomectomy is the traditional treatment for women who want to preserve their fertility.
Laparoscopic myolysis
This procedure is similar to a laparoscopic myomectomy except that instead of removing the fibroid, the surgeon cauterizes it with a needle. Surgeons may use this technique when a fibroid is near a major blood vessel.
Uterine artery embolization (UAE)
This minimally invasive procedure has been used for more than two decades to treat postpartum and other traumatic pelvic bleeding but only recently for treating fibroids. This alternative fibroid treatment shrinks fibroids by cutting off their blood supply. The patient is put under mild sedation and local anesthesia, and the surgeon threads a catheter from the groin up into the uterine artery. X-rays are made while a contrast dye is injected, giving the surgeon a view of the blood vessels supplying fibroids and the uterus. An embolism agent (usually polyvinyl alcohol or FVA, particles) is then slowly pumped into the artery to block blood flow to the fibroid.
Short-term studies have found that fibroids treated by this method shrink an average of 48%-78%. Long-term controlled studies are needed to assess the procedure’s risks, its performance against other uterine conserving surgical approaches, its impact on fertility, and the long-term effects of FVA. For instance, in one center performing UAE, 15% of patients had to be re-hospitalized for “post-embolization syndrome” – fever, nausea, vomiting, and abdominal pain. Hysterectomy may be required in cases of severe post-embolization syndrome. Uterine Fibroid Embolization is not yet widely available and may not be covered by insurance.
Hysterectomy
Hysterectomy may be considered when fibroids are a source of pain, pressure, or bleeding so severe that they interfere with daily life or cause severe anemia. However, if you are told that you need a hysterectomy, you should get a second opinion (which, in any case, is often required for insurance coverage). There are many surgical options as well as varying degrees of invasiveness. Explore the possibilities thoroughly with your clinician or surgeon.
WHEN ENDOMETRIOSIS IS THE PROBLEM
Endometriosis
Endometriosis is a chronic condition in which bits of tissue from the uterine lining become displaced and implant themselves in the abdomen outside the uterus, causing inflammation, pelvic pain, severe menstrual cramps, pain during intercourse, infertility, and irregular bleeding. Endometrial tissue implanted outside the uterus responds to the menstrual cycle the same way the endometrium does: it breaks apart and bleeds at the end of the cycle. But outside the uterus, the blood has no outlet, so it causes swelling in the surrounding areas. The resulting inflammation can produce scar tissue.
Endometriosis is the second most common reason for a hysterectomy. In this case, the ovaries are almost always removed as well, to stop the production of estrogen. But there are many other options to try first.
Drug therapy
Pain from endometriosis may be relieved with medications such as ibuprofen (Motrin, Advil) or, for severe pain, codeine. Other drug treatment is aimed at disrupting hormones that govern the menstrual cycle and may be most effective when the tissue implants are small. Options include birth-control pills; progestins like Depo-Provera; danazol (Danocrine), a weak synthetic male hormone; and GnRH agonists.
Consentative surgery
Laparoscopic surgery, in which endometrial implants are cauterized or vaporized, is often effective, although endometriosis can recur. This treatment is indicated only if the surgeon can see the pelvic structures clearly through the laparoscope. Experimental procedures that disrupt pain signals between the sacral nerves and the brain are under study.
Hysterectomy
If the fibroid symptoms can’t be controlled with drugs or conservative measures, or when symptoms are caused by a related condition called adenomyosis (in which the endometrial tissue is embedded at several locations within the uterine wall), a hysterectomy may be advised.
OTHER CONDITIONS
Menorrhagia (heavy menstrual bleeding) that can’t be attributed to fibroids, endometriosis, or infection often occurs in women who are close to menopause or in younger women who have irregular periods. Menorrhagia is more annoying than it is painful, but it sometimes disrupts the quality of women’s lives enough for them to seek hysterectomies. Less invasive treatments are available and should be considered first. For some women, low-dose estrogen birth control pills or progestin-only agents offer considerable relief. At the one-year follow-up of a new study comparing a Ievonorgestrel-releasing intrauterine device to hysterectomy, researchers found that for menorrhagia, the IUD was just as effective and cost a lot less.
Enciomefrial ablation may also relieve heavy menstrual bleeding, but it stops menstruation and results in infertility, and it may have other long-term effects that are not yet known. Instruments inserted through the vagina and cervix into the uterine cavity use electrocauterization or laser energy to destroy the uterine lining, or endometrium. A technique recently approved by the Food and Drug Administration involves inserting a balloon into the uterus and filling it with a heated fluid to destroy the uterine lining. Two newer approaches are under study; one uses microwave energy and the other destroys tissue by treating it with a light-sensitive compound followed by photoactivation.
Some women undergo a hysterectomy because of uterine prolapse. The cumulative toll of age and childbearing may weaken the pelvic muscles and ligaments supporting the uterus, causing it to drop, press against the bladder, and even protrude into the vagina. If prolapse isn’t too advanced, Kegel exercises can help strengthen the pelvic muscles, or a pessary may be inserted to support the uterus (see KWHW March 2001, pp. 5-7). There are also surgical procedures less extensive than hysterectomy that tighten the supporting ligaments without removing the uterus. However, when prolapse is severe, a vaginal hysterectomy may be recommended (see HWHI/V November 2000, p. 8).
A Word About GnRH Agonists
GnRH agonists can shrink fibroids and reduce endometrial thickness. Speak with your clinician or surgeon about the advisability of taking a GnAH agonist before having a surgical procedure. A course of treatment for a few months might eliminate the need for hysterectomy for endometriosis, fibroids, or abnormal bleeding, or it might permit the use of less invasive procedures. For women facing hysterectomy, this could mean:
- vaginal rather than abdominal surgery
- laparoscopic rather than abdominal surgery
- endometrial ablation rather than hysterectomy
- myomectomy or myolysis rather than hysterectom
As an educational service, members of the FTC provide questions and answers regarding fibroids. Feel free to ask one of our fibroid specialist about alternative fibroid treatment such as fibroid embolization. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.