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Alternatives to Hysterectomy

September 30, 2020March 29, 2000 by admin

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.

Hope Offered Against Hysterectomy

July 12, 2019January 17, 2000 by admin

By: Kathleen Fackelmann

NEW YORK (AP) — Arleen Chatman’s mother had a hysterectomy. Her grandmother had a hysterectomy. So did her sister, two aunts and a cousin, who was only 32 when the family problem uterine fibroids struck her as they do millions of women every year.

Chatman, 57, was determined to buck her history, fight through her fibroid-related pain and find a way to avoid a hysterectomy, despite five miscarriages and periods so heavy she used a box of sanitary napkins combined with tampons in a single day.

“I got very anemic and was missing work,” said the elementary school librarian in Los Angeles. “I grew up in the old school of ‘It’s just a woman’s curse and you have to put up with it.’ Then I started reading and everybody was talking about hysterectomies being done that weren’t needed, saying there should be alternatives.”

The alternative Chatman chose three years ago is a relatively new treatment that allows women to avoid the risks and lengthy recovery periods of surgery. It’s called uterine artery embolization, and it’s done by interventional radiologists, not gynecologists.

Under local anesthesia accompanied by pain medication, a quarter-inch incision is made in the groin. A catheter the circumference of spaghetti is threaded into the two arteries that supply blood to the uterus and feed blood-dependent fibroids.

Guided by bursts of die projected by X-ray imaging, plastic particles the size of sand granules are injected into the vessels, blocking blood to the tumors while allowing the uterus to receive nourishment from other sources.

Fibroids slowly deteriorate over three months to a year after embolization, offering women an average 40 percent to 60 percent reduction that appears to be permanent, said Dr. Robert Worthington-Kirsch, a Philadelphia radiologist who has performed a little more than 600 uterine artery embolizations, the most in the United States. The procedure usually takes care of multiple fibroids, not just the prominent ones, unlike surgery.

About 4,500 women have undergone the procedure in the United States, and 6,000 to 8,000 worldwide. The procedure is successful in easing symptoms in about 90 percent of cases, Worthington-Kirsch said.

Recipients are screened by gynecologists prior to embolization to rule out uterine cancer, detect infections that could lead to complications and determine whether other problems such as endometriosis are severe enough to lead to hysterectomy anyway.

Most women spend a night or less in a hospital and resume their lives within a few days, compared to weeks of recovery after surgery. The downside is painful cramps that hit some women for a day or two after the embolization. And much more study is needed to gauge long-term effects of the procedure on fertility, among other factors.

As an educational service, members of the FTC provide questions and answers regarding fibroids. 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.

Researchers Take Aim at Uterine Fibroids

July 12, 2019April 5, 1999 by admin

New Techniques Expand Treatment Options to Help Women Avoid Major Surgery

By Gail McBride, Special to The Washington Post
April 6, 1999

They may affect up to half of women of childbearing age and can cause bleeding, pain and perhaps infertility. Yet until recently, medical research paid scant attention to those benign growths in the uterus called fibroids.

Now a range of new procedures–from a technique that blocks blood vessels in the uterus to experimental drugs–may allow many women more options besides major surgery to treat uterine fibroids. For years, the principal treatment has been hysterectomy, in which the whole uterus is removed, or another operation called myomectomy in which the individual fibroids are cut out. But increasingly it looks like fibroids may be forced into submission in other ways.

The newest treatment shrinks fibroids by cutting off their blood supply. Called uterine artery embolization (UAE), it was first performed in Paris in 1991 by gynecologist Jacques-Henri Ravina. Today it is done in many countries, including the United States.

In this procedure, a catheter is inserted into an artery in the groin. With X-ray guidance, a specially trained “interventional radiologist” directs the catheter into the two arteries that supply the uterus and the fibroids with blood. Small plastic or gel particles are injected through the catheter into the arteries, causing the blood to clot. The result is closure of the arteries, marked shrinkage of the fibroids and cessation of bleeding.

The procedure takes 60 to 90 minutes, according to interventional radiologist Scott Goodwin, who with gynecologist Bruce McLucas has performed more than 200 of them at UCLA Medical Center. Patients are sedated but do not have to undergo general anesthesia. Afterward, there is considerable cramp-like pelvic pain, and pain medication is necessary. Infections occasionally occur. Patients are encouraged to take a week off from work or other daily routines.

For some women, this treatment is a welcome alternative to a hysterectomy. “My uterus was full of fibroids, and I had been to four or five gynecologists,” said Susan DeBoismilon of Orinda, Calif. “They all urged me to have a hysterectomy.” Then she heard about McLucas’ work. “The procedure made sense to me, and I had it done a month later. It’s definitely the best course.”

Goodwin said that about 80 percent of the 2,000 women worldwide who underwent UAE have had relief of symptoms, shrinkage of fibroids and no need for a hysterectomy.

Six patients of Goodwin and McLucas have become pregnant and had normal or C-section deliveries after UAE, but no one really has kept close track of patients’ attempts to get pregnant until very recently. There is some concern, Goodwin said, that the blood supply to the ovaries may be damaged by UAE in 1 percent to 2 percent of cases, and he warns women about this if they want to maintain fertility.

Until the uncertainties about long-term results and pregnancy are resolved, the procedure “probably will be best for women at the end of their reproductive lives,” said Bryan Cowan, professor of obstetrics and gynecology and director of the division of reproductive endocrinology at the University of Mississippi in Jackson.

“On the other hand, someone needs to be out there doing new procedures.”

Another relatively new procedure destroys fibroids by zapping them with electricity or a laser. Called myolysis, it was introduced in the United States in 1990 by gynecologist Herbert Goldfarb of Montclair, N.J., and Manhattan.

In this approach, a woman first takes drugs such as Lupron to suppress the production of estrogen, known to enlarge fibroids, for about three months. Then after surgery to remove the uterus’s inner layer, the patient undergoes a laparoscopic procedure, in which the surgeon makes small incisions in the abdomen and uses tiny instruments employing magnification to guide the operation.

With the patient under general anesthesia, each fibroid is treated individually by repeated application of an electric current (which Goldfarb uses) or a high-intensity laser beam that destroys cells on contact. There is some pain and discomfort with the one-day procedure, Goldfarb said, although less than with UAE. Goldfarb reports a success rate of nearly 90 percent in the 400 patients he has treated.

The problem with myolysis is that scar tissue may form after the surgery and entangle internal structures, including fallopian tubes. This can interfere with pregnancy. Some gynecologists advise women who want to become pregnant to do so as soon as possible after myolysis.

Charles March, professor of obstetrics and gynecology at the University of Southern California, is cautious about both myolysis and UAE. “They are probably best suited to carefully selected patients who are not concerned about fertility or who don’t want to undergo major abdominal surgery,” he said. “Certainly, only doctors with a lot of experience should be doing them.”

Meanwhile, researchers are also looking into gene therapy and experimental drugs. At Brigham and Women’s Hospital’s Center for Uterine Fibroids in Boston, cell biologist Romana Nowak is studying two substances called growth factors that stimulate the formation of collagen or new blood vessels and accelerate the growth of tumors. Several agents that inhibit both growth factors are being considered for fibroid treatment, Nowak said.

Just what causes fibroids is not known. Cynthia Morton, a molecular geneticist at Harvard Medical School and Brigham and Women’s Hospital is looking for genetic clues. She and her colleagues are investigating two of the chromosomal abnormalities that occur in 40 percent of fibroids. In addition, they and others at the Center for Uterine Fibroids are recruiting sisters or other close family members who have fibroids in an effort to identify a common genetic factor.

Doctors point out that many women with fibroids have no symptoms. As March noted, “it’s only necessary to remove fibroids when they are causing symptoms.” Many women with symptomatic fibroids try to hang on until menopause, hoping the fibroids will shrink as their hormone levels decrease. Fibroids are sensitive to both estrogen and progesterone, said cell biologist Janet Andersen of the State University of New York at Stony Brook. After menopause, when levels of these hormones decline, many women experience relief.

For women whose symptoms require treatment, hysterectomy remains the only true cure: no uterus, no fibroids. However, hysterectomy carries the risks of all major surgical procedures. Also, recovery requires a lot of “down time,” and some patients contend there are lasting adverse effects on health and sexual function.

Moreover, many women just don’t want to lose their uteri. The only surgical alternative is myomectomy, but this operation is not always successful. Blood transfusions may be needed during surgery, and fibroids recur in 30 percent of cases. In addition, the operation can lead to problems from scar tissue.

For women who still want children, myomectomy has been the only route, although Caesarean section is required for delivery because the uterus is too weak. Now there are alternatives.

Are they better than myomectomy? “Let’s put it this way,” said McLucas. “If myomectomy were a better procedure, I wouldn’t be advocating UAE–or even myolysis. New procedures may come alon
g in a few years, but right now, if I were a woman who wanted to become pregnant, I’d consider UAE as my first alternative.”

Resources

There are at least three fibroid web sites in the Internet:

* www.fibroids.net is maintained by the Center for Uterine Fibroids, Brigham and Women’s Hospital, Boston.

* www.fibroidcorner.com is maintained by gynecologist Francis L. Hutchins Jr. and interventional radiologist Robert L. Worthington-Kirsch, both of the Philadelphia area.

* www.fibroids.org is maintained by the UCLA Medical Group Uterine Artery Embolization team.

Fibroid Tumors at a Glance

Uterine fibroids are benign tumors. They occur in more than 20 percent of women of childbearing age, although symptoms do not generally develop until the patient is in her late thirties or forties.

Fibroids are the most common cause of hysterectomies. They are named for their position in the uterus. Submucosal or intramural fibroids are often associated with abnormal bleeding, while pelvic and back pain are frequently caused by intramural and subserosal fibroids.

Source: Georgetown University Medical Center