Imagine this scenario—a woman has uterine fibroids (benign growths on the uterine wall) that cause heavy menstrual bleeding and pelvic pain. Her doctor says that she needs a hysterectomy (surgical removal of the uterus). She complies—then experiences several days of severe postoperative pain, misses several weeks of work and feels an unexpected sense of loss. Eventually she switches to a different physician and is shocked to learn that her hysterectomy may not have been necessary at all.

This is an all-too-common occurrence. Many women are told that hysterectomy is the only appropriate treatment for their conditions-even when medical advances may provide nonsurgical treatments or less invasive surgical options.

Self-defense: If your physician insists that a hysterectomy is the only way to go, seek a second or even a third opinion.

Surgery Worries

Second only to cesarean section, hysterectomy is the most common surgical procedure performed on women in the US. By age 60, one in three women has had a hysterectomy.

Gynecologic problems often can be treated without resorting to hysterectomy-yet as many as two-thirds of women who undergo hysterectomy do so without a compelling medical necessity. Concerns…

  • Like any major surgery, hysterectomy involves risks—the possibility of blood clots, excessive bleeding, infection and adverse reactions to anesthesia. In rare cases, the urinary tract and/or rectum are damaged during surgery.
  • In premenopausal women, hysterectomy brings an abrupt end to menstruation. If ovaries also are removed, it can trigger severe or persistent menopausal symptoms, such as hot flashes, lowered libido and depression.
  • Some women undergo hysterectomy only to find that the surgery does not completely relieve their symptoms. This often occurs with chronic pelvic pain (which may be caused by an undiagnosed intestinal or urinary tract problem, rather than a uterine problem) ...and with endometriosis, a condition in which tissue from the uterine lining (which should stay inside the uterus) attaches itself to organs outside the uterus.

Note: Hysterectomy is warranted for…

  • Uncontrolled uterine bleeding, due to complications of childbirth, or extreme fibroid-related bleeding.
  • Cancer of the uterus, cervix or ovary.
  • Severe uterine prolapse in which the uterus protrudes outside the vaginal opening

What You Need To Know

If your physician suggests hysterectomy, ask these questions…

  • What could happen if I don't have the hysterectomy? If the risks are modest, you may prefer to continue as you are. If potential consequences are serious, such as severe hemorrhaging or debilitating pain, ask how commonly they occur.
  • How urgent is my situation? Unless it's an emergency, you may be able to take several months to decide about surgery.
  • Will my condition improve on its own after menopause? For example, once menstruation ends, hormones that prompt endometriosis and fibroids generally no longer cause problems-so consider whether you are close enough to menopause (which typically occurs between ages 48 and 52) to wait it out. On the other hand, uterine prolapse tends to worsen with age—so waiting won't help.
  • Are there less invasive surgical alternatives or nonsurgical therapies? Discuss the risks and benefits of your treatment options (as described below), including how each affects fertility, if this is relevant for you.
  • How effective are these alternatives? To put an end to symptoms permanently, hysterectomy could be the best choice. If you would be satisfied with partial or temporary improvement, try other options first.

Alternatives To Hysterectomy

Here are common gynecologic problems and treatments that may allow you to avoid having a hysterectomy…

  • Abnormal vaginal bleeding, due to menstrual problems, endometriosis or endometrial byperplasia (overgrowth of the uterine lining).
  • Intrauterine device (IUD) with progesterone is a small hormone-coated contraceptive device that can be left in the uterus for up to five years.
  • Endometrial ablation, an outpatient procedure, uses a surgical device to destroy the inner layer of the lining of the uterus, Stopping or severely reducing menstrual flow.
  • Endometriosis, which can cause pain, heavy bleeding and infertility,
  • Oral contraceptives taken continuously, without the usual week off each month-relieve mild-to-moderate symptoms.
  • GnRH agonists (medications that block estrogen production) temporarily halt menstruation and shrink endometrial tissue, buying you time if you are close to menopause.
  • Laparoscopic excision involves inserting a lighted fiber optic tube (laparoscope) and surgical instruments through small abdominal incisions, then removing the errant endometrial tissue.
  • Uterine fibroids, growths that can vary in size from a speck to a melon and may number from one to hundreds. With the procedures below, fibroids may or may not recur.
  • GnRH agonist medications can temporarily shrink fibroids.
  • High-intensity focused ultrasound combines ultrasound waves and magnetic resonance imaging to destroy fibroid cells.
  • Myomectomy removes individual fibroids with a laser, electrical current or scalpel.
  • Uterine fibroid embolization shrinks fibroids by blocking their blood supply with tiny plastic beads injected into small blood vessels.
  • Uterine prolapse that is mild to moderate (the uterus drops into the vagina but does not yet bulge out of the vaginal opening).
  • Oral estrogen therapy helps thicken supporting pelvic tissues.
  • Pessary is a plastic cap worn in the vagina to reposition the uterus,

If You Opt For Hysterectomy

Once the decision has been made to have a hysterectomy, discuss with your doctor…

  • What will surgery remove?
  • Supracervical hysterectomy removes the uterus but not the cervix. It should not be used if your Pap test reveals potentially precancerous cervical cells.
  • Hysterectomy with bilateral salpingo-oo-phorectomy removes the uterus, fallopian tubes and ovaries. I typically recommend this procedure to patients who are close to or past menopause.
  • Total hysterectomy removes the uterus and cervix, leaving ovaries intact. This often is used for women with severe uterine bleeding.
  • Radical hysterectomy removes the uterus, cervix, top of the vagina and most tissue surrounding the cervix. It is generally used to treat cancer.
  • How will the surgery be done?
  • Abdominal hysterectomy requires an abdominal incision of about six inches. I use the procedure when a woman has a very large uterus or scarring from previous abdominal surgeries. Recovery: About six weeks.
  • Laparoscopic hysterectomy is done through several small abdominal incisions. It often is used for endometriosis or persistent pelvic pain. Recovery: About two weeks.
  • Vaginal hysterectomy involves a small incision in the vagina through which the uterus is cut and removed. Used for uterine prolapse, it leaves no visible scars. Recovery: About two weeks.

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