Hysterectomy and Its Alternatives

Last year, almost 550,000 American women had a hysterectomy. Yet it’s estimated that around 30 percent of these operations are unnecessary. Before you consent to a hysterectomy, find out what alternatives are available.

Hysterectomy, the removal of the uterus or womb, is the second most frequently performed operation for women, topped only by cesarean section. Seventy-four percent of hysterectomies are done when women are between the ages of 30 and 54; by age 65, more than 37 percent of all women in the United States will have had one. Although the number of such surgeries performed annually has dropped by about 160,000 in the past decade, many experts believe that isn’t enough.One fact that substantiates their claims is that hysterectomy rates vary greatly geographically. In fact, compared with women living in the Northeast, women are 78 percent more likely to have a hysterectomy if they live in the South; 41 percent more likely if they live in the Midwest; and 20 percent more likely if they live in the West. An American College of Obstetricians and Gynecologists (ACOG) task force attributed the geographical disparities partly to regional differences in gynecologists’ training. Some patient advocates believe that inappropriate hysterectomies are done because some physicians believe that removing the womb is the best solution for many different gynecological problems, doctors have grown so accustomed to doing the operation that they often fail to consider less extreme treatments, or they recommend hysterectomies for their own convenience or profit.

Whatever the reasons, cutting these high rates requires a better understanding by both doctors and women of more conservative possibilities. In fact, a new study from the University of North Carolina suggests women can cut their chances of having a hysterectomy by making their feelings clear to their doctors and by choosing younger gynecologists, who are less likely to think surgery is the best treatment.

What is a Hysterectomy

In order to remove the uterus, a surgeon usually makes a vertical or horizontal incision in the abdomen. Or the doctor can perform a laparoscopically assisted vaginal hysterectomy (LAVH), a type of surgery that requires less extensive incisions, making it less traumatic. In this technique, tiny incisions in the abdomen serve as entry ports for a camera and operating tools. Once the uterus is severed, it is then removed via the vagina. But LAVH is still experimental and questions have been raised about its safety. For example, it appears to pose a higher risk of bladder damage than traditional surgery. One of the most controversial issues surrounding hysterectomy is the simultaneous removal of healthy ovaries (oophorectomy). This procedure, which can cause extreme side effects, is done in about 50 percent of women who have a hysterectomy. Older women are more likely than younger women to have their ovaries removed.

The Organs Affected
This figure illustrates the woman’s reproductive organs that are affected by hysterectomy. The uterus, or womb, is a hollow, muscular organ that nourishes the developing fetus for the nine months of pregnancy. The endometrium is the tissue that lines the uterus. The ovaries produce the female sex hormones estrogen and progesterone, and store the ovum (eggs), releasing one a month. The fallopian tubes then carry the egg from the ovary to the uterus. If fertilized, the egg implants itself in the uterus. Otherwise, it is expelled through menstruation.

What Are the Side Effects of a Hysterectomy?

ACOG estimates that 25 to 50 percent of hysterectomy patients will have one or more complications, although they consider most to be minor or reversible. First, a hysterectomy ends a woman’s ability to become pregnant. Other postoperative complications may include severe vaginal bleeding, injury to the bowel or bladder, infection, persistent pain and diminished sexual response. As with any type of surgery, hysterectomy carries some higher risks: more than 500 women die each year as a result of the operation. Also, since the uterus produces prostacyclin, a hormone that inhibits blood clots, removal of the organ may make blood more likely to clot and could be a factor in the increased risk of heart attack among women who have had a hysterectomy.

If the ovaries are taken out, a woman loses her supply of the female sex hormone, estrogen. Women who cannot take estrogen replacement therapy, will experience instant menopause and may have a greater chance of developing heart disease and osteoporosis. Whether or not they have had their ovaries removed, many women also report fatigue, weight gain, aching joints, urinary tract disorders and depression after having a hysterectomy.

When Is Hysterectomy Necessary?

In a few instances, a hysterectomy may be the only way to save a woman’s life. Such life-threatening conditions usually require having a hysterectomy because no alternative treatment effectively combats the problem. These include:

• Cancer of the uterus and possibly of the ovaries
• Uncontrollable hemorrhaging after delivery
• Severe pelvic infection

What are the Alternatives?

Doctors often recommend hysterectomy to relieve conditions like chronic pain or heavy bleeding even though there are a variety of other therapies that can be tried. In fact, doing nothing is often a viable alternative depending on how much the symptoms affect a woman’s daily life. These alternatives aren’t always perfect, but a woman should be given the opportunity to consider them before having her uterus removed. In fact, ACOG advises that hysterectomy is a treatment of last resort and should be performed only after: Proper diagnostic tests have been performed to confirm the underlying condition; conservative treatments have failed to improve the condition and fertility is not an issue for the woman; and the woman has been properly counseled on the risks and benefits of the procedure. Here, a list of the most common reasons given for removing a woman’s uterus (in order of prevalence), treatment options and when a hysterectomy may be necessary.

Fibroid Tumors
Medically known as leiomyomas, these non-cancerous uterine tumors are sometimes symptomless and often require no treatment. However, they can cause excessive bleeding, anemia and pelvic pain. Fibroids can also interfere with pregnancy, and, if they grow too large, can crowd other organs and prevent them from functioning properly. Since fibroids grow in response to estrogen, they often shrink once a woman reaches menopause and estrogen levels drop.

Treatment options

• Drug therapy. The synthetic hormone leuprolide shrinks tumors by shutting off the ovaries and depriving tumors of the estrogen they need to grow. Leuprolide is not recommended for long-term use since it triggers temporary menopause, complete with hot flashes and vaginal dryness. Though fibroids grow back after treatment stops, many women continue to have relief from pain and other symptoms. Leuprolide can also be used to shrink bulky tumors prior to a myomectomy.
• Myomectomy. In this surgery, just the tumors are removed either through an incision in the abdomen or by using a vaginal procedure. Although there is a 30 percent chance tumors may recur, a myomectomy retains a woman’s ability to have children.
• Hysterectomy may be appropriate if these alternatives fail to control symptoms, such as heavy bleeding or pain. Also if fibroid tumors continue to grow in post-menopausal women, removing the uterus might be necessary to determine whether the tumors are cancerous.

Abnormal Bleeding
Persistent, heavy vaginal bleeding not related to menstruation or any known illness can have an enormous impact on a woman’s life.

Treatment options

• Drug therapy. The following drugs may control bleeding: Nonsteroidal anti-inflammatory drugs, such as ibuprofen; a group of hormones known as progestins; and oral contraceptives. Drugs that block estrogen production (leuprolide or danazol) may work too, but they induce menopausal symptoms while they’re taken.
• Endometrial ablation. Gynecologists view the inside of the uterus with a special scope and then burn away the lining of the uterus with a laser. This procedure causes sterility, but it does not trigger menopause and menstrual flow is largely reduced or eliminated.
• Hysterectomy is recommended when other treatments fail to control bleeding that interferes with a woman’s daily life and retaining the ability to bear children is not an issue for the patient.

Endometriosis
In this disorder, tissue from the lining of the uterus, or endometrium (see illustration), attaches itself to other pelvic structures. Endometriosis can result in pelvic pain, extremely painful menstrual periods, pain during urination, irregular bleeding, infertility and painful intercourse.

Treatment options

• Drug Therapy. The antihormones leoprolide or danazol can sometimes reduce or eliminate endometriosis.
• Laser surgery. The troublesome endometrial tissue can sometimes be removed with miniature instruments inserted through small incisions made in the abdomen.
• Hysterectomy may be necessary when symptoms cannot be controlled with other treatments or when endometrial tissue is found within the wall of the uterus. The ovaries and fallopian tubes may also have to be removed if wayward tissue has spread to those organs. If the tissue has already seeded itself throughout the pelvis, removing the ovaries as well may cause the excess tissue to atrophy.

Uterine Prolapse
A weakening of the supporting muscles and ligaments of the uterus can cause it to sag into the vagina and eventually protrude from the body. Symptoms can include a sensation of heaviness in the pelvic area and urinary incontinence.

Treatment options

• Pelvic floor exercises. If done at the first sign of prolapse, Kegel exercises, which strengthen vaginal muscles, may prevent this condition from worsening.
• Drug Therapy. Estrogen replacement therapy for post-menopausal women may lessen symptoms.
• Conservative surgery. A minor prolapse may be treated with surgery to repair supporting ligaments.
• Pessary. This diaphragm-like device can be inserted around the cervix to help prop up the uterus. The drawbacks: it may dislodge or cause irritation, may interfere with intercourse and must be removed regularly to be cleaned.
• Hysterectomy may be in order if other treatments fail to effectively support the uterus and alleviate discomfort.

Chronic Pelvic Pain
If a woman experiences chronic pelvic pain of unknown origin, a thorough evaluation is necessary to make sure there are no gastrointestinal, urinary or muscular causes. Psycho-logical evaluations are also encouraged.

Treatment options

• Multidisciplinary approaches. Non-steroidal anti-inflammatory drugs and oral contraceptives in conjunction with physical therapy, and nutritional and psychological counseling may be effective against the pain.
• Hysterectomy may be necessary to relieve lower abdominal pressure for the few women whose pelvic veins are persistently swollen or when all other measures have been exhausted. However, it is not always effective in relieving the pain.

Endometrial Hyperplasia
This potentially serious condition causes an overgrowth of the tissue lining of the uterus that can develop into cancer over time.

Treatment options

• Drug Therapy. Treatment with a synthetic hormone called progestin usually stops tissue growth. However, frequent biopsies may be necessary to monitor any indications of cancer.
• Hysterectomy is recommended only when endometrial cancer is diagnosed.

Making a Treatment Choice If you are deciding whether or not to have a hysterectomy, weigh its risks and benefits carefully. Find out as much as you can about the alternatives available. Some women with hysterectomies welcome the freedom from pain, discomfort and bleeding. Others wish they had exhausted all of their options before agreeing to surgery. Talking to more than one doctor and to other women who have chosen to have or not to have a hysterectomy, may also help you decide what is best for you (see Patient’s Corner).

Our thanks to Maxine H. Dorin, M.D., Associate Professor, Division of Gynecology, University of New Mexico Medical Center, Albuquerque, NM, for reviewing this article.

Talking to Your Doctor

You should always seek a second opinion when a hysterectomy is recommended. Indeed, many insurance companies will not cover the procedure if you don’t. Be sure to consult other doctors who treat cases similar to yours (see For More Information on the following page for a list of places to call for referrals to local specialists). To help you make a decision, discuss the following issues with your physicians:

• Are more conservative options appropriate? If not, why?
• How much relief can I expect from my symptoms after surgery?
• Will my ovaries be removed as well? If so, why?
• If my ovaries are removed, should I have hormone-replacement therapy?
• Will hysterectomy affect my sexual responsiveness?
• Will my cervix be removed?
• What are the possible complications?
• What are the hospital’s and the surgeon’s complication rates?
• Is a vaginal or laparoscopic hysterectomy possible? If so, is the surgeon experienced in the technique?

For More Information

The following organizations and books can give you further information on hysterectomy:

Hysterectomy Educational Resources and Services (HERS)
Offers patient information about alternatives to surgery, doctor referrals, and individual counselors for emotional and psychological support.
422 Bryn Mawr Ave.
Bala-Cynwyd, PA 19004
610-667-7757

The Endometriosis Association
Provides extensive information about hysterectomies.
8585 N. 76th Place
Milwaukee, WI 53223
800-992-3636

Hysterectomy: Before & After, by Winnifred B. Cutler, Harper Collins, 1990

The No-Hysterectomy Option, by Dr. Herbert A. Goldfarb with Judith Greif, Wiley, 1990

The Hysterectomy Hoax, by Dr. Stanley West and Paula Dranov, Doubleday, 1994