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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
1. 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.
2. 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.
3. 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
1. 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.
2. 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.
3. 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
1. Drug Therapy. The antihormones leoprolide or danazol can sometimes reduce or eliminate endometriosis.
2. Laser surgery. The troublesome endometrial tissue can sometimes be removed with miniature instruments inserted through small incisions made in the abdomen.
3. 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
1. Pelvic floor exercises. If done at the first sign of prolapse, Kegel exercises, which strengthen vaginal muscles, may prevent this condition from worsening.
2. Drug Therapy. Estrogen replacement therapy for post-menopausal women may lessen symptoms.
3. Conservative surgery. A minor prolapse may be treated with surgery to repair supporting ligaments.
4. 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.
5. 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
1. 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.
2. 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
1. 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.
2. 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).
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:
1. Are more conservative options appropriate? If not, why?
2. How much relief can I expect from my symptoms after surgery?
3. Will my ovaries be removed as well? If so, why?
4. If my ovaries are removed, should I have hormone-replacement therapy? 5. Will hysterectomy affect my sexual responsiveness?
6. Will my cervix be removed?
7. What are the possible complications?
8. What are the hospital's and the surgeon's complication rates?
9. Is a vaginal or laparoscopic hysterectomy possible? If so, is the surgeon experienced in the technique?