HYSTERECTOMY: An Overview
Hysterectomy - the word alone
makes some of us cringe. What really is a hysterectomy, and why is it done?
What can I expect to feel like and to be like afterwards? Are there any
other choices for my problem? This article will look at all of these
questions.
In the
A very
small number of hysterectomies are absolutely necessary to save a woman’s
life. The rest are done to improve the quality of life. Cancer of the
uterus, the cervix or the tubes and ovaries is usually treated by
hysterectomy. Sometimes if the cancer is very large, x-ray treatment or
chemotherapy might be suggested before an operation or instead of surgery.
Aside from cancer, the only other reasons why hysterectomy is done as an
emergency to save a woman’s life are for uncontrollable bleeding or
infection in the organs that is so severe that antibiotics are not helping.
So, since
these terrible situations are rare, why are so many hysterectomies done?
Bleeding, pain with periods or in the pelvis and growths on the uterus
(fibroids), ovaries (cysts) that are not cancers are all sometimes reasons
for hysterectomy. Also, sometimes the muscles and ligaments that support the
uterus become weak and the uterus may literally fall down outside the
vagina. This condition, too, may be treated with removal of the uterus and
tying up the sagging parts.
Abnormal
bleeding
is the most common reason that hysterectomy is recommended to women. I like
to divide this problem into its two causes: hormone imbalances and
structural problems. In my simple approach, hormone fluctuations - which are
very common both in teenagers just starting their periods and in women
getting towards menopause - should be easily treated with medicine - often
birth control pills - to smooth out the rollercoaster, Sometimes women can’t
take hormones or they feel terrible on the medication and will choose to
have the uterus removed to resolve the bleeding. A procedure called
endometrial ablation (endometrium
is the lining of the uterus that sheds with a period; ablation means
destruction) can sometimes help women with bleeding problems who don’t want
to take medicine and choose not to have a hysterectomy. While it is still
surgery, the recovery from endometrial ablation is less than a week and it
offers women a chance to keep their parts. The downside is that it might not
work, or it might solve the problem only temporarily. As many as half of
women who have an endometrial ablation, will need another pelvic operation
by 5-10 years afterwards.
Fibroid tumors of the uterus probably account for at least 200,000 hysterectomies each year. They are very common and tend to grow as women get older (more mature?). They may cause heavy bleeding or pressure in the pelvis - it doesn’t feel very good to have a basketball growing inside! We are very lucky; in the 21st century hysterectomy is not the only choice women have for treatment of the fibroids. Small fibroids (or uterine polyps as well) when they grow inside the uterus, cause very heavy bleeding. They can be removed through a tiny telescope called a hysteroscope (hyster means uterus - scope means to look at). The scope is placed through the opening in the cervix and up into the uterus where these small tumors can be shaved off. The procedure is easy to recover from and will allow a woman to get pregnant. Again, the downside is that women tend to grow additional fibroids over time, so another operation might be needed in the future.
For women with lots of
fibroids, or very large ones, an operation called
myomectomy (myoma
is the medical word for fibroid; -ectomy means
removal) can be done. This is major surgery and demands a fair amount of
skill on the part of a surgeon, but myomectomy
is definitely another choice for women who have symptoms from fibroids and
don’t want to lose their uterus. Finally, there is a “high-tech” option for
women with fibroids who don’t want surgery at all but do not want to become
pregnant in the future. Uterine artery embolization
(or uterine fibroid embolization) is a procedure
where a small tube is placed through the big artery in the groin (femoral
artery) and threaded into the blood vessels that supply the uterus. The
doctor then squirts small particles into the arteries to block off the blood
flow to the uterus. Because the fibroid tissue dies without the oxygen
supplied by the blood, the growths shrink and the symptoms usually go away.
The procedure is done in the hospital and does require a lot of skill and
experience. It may however be a good choice for some women.
If after thinking about all
the options, a hysterectomy seems like the best way to go, there are still
some decisions to make: How will the surgery be done
-
through the vagina, through
a cut in the belly, or using an operating telescope with several small cuts
in the belly? Is there a reason to remove the tubes and ovaries? What about
keeping the cervix? Under most circumstances, having the surgery through the
vagina is the safest, most cosmetic and easiest to recover from. The
operating telescope is sometimes needed if hysterectomy is being done for
pain symptoms (to be able to see everything in the belly) or for growths on
the ovary. Making a cut in the belly wall (abdominal hysterectomy) is almost
always done to treat cancer and when fibroid tumors are so large that they
cannot be removed any other way.
Some people think there is
an advantage to leaving the cervix in place at the time of hysterectomy. The
theory is that we keep the structures that provide support for the bladder,
vagina and cervix intact and avoid “falling of the parts” later on. Others
believe that nerves traveling next to the cervix can be hurt if the cervix
is removed at hysterectomy. These nerves may contribute to sexual sensation
and orgasm. The truth is that studies looking at both of these issues have
shown absolutely NO DIFFERENCE in sexual function or in pelvic support
between women who had the cervix removed and women who did not. Sometimes
there was bleeding from the cervix after hysterectomy if the cervix was left
in place. Bottom line - this is
a personal choice and something to discuss with your doctor, but you can
expect excellent results and ongoing normal (for you) sexual function after
hysterectomy whether or not your cervix is removed.
Finally, what about the
ovaries? The
only reason to remove normal ovaries is to reduce the risk of ovarian
cancer. Surprisingly, even complete removal of both tubes and ovaries does
not eliminate the possibility of getting this devastating cancer. If there
is a strong family history of ovarian or breast cancer, or if you personally
have had breast cancer and you understand that you will very likely need to
take medication at least for a while to help you with the sudden menopausal
symptoms, you may decide to have the ovaries removed. Rarely women suffer
from migraine headaches or premenstrual symptoms so severe that they will
choose to have their natural source of hormones removed. As women, we fear
ovarian cancer because it is so hard to find at an early stage, and it is so
deadly. Again, we should make our choices,
though,
based on facts. The truth
-
only one
woman out of 140 who have had a hysterectomy with the ovaries left, will go
on to develop ovarian cancer sometime in the rest of her life. That is less
than 1%! The downside is not only loss of our natural estrogen, but also
loss of other hormones that contribute to our sense of well-being and even
our sex drive. My basic philosophy is
-
if it
isn’t broken don’t fix it. For women of average risk, the benefits of
keeping our natural hormones usually outweigh the risk of cancer.
So, how will you feel after a hysterectomy? Overwhelmingly, women who make an informed choice to have the uterus removed, women who have considered all the options I’ve discussed and have picked hysterectomy as their choice do extremely well. After a short period of recovery, life without bleeding and the problems related to monthly menstrual cycles can be better than ever.