Hysterectomy, the surgical removal of the uterus, is a procedure surrounded by controversy - and for good reason. Hysterectomy is the second most common major operation performed in the United States today, second only to cesarian section. Approximately 600,000 American women have a hysterectomy every year, at a cost of almost 5 billion dollars. By the age of 60, one out of every three women in the U.S. has had a hysterectomy.
The percentage of American women who have a hysterectomy is much higher than the percentage of European women having a hysterectomy. For example, American women are twice as likely to have a hysterectomy as women in England and four times as likely as Swedish women. French doctors almost never perform a hysterectomy for fibroids, which is the most common reason for hysterectomy in this country. Many factors are embodied in these differences, including cultural attitudes, physician training, the availability of elective surgery in a particular country, the ability to pay for care, etc. However, overall, it appears that the rate of hysterectomy in the United States is high.
Hysterectomy has become a political issue. Some authors state that only 10% of hysterectomies are necessary, only those that are performed for cancer. However, if the other 90% of hysterectomies are absolutely unnecessary, that leaves little room for women who are truly suffering from non-cancerous gynecologic problems. While some symptoms that result from uterine problems, i.e. -severe pain or bleeding, will often respond to medications or other non-surgical treatment, sometimes these symptoms do not get better. Those women, with intractable symptoms that affect their lives, may benefit from hysterectomy. As noted later in this chapter, a recent American study done by a female doctor at Harvard found that most women who had a hysterectomy performed because of moderate or severe symptoms were "very satisfied" with the results of surgery, and they noted an improvement in their quality of life.
One of the most important factors in helping you choose appropriate medical care is your comprehensive understanding of the reasons for treatment, the risks, and the potential benefits. This especially applies to hysterectomy. If hysterectomy has been suggested to you as an option for your particular problem, you should carefully weigh the pros and cons, the alternative treatments, and the potential benefits and risks. We have tried to provide you with some of that information and we hope you will be able to make a comfortable and informed decision about whether hysterectomy is right for you.
Total hysterectomy removes the entire uterus, including the cervix. Subtotal hysterectomy removes only the upper body of the uterus, and the cervix is left in place, connected to the top of the vagina. If the hysterectomy is performed because of cervical cancer, then the cervix must be removed, and total hysterectomy is always performed. The same is true for uterine cancer, since the cancer can spread down the body of the uterus and involve the cervix.
However, if the hysterectomy is performed for uterine fibroids, abnormal bleeding, or pelvic pain, you can have a choice as to whether the cervix should be removed or not. Some women feel that if the cervix is removed, they will have diminished sexual pleasure, while other women do not feel the cervix is part of their sexual enjoyment. This issue is discussed in detail later in the chapter.
Total hysterectomy indicates removal of the entire uterus, including the cervix
Supracervical hysterectomy indicates removal of the body of the uterus, but the cervix stays in place.
There are presently three ways to perform a hysterectomy; abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy. The different types of hysterectomy are discussed in our book.
Laparoscopic hysterectomy is a relatively new surgical procedure that allows the uterus to be detached from inside the body by laparoscopic instruments while the doctor is viewing the uterus, tubes, and ovaries through a camera attached to a telescope. After the uterus is detached, it is removed through a small incision at the top of the vagina. One advantage of laparoscopic hysterectomy is that the incisions are smaller (1/2 inch) and much less uncomfortable than that of abdominal hysterectomy. Also, the hospital stay of 1 day and the ability to resume normal activity in about 2 weeks are substantially shorter than for abdominal hysterectomy and slightly shorter than for vaginal hysterectomy.
For patients who have known or suspected pelvic scar tissue or endometriosis, laparoscopic surgery allows the surgeon to remove the diseased tissue with the laparoscope before performing a vaginal hysterectomy, thereby reducing the risk that the intestines or bladder might be injured during surgery. For patients who have fibroids that are large and might otherwise be difficult to remove by vaginal hysterectomy, laparoscopic hysterectomy allows the surgeon to detach the blood vessels to the uterus while viewing them through the laparoscope. Then, the uterus can be removed through the vagina more easily and with less blood loss. Laparoscopic hysterectomy does require considerable skill and experience on the part of the surgeon.
There has been a bit of controversy for the past few years over the advantages and disadvantages of subtotal hysterectomy. Subtotal hysterectomy was the most common type of hysterectomy performed before 1940. Leaving the cervix in place avoided some of the risk of injuring the nearby ureters, bladder or intestines and reduced blood loss. However, the remaining cervix was susceptible to developing cancer, a fairly common condition at that time. As surgical and anesthetic techniques became safer and antibiotics became available, doctors began performing more total hysterectomies in order to prevent the future development of cervical cancer. These changes all preceded the discovery of the pap smear. Once the pap smear became widely used as a means to find pre-cancer, an easily curable condition, removing the cervix was no longer essential for all women.
Laparoscopic hysterectomy has been shown to be associated with a shorter hospital stay and recovery than abdominal hysterectomy. Women having laparoscopic subtotal hysterectomy may have an even faster recovery. The fact that no surgery is needed near the vagina and no sutures are left inside the vagina may be responsible for reducing discomfort during the recovery period. A few studies have shown just that, with return to work in one week, rather than the two weeks it may take after laparoscopic total hysterectomy. We have been performing laparoscopic subtotal hysterectomy, when indicated and requested by the patient, for the past few years and have seen the same excellent results, early recovery and return to normal activity as reported in the medical journals.
It seems clear that too many hysterectomies are performed in this country every year and that some women could have avoided surgery had they been aware of other alternatives and treatments. However, it is also clear that some women benefit from having a hysterectomy. Not many would argue with the usefulness of removing the uterus for cervical, uterine, or ovarian cancer, where hysterectomy can be life-saving. But, many other women have symptoms that, while not life-threatening, do affect their general physical and emotional health and their ability to perform normal activities. Is there any evidence that a hysterectomy can be of any benefit to these women?
An important study was published in 1994 (the Maine Women's Health Study) that examined how women felt both physically and emotionally before and after hysterectomy. More than four hundred women were interviewed before they had a hysterectomy and then followed for a year after their surgery. Likewise, a separate group of 380 women who had similar gynecologic problems, but chose not to have a hysterectomy, were interviewed.
What is especially noteworthy is that the study found that a substantial number of women had a marked improvement in their symptoms following hysterectomy, including symptoms such as pelvic pain, urinary problems, bleeding, fatique, and psychological and sexual problems. They also reported a significant improvement in mental health and general health at the end of one year. And, after hysterectomy, many of the women reported a marked improvement in the quality of their lives. Therefore, for some women, especially those who have significant symptoms as a result of gynecologic problems, hysterectomy may be beneficial.
New treatments for fibroids and abnormal bleeding, two of the most common reasons for hystectomy, should decrease the need for hysterectomy. Myomectomy (see chapter 2) by either hysteroscopy, laparoscopy, or abdominal surgery can often be used to remove fibroids and alleviate symptoms without removing the uterus (see fibroid chapter). Myoma coagulation (see chapter 2) is a new procedure that uses a laparoscopic technique to destroy fibroids without removing them at all.
Abnormal bleeding may now be treated by endometrial ablation (see chapter 3) with 90% of women reporting excellent results, allowing them to avoid hysterectomy. Endometriosis, the third most common reason for hysterectomy may be treated by medical therapy, although the side-effects and expense of the medications limit its use at the present time. Laparoscopic techniques short of hysterectomy may also be used to alleviate pelvic pain associated with endometriosis (see chapter 6). Hysterectomy, for most of these conditions, should be a last resort, not the first one.
It is important for you to understand the reasons that your doctor has suggested a hysterectomy as treatment for your gynecologic problem. The best way to help you make a decision as to whether the procedure is right for you is to ask your doctor the right questions.
The most common reasons for surgery are pain, bleeding, or symptoms from fibroids. You know the reason you went to see the doctor in the first place. And, the first question that you should ask is what specifically is the cause of your problem. For example, ask, "What exactly is causing my pain?" Sometimes the reason will not be entirely clear to the doctor. In particular, the cause of pelvic pain may originate in the intestines or the bladder and not from the uterus. You should ask if there are other tests that can be done to make the diagnosis more apparent. The decision whether to have these tests or not should be yours and should be balanced with the side effects and cost of the tests. For example, laparoscopy can help to make a diagnosis of the cause of pelvic pain, but you may or may not wish to go through an operation to have an exact diagnosis made.
Once a diagnosis, or probable diagnosis, has been established, you should also ask what the consequences to your health will be if you do not have surgery, either at all, or at this time. For non life-threatening problems, one option is always to do nothing. However, doing nothing often means more frequent visits to your doctor to monitor your problem.
The next question to ask the doctor is what are the non-surgical alternative therapies available to treat your condition. For every condition, there are usually alternatives of varying degrees of effectiveness. As described throughout this book, medications, pain management, even homeopathics or other alternative therapies, may sometimes be tried to alleviate symptoms. But again, I would advise you to continue to see your doctor regularly in order to detect any changes in your condition.
You should also ask about your doctor's experience doing the operation that has been proposed. You should feel comfortable with the number of procedures he or she has performed for problems like yours. If their experience is limited, you may ask who the assistant is going to be, and how much experience the assistant has had. For some of the newer procedures, such as endometrial ablation, laparoscopic surgery, or laparoscopic hysterectomy, additional training and experience must be acquired before the procedures can be safely performed. The same questions should be asked of an interventional radiologist regarding uterine artery embolization. Some hospitals have strict requirements for training before a doctor is allowed to perform these operations or procedures, while other hospitals have no such requirements. Therefore, it is important for you to ask about surgical training and experience.
You should also ask your doctor whether a second opinion would be a good idea. Most doctors will welcome the idea of a second opinion. If they have done a complete job on the diagnosis and on the explanation of the problem to you, then they should feel confident about the range of options they have suggested to you. In addition, no doctor knows everything, and your doctor may welcome any other new ideas about your problem. This is your body and your life and you deserve to know everything you can about all the options available.
I have changed my view about this controversial subject since the first edition of this book was published. At that time, I suggested that women who were having a hysterectomy performed for appropriate reasons also consider having their ovaries removed after the age of about forty-five. My thinking at the time was that the ovaries would continue producing hormones for only a few years thereafter, and this advantage would be overshadowed by the benefit of removing the ovaries and eliminating the 1 percent chance of developing ovarian cancer in your lifetime. However, a number of issues have come to my attention since then, and I now believe that the ovaries should almost never be removed at the time of hysterectomy.
First, the risk of ovarian cancer goes down if the ovaries remain after hysterectomy. The reason for this is not clear, but it may be that the path for potential carcinogens from the vagina to the ovaries is interrupted when the uterus is removed. Thus, the risk of a woman developing ovarian cancer after hysterectomy is probably closer to 1 in 300 rather than 1 in 80 for women who have not had a hysterectomy. The benefit of removing ovaries for ovarian cancer prevention has been overstated in the medical literature and is, therefore, misunderstood by most physicians.
Significantly, the ovaries produce hormones long after menopause. Estrogen continues to be produced in small amounts, about 25 percent of normal pre-menopausal levels. Blood levels of estrogen in some post-menopausal women are equivalent to the levels attained by low-dose estrogen patches used for estrogen replacement in menopause. The circulating level of estrogen produced by the patch has been shown to be sufficient to prevent bone loss in clinical studies. Studies also show less bone loss in women who have ovaries than in women who have had their ovaries removed. Studies show that women who have had their ovaries removed (and have not taken replacement estrogen) have higher rates of heart disease than women the same age who still have their ovaries.
Testosterone is usually thought of as solely a male hormone. However, it and other androgen (male) hormones are produced by the ovaries from the time of the first menstrual period. These androgens continue to be produced by the ovaries after menopause. Testosterone has many direct and indirect benefits to your body. Some of the testosterone is converted into estrogen by your body, and it circulates in the bloodstream to all of your tissues where it has a direct effect on many organs. It helps to build bone and thus reduces osteoporosis. Its steroid features prevent muscle loss that often occurs with aging. Testosterone directly affects the brain and increases libido. Sexual feelings, desire, and arousal are all related to androgen levels. Testosterone also affects brain function and mood. Women with hormones from their own ovaries have a lower rate of depression than women who have had them removed, even if estrogen replacement therapy (ERT) is taken.
Some physicians have argued that women can replace estrogens and androgens with medications. However, less than 30 percent of women who have a hysterectomy and removal of their ovaries will actually take hormones. Therefore, 70 percent of women will not have the benefit of their own hormones. Some women do not take ERT because they feel fine and do not understand the benefits of taking estrogen for their bones. Some women are concerned about the still controversial issues surrounding estrogen and breast cancer, although it appears that the effect of estrogen on the risk of breast cancer may be small. Some cannot afford the medication. For whatever reason, most women would be better off with their own supply of estrogen and testosterone from their ovaries.
Another problem with estrogen replacement therapy (ERT) is the dilemma that some doctors and women have as they try to find the right doses. Some women note that despite trying multiple regimens of ERT, they still do not feel right. Because hormone production and metabolism is a complex issue, it should not be a surprise that we are not able to mimic normal hormone levels in all women. For all the above reasons, I have recently started recommending that most women choose to keep their ovaries at the time of hysterectomy for uterine problems, regardless of their age.
However, there are a few situations where women may wish to have their ovaries removed at the time of hysterectomy. If the ovaries are affected by endometriosis or a woman has severe endometriosis and pelvic pain, studies show that removing the ovaries is associated with better long-term relief of pain than if the ovaries are not removed. Severe adhesions, or scar tissue, around the ovaries may also cause continued pelvic pain.
As noted in Chapter 10, some women are at increased risk for developing ovarian cancer. If you feel your family history suggests an increased risk for ovarian cancer, you should see a genetic counselor to help evaluate your risk. The counselor may suggest you have BRCA (breast/ovarian cancer) gene testing to determine if you have inherited the gene that increases your risk. If you have an increased risk, you should strongly consider having your ovaries removed. In this case, the benefits of removing your ovaries and preventing ovarian cancer should far outweigh the benefits of keeping your own ovarian hormones.
Some women are very uneasy about leaving their ovaries in because of the fear of ovarian cancer. They may have seen a friend or relative die of this terrible disease. As a result, some women may choose to have their ovaries removed at the time of hysterectomy. But for each woman, the risks should be weighed carefully against the benefits of having her own hormones from her own ovaries after menopause. Women tend to make very different decisions based on their particular circumstances, their feelings about estrogen replacement therapy, and their risk and fear of ovarian cancer. However, it is always best to make these decisions based on accurate and current medical information. This decision is yours to make and should be discussed in detail with your doctor. As always, if there are unanswered questions or concern, get a second opinion.
For an update on this information, please see: http://www.ovaryresearch.com/
The decision to have a hysterectomy should not be taken lightly. There are medical conditions that require treatment - cancer, prolonged heavy bleeding to the point of severe anemia, or incapacitating pain. However, as outlined throughout this book, all medical conditions have more than one option for treatment. Medicine is an evolving art as well as a science. Recently, with more open attitudes towards women's opinions and feelings, and with the advent of new technology, doctors have been looking for new medical treatments for gynecologic symptoms in order to avoid hysterectomy. As outlined above, there are possible side effects of hysterectomy, none of which are entirely predictable for each individual. But, for some women, hysterectomy will be the right treatment.
As with most decisions, you should carefully consider the pros and cons of hysterectomy as they relate to your particular medical situation and emotional well-being. On one hand, you should weigh the degree of discomfort that your gynecologic problem presents to you, the ways in which it interferes with your health, both emotionally and physically. On the other hand, weigh the potential risks of the operation, including the possible physical as well as the emotional side-effects of having a hysterectomy. There are women who happily choose to live with fibroids the size of a 5 month pregnancy despite the fact that they have some daily discomfort and look pregnant. Other women choose surgery for small fibroids because they are distressed by symptoms, or by worry, and don't wish to live with the problems any longer.
Ultimately, the final decision about the appropriateness of a hysterectomy, or any type of surgery or medical care, should be made by each woman herself. That is what this book is about.
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