MEDICALLY NECESSARY, BUT NOT URGENT?
ONE OF SEVERAL OPTIONS?
By age 60, about 1/3 of American women will have had a hysterectomy. Hysterectomy is a surgical procedure to remove the uterus (womb), in order to treat a gynecologic problem. We suggest surgery to our patients when it offers health or quality of life benefits that outweigh the risks of having surgery. On the other hand, a woman herself will sometimes tell her doctor that she is ready to consider a hysterectomy when the doctor has not recommended it.
In either situation, the decision to have surgery requires clear communication between a woman and her physician. When we recommend surgery, we want a woman to understand what benefits she can expect, what risks she might encounter, and what treatment other than surgery might improve her problem. The same is true when the patient is requesting that we offer surgery. But in this situation, we also want to hear what the woman is experiencing. Perhaps her doctor has not understood the severity of her discomfort or how much irregular bleeding has interfered with her normal life.
In this post, I hope to offer you a short explanation of the most common reasons we may recommend a hysterectomy, and the situations where we may advise against it.
We recommend emergency or prompt surgery when…
A hysterectomy may save your life. Sometimes a woman faces such a serious gynecologic problem that the need for surgery is urgent. The possibility of cancer and bleeding that cannot be controlled are two urgent situations. Remember that any bleeding or spotting after menopause, no matter how light or infrequent, is not normal. See your doctor promptly if you notice bleeding after menopause.
Cervical Cancer–A Pap Test is used to discover cancer or pre-cancer of the cervix. An outpatient procedure to remove the abnormal cells will often solve the problem without the need for a hysterectomy. But if Pap screening leads to a diagnosis of cervical cancer, a hysterectomy is necessary.
Endometrial (Uterine) Cancer–The lining of the uterus can also develop abnormal pre-cancerous or cancerous cells. Changes in the uterine lining often cause irregular or abnormal bleeding. Your doctor will first recommend a biopsy to look for cancer cells or cells that have a high risk of becoming cancerous. If your biopsy contains these cells, we will recommend a hysterectomy.
Ovarian Cancer—Ovarian cancer is not so easy to discover early, and that is why it is so serious. A diagnosis of ovarian cancer will require a hysterectomy.
Uncontrolled Bleeding–The need for hysterectomy is also urgent if a woman has bleeding that cannot be controlled. A rupture of the uterus during childbirth or failure of the uterus to contract after delivery may lead to life-threatening, uncontrolled bleeding.
Unmanageable Infection—Pelvic inflammatory disease is an infection within a woman’s reproductive organs. When the infection cannot be controlled by antibiotics, and the patient is becoming critically ill, a hysterectomy to remove the infected tissues may be life-saving.
We may also recommend surgery after considering other options…
Pelvic Pain—Pain in the lower abdomen may be caused by problems with the reproductive organs. Endometriosis, uterine fibroids, infection, and problems with the ovary or fallopian tube can cause pelvic pain. Scar tissue that forms due to previous surgery in the abdomen can also cause pain. If you have pain, we first need to determine whether your reproductive organs are involved. For endometriosis or uterine fibroids, we want to offer the most conservative treatment first, especially if you are considering a future pregnancy. If hormonal medications are not helpful, we may suggest a conservative surgery to remove endometriosis tissue or fibroids without removing the uterus. These are usually not permanent solutions. But they may offer enough improvement to avoid a hysterectomy. Sometimes fibroids and endometriosis will improve after menopause.
Note: Pelvic pain, along with abnormal uterine bleeding and a positive pregnancy test, may indicate a tubal pregnancy. A tubal pregnancy requires immediate evaluation and treatment.
Heavy or Frequent Periods—Sometimes a woman’s periods become heavier, more irregular or uncomfortable because of endometriosis, fibroids, or hormonal changes associated with approaching menopause. Hormonal medication may provide relief. Whether to consider hysterectomy depends on how much a woman’s periods interfere with her quality of life and on her plans for future pregnancy.
Pelvic Organ Prolapse—Sometimes, related to childbirth or simply growing older, a woman’s pelvic muscles lose their ability to support the uterus, vagina, bladder, and other pelvic structures in place. Symptoms include feeling pressure, sagging, and problems with bowel or bladder control. Conservative treatments include pelvic exercises, hormone medication, and a vaginal insert to help support the pelvic organs. Whether to consider surgery depends on the degree of discomfort and on the severity of the prolapse.
Genetic Risk–Women who carry genetic risk for ovarian or uterine cancer (BRCA gene mutations, Lynch Syndrome) may consider surgery to remove the ovaries or a complete hysterectomy after their childbearing plans are complete, to reduce the risk of these cancers.
We may advise against hysterectomy…
Life circumstances can change. A woman considering hysterectomy should carefully consider whether any change in her life would affect her future childbearing plans. Women with serious, non-gynecologic health problems will want to consider the risks that surgery poses. We will work closely with other physicians involved in your care if you need to have surgery. A hysterectomy will be the best treatment for many women. But having a hysterectomy does not guarantee relief from pelvic pain or symptoms of endometriosis. It does not treat uncomfortable symptoms of peri-menopause (hot flashes, mood problems). Hysterectomy is generally not recommended to treat premenstrual dysphoric disorder (intense physical and emotional symptoms related to the menstrual cycle). We want to help you explore the most conservative treatment options first.
The good news, if you decide to have surgery…
For over 90% of our patients undergoing hysterectomy, we are able to offer a minimally-invasive procedure, either a vaginal or robotic hysterectomy. The robotic approach has made minimally-invasive hysterectomy available to women who—because of large fibroids, prior pelvic surgery, or other conditions–would otherwise have required large abdominal incision.
The physicians at Sparks & Favor feel that robotic surgery offers the possibility of less blood loss, less post-operative pain, shorter hospital stays, and a quicker return to your normal activities compared with traditional abdominal surgery. Today, a woman undergoing hysterectomy generally does not have to plan for 4 to 6 weeks away from her normal life. Most of our patients stay overnight in the hospital and return to work or their usual activities in one to two weeks.