Brian W. Walsh, MD
Brian W. Walsh, MD, director, division of surgical gynecology, Brigham and Women’s Hospital, Center for Reproductive Medicine, Boston, Massachusetts.
Hysterectomy is the second most common surgery in the US for women — by age 60, one in three American women will have her uterus surgically removed. Though this presents a seemingly direct solution to one set of problems — such as excess bleeding from fibroids or endometriosis — as major surgery, it has risks. In addition, possible unintended consequences from hysterectomy include chronic pelvic pain, bladder injury and decreased sexual sensation.
The good news, according to Brian W. Walsh, MD, director of the division of surgical gynecology at Brigham and Women’s Hospital in Boston, Massachusetts, is that there are a growing number of less invasive alternatives to conventional, open hysterectomy, which can reduce some of the side effects and risks and are appropriate for many conditions. No woman should have a hysterectomy without first carefully and fully exploring the wide variety of options available today.
Sometimes the decision is clear — for instance, if you have a reproductive cancer, a hysterectomy may be the only way to save your life. These account for about one in 10 hysterectomies. But the majority of hysterectomies are considered “elective” for reasons that include:
In the US, the most common “cure” for many gynecological complaints continues to be surgery in the form of traditional open hysterectomy, in which the uterus (with or without the cervix, ovaries and fallopian tubes) is removed through a large incision, typically through the abdomen, that can be quite painful. This is major surgery with major repercussions. It requires a hospital stay of one to four days and a recovery of four to eight weeks — not to mention all the assorted risks of anesthesia and infection that accompany surgeries of this kind.
Less invasive options are now available, including…
Laparoscopic hysterectomy. A laparoscopic procedure — performed with small instruments through multiple small incisions in the abdomen — is usually a far better choice than open surgery, says Dr. Walsh. This outpatient procedure reduces pain, minimizes scarring and shortens recovery time. The average patient returns to work just a week or so following laparoscopic surgery. However, this is a specialized surgery that requires extensive training, and not all gynecologists perform it. If your doctor doesn’t, you may want to consult with one who does. Laparoscopic hysterectomies are best when the fibroids are not too large or if the scar tissue is not too severe.
Myomectomy. This increasingly popular alternative allows removal of fibroids while leaving the uterus intact. It’s an excellent option for women who want to retain their uterus and ability to have children. While substantial bleeding can sometimes be a problem with myomectomies, Dr. Walsh notes that he is able to circumvent this complication by placing a tourniquet around the arteries leading to the uterus before removing fibroids.
Endometrial ablation. This is an outpatient procedure to treat heavy uterine bleeding, which can be done in one of three different ways: A balloon is threaded through the vagina and cervix and into the uterus, then filled with fluid and heated, causing the uterine lining to slough off like a period. Or the same result can be achieved with cryotherapy (freezing) or electrocautery (burning, with electrical current or a laser). Since endometrial ablation destroys the lining of the uterus, it’s unlikely that a woman could get pregnant afterward — however for those few who do, the pregnancy is very high risk, so contraception is advised after an ablation.
Uterine artery embolization. In uterine artery embolization, a radiologist inserts a slender, flexible tube into uterine arteries and injects tiny synthetic particles to block blood flow to fibroids. They stay there forever, but do not seem to cause problems. Starved of their blood supply, the fibroids shrink and die. This technique preserves the uterus, doesn’t require a large incision and causes only minimal blood loss. However, pain and cramping are common afterward. Patients are usually hospitalized overnight and given narcotics. The pain can last for 48 to 72 hours, and all symptoms may not be relieved — the procedure is about 70% effective. Also, there’s little data on long-term effect on fertility, so women who want to leave open the option to have children might want to make a different choice. Gynecologists do not perform this procedure so if you’re interested, ask for a referral to an interventional radiologist.
No two women are exactly the same, so take your time, do your homework and look at all possible treatment alternatives — especially less invasive ones — to decide which is best for you. Natural remedies may be effective also. If uncomfortable symptoms persist and surgery is recommended, choose carefully — a second opinion is usually a good idea to help clarify your alternatives. Keep in mind, too, that if you are close to menopause, you may be able to simply wait it out. Fibroids shrink naturally when they are deprived of estrogen, their natural fuel. Time is on your side, and sometimes the best treatment is to just let nature take its course.
