Hysterectomy – HealthyWomen

Diagnosis

A hysterectomy may be recommended as treatment for a variety of gynecologic conditions. However, in most cases, a hysterectomy is the most invasive option and only one of various treatments that may be available to you. Like any major surgery or treatment, it should be considered carefully, and you should understand why it’s being recommended and the risks and benefits associated with it.

There has been much concern in recent years that too many unnecessary hysterectomies are performed. To decide if a hysterectomy is the right procedure for you, consider getting a second opinion. Most insurance companies will cover the cost. You may want to ask your primary care doctor for a referral to another doctor. Seeking the advice of another health care professional could reveal options you may not have considered.

Below is a list of conditions that often are treated with a hysterectomy; benefits and risks of other treatment options are also included.

Abnormal Uterine Bleeding (AUB)

Many women with abnormal uterine bleeding (AUB) have a hysterectomy, but this approach may be more aggressive than necessary. Abnormal uterine bleeding, or menorrhagia, refers to menstrual periods that are abnormally heavy, prolonged or both or may refer to bleeding between periods. In general, AUB is diagnosed when abnormal bleeding interferes with daily activities and there is no evidence of a physical cause (like cancer or endometriosis).

Abnormal uterine bleeding is a common problem for women between ages 40 and 50 when hormone levels begin to change in the five to seven years before menopause—when menstrual periods end forever.

Here are several alternatives to hysterectomy as a treatment option for AUB:

• Endometrial ablation. This minimally invasive surgery uses electrical energy, heat, a balloon or freezing to destroy the endometrium, or uterine lining. It can minimize or stop heavy bleeding, but should only be considered in women who are certain they no longer wish to ever become pregnant.Success rates of endometrial ablation vary depending on the specific procedure used and the patient, but success rates for the following three to five years are generally quite high.Risks of endometrial ablation are rare. They include:
  • perforation of the uterus
  • injury to other pelvic organs
  • bleeding
  • infection
  • overloading of fluid into the bloodstream
  • accumulation of blood within the uterus because of scarring.
• Hormonal treatments. Abnormal uterine bleeding can also be treated with hormonal treatments, like oral contraceptives (estrogen and progestin) that help to balance your body’s hormones. Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.
• Progesterone IUD. Mirena, an intrauterine device that contains the progesterone levonorgestrel, helps decrease heavy bleeding for some women by slowly releasing progestin into the uterus for up to five years.

Uterine or Endometrial Cancer

Uterine (endometrial) cancer is the most common reproductive cancer in women. Hysterectomy, together with some form of cancer therapy, may be the only treatment choice you have. Your chances of curing this cancer are usually good if it’s diagnosed in its early stages—when the cancer is confined to the uterus and hasn’t spread to other organs.

The type of treatment recommended depends on when the cancer is diagnosed. Hysterectomy is the most common treatment. It generally involves removing the uterus and cervix. This type of hysterectomy is called a total hysterectomy. (Details about other types of hysterectomy can be found in the Treatment section of this topic.) The surgeon may also remove pelvic lymph nodes to determine if the cancer has spread beyond the uterus.

Surgery may be preceded or followed by radiation therapy and, in some cases, chemotherapy.

Ovarian Cancer

Ovarian cancer is the fifth-leading cause of cancer death among women. It is the leading cause of death from gynecologic cancer because less than 20 percent of cases are diagnosed before the cancer has spread beyond the ovaries. If diagnosed and treated at an early stage, however, the five-year survival rate is up to 94 percent.

The initial treatment for ovarian cancer is surgery to remove the ovaries. A hysterectomy is often performed, too, depending on how far the disease has spread and a woman’s age.

Fibroids

About one-third of hysterectomies are performed every year in the United States to treat fibroid tumors. Noncancerous balls of muscular tissue, fibroids can grow inside the uterus, on the surface of the uterus or in the muscular wall of the uterus. They can range in size from less than an inch in diameter to the size of a grapefruit. They don’t always produce symptoms.

However, even small fibroids that bulge into the uterine cavity can cause heavy menstrual bleeding. Plus, these fibroids may affect fertility by interfering with an embryo’s ability to attach to the uterus. Large fibroids might cause frequent urges to urinate; they can also cause heaviness and discomfort in the pelvic region.

If fibroids aren’t causing any problems, however, you don’t need treatment. Plus, because fibroids tend to shrink after menopause, women in their late 40s or early 50s with fibroid-related symptoms may opt to wait to see if symptoms go away with menopause.

Although hysterectomy permanently removes fibroids (because a hysterectomy removes your uterus), there are other options for treating fibroids. These include:

• Hormone-suppressing drugs. Drugs called gonadotropin-releasing hormones (GnRH) agonists, such as leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex) that are typically used to treat endometriosis, can also help shrink fibroids. Their effects, however, are usually temporary, and the fibroids may eventually grow back larger than before. GnRH agonists also produce side effects in some women, such as hot flashes, headaches, vaginal dryness, constipation and decreased sex drive.
• Myomectomy. This procedure is one of the best options for treating fibroids if you want to preserve your fertility. During an abdominal myomectomy, fibroids are cut out of the uterus and removed through an incision in the abdomen, and the uterine muscle wall is reconstructed with sutures.If fibroids are located in the uterine cavity, they may be removed through the vagina without an abdominal incision in a procedure called hysteroscopic myomectomy. The technique involves the use of an instrument called a hysteroscopic resectoscope and is primarily useful for women with bleeding or fertility-related problems.They may also be removed laparoscopically, using a small telescope called a laparoscope. During this procedure, a few small cuts are made in your abdomen or pelvis, which allow the laparoscope and other small instruments to be slipped inside, thus enabling the surgeon to remove the fibroids without having to make a large incision.The benefit of a myomectomy is that it preserves the uterus and cervix so pregnancy is still possible. Myomectomy is also an option for women who wish to preserve their uterus for any reason.Also, it may take longer to recover from an abdominal myomectomy than from a vaginal or laparoscopic hysterectomy. Although the goal of myomectomy is to preserve your uterus and your ability to have children, the procedure may cause scarring in the uterus that could require you to have a cesarean with your next pregnancy.
• Uterine artery embolization (UAE). In this minimally invasive procedure, a narrow, flexible tube called a catheter is passed through the femoral artery in the groin into the uterine artery. Once there, tiny plastic particles the size of grains of sand are slowly released into the blood vessels feeding the fibroid. The particles wedge in the vessels (but can’t travel to other parts of the body), blocking blood flow to the tumor. Without a blood supply, the fibroids shrink.Fibroid embolization usually requires an overnight hospital stay. Most women return to normal activities within a week. Risks include moderate to severe pain and cramping in the first few hours after the procedure, and nausea, fever and infection. Rarely, a woman might enter menopause after embolization. A small percentage of women are readmitted to the hospital after the procedure for complications, some of whom require additional surgery.

Endometriosis

Endometriosis occurs when cells from the endometrium—or your uterine lining—grow outside the uterus and adhere to other parts inside your pelvis, such as the ovaries, bowel, fallopian tubes or bladder.

Hysterectomy is generally recommended for endometriosis only when the disease is severe.

Hormone-suppressing drugs used to treat fibroids are also considered effective for endometriosis since both conditions are affected by your body’s production of estrogen. As with fibroids, benefits from these treatments may be temporary.

Aside from hysterectomy, surgical treatments for endometriosis include:

• Electrocautery techniques, in which stray endometrial tissue is burned away
• Excision, in which endometrial tissue is cut out
• Laser vaporization, which uses the laser to destroy the affected tissue

These procedures can usually be done laparoscopically and are often used when preserving fertility is important. Endometriosis frequently recurs, but the addition of postsurgical medical therapy, such as birth control pills or GnRH agonists, such as leuprolide (Lupron) or danazol (Danocrine), for six months may increase the pain-free interval.

The only definitive treatment for endometriosis is removing the ovaries to reduce your body’s production of estrogen, which triggers the growth of endometrial tissue.

Pelvic Prolapse

Pelvic prolapse (a term that describes when the uterus drops into the vaginal canal) occurs when the ligaments that support the pelvic organs fail.

This weakening can occur with age, estrogen deficiency, obesity or after multiple births. Once this pelvic support weakens, pelvic organs, including the uterus, bladder and rectum, may sag, resulting in pressure, rectal discomfort and problems with bladder and bowel control.

Losing weight, stopping smoking and avoiding constipation by getting plenty of liquids and fiber in your diet can sometimes help. Additionally, you can strengthen your pelvic muscles with Kegel exercises. To do these exercises, tighten and relax the muscles used to stop the flow of urine. This strengthens the vaginal canal and pelvic floor muscles, helping control urine flow and enhancing orgasm.

You may also be fitted with a pessary, a device placed in the vagina that holds the organs in place.

Another treatment is short-term hormone therapy to make the vaginal tissue suppler. Estrogen prevents drying and thinning of the vaginal tissues. Supplemental estrogen can help strengthen vaginal tissues. However, because of the potential risks of estrogen therapy, such as increased risk of blood clots, breast cancer and gallbladder disease, the decision to use estrogen must be made only after you and your doctor have weighed all the pros and cons.

Surgery can be an option when organs have prolapsed. Surgery may involve creating a sling for the bladder or using specialized surgical tape to keep the bladder or uterus in place, or removing the uterus, via hysterectomy.

Dysplasia

Removing the uterus and cervix was once standard practice for a common precancerous condition called dysplasia, or cervical intraepithelial neoplasia (CIN). Today, cutting, burning or freezing the diseased portion of the cervix is generally recommended for CIN, and hysterectomy is rarely performed for this condition.

Treatment depends on the severity and location of dysplasia, your age, health status and whether you want to preserve your ability to have children.