Hysterectomy Alternatives

What is a hysterectomy?

A hysterectomy is the surgical removal of a woman's uterus (and sometimes other reproductive organs) for medical reasons. The cervix, fallopian tubes, ovaries, and even part of the vagina may also be taken out. It's a common operation: About 600,000 hysterectomies are performed each year in the United States.

Why are hysterectomies performed?

If a woman has invasive cancer of the cervix, ovaries, or uterus, her doctor might prescribe hysterectomy to save her life. In such a serious situation, there may be no alternative. In addition, hysterectomy is sometimes the only option for women with very large uterine fibroids or ovarian cysts, advanced cases of pelvic inflammatory disease, and certain complications during pregnancy.

But the operation is also used to treat many conditions, such as excessive menstrual bleeding or moderate-sized uterine fibroids, for which less invasive procedures are available. If your doctor has advised a hysterectomy for a problem that isn't life-threatening, it's important to know that you may have other options.

Why should I seek alternatives to a hysterectomy?

If you are of childbearing age, perhaps the most important reason is that you would no longer be able to have a baby. Women who want to preserve this ability need to see if they have options besides hysterectomy.

And though doctors used to think that women's reproductive organs were valuable only for conception and gestation, recent research shows that the hormones produced by your ovaries may benefit your health even after you've gone through menopause.

Finally, consider the possibility that your sex life might change somewhat. Between 10 and 40 percent of women who have a hysterectomy report some loss of sexual desire or function after a hysterectomy, according to various studies. (One recent study, however, found little difference in sexual satisfaction between women who'd had a hysterectomy and those who hadn't.) In some cases, the drop in libido seems to be linked with changes in hormone levels and to the absence of the uterus, whose contractions during orgasm are thought to make the climax more satisfying.

How can I know whether I'm a good candidate for alternative treatment?

If you have uterine fibroids, menstrual bleeding that's unusually heavy and goes on for more than a week, chronic pelvic pain, prolapse of the uterus, or endometriosis, you probably can explore treatments besides hysterectomy. These will likely include drug therapy and less invasive forms of surgery.

What are the alternatives to hysterectomy?

It depends on your condition. Here are some possibilities:

  • Fibroids. An estimated one third of hysterectomies are done to treat fibroids (noncancerous fibrous growths in the uterus). One alternative, if the fibroids aren't causing any real problems, is the "wait and see" approach: You have a pelvic exam every six months so your doctor can keep tabs on their development.

If you're in considerable pain, however, you might want to have surgery to remove the fibroids. In this case, a myomectomy could be your best option: This procedure allows a surgeon to take out the fibroids while repairing your uterus and leaving it intact. You might also try hormone therapy; taking synthetic progestin or natural progesterone often alleviates fibroid-related bleeding. Some doctors prescribe GnRH (gonadotropin-releasing hormones) to shrink fibroids so that surgery won't be necessary, but in general they shouldn't be used for a period longer than six months. Since the GnRH hormones drugs induce a sort of artificial menopause, they'll likely be prescribed only if you're near menopause. The good news is that when you reach menopause the fibroids will begin to shrink naturally.

A relatively new method of treating fibroids without surgery is uterine artery embolization (also called uterine fibroid embolization). In this procedure, the doctor makes a small cut in your groin and inserts a catheter into an artery above the fibroid. Through the catheter, tiny particles are injected into the artery. The particles then block the blood flow to the fibroid, causing it to shrink. While artery embolization has been in use for over 20 years, it has only recently been approved in the treatment of fibroids. The U.S. Food and Drug Administration cautions that the procedure isn't without risk, with premature menopause, pelvic infection, pregnancy complications, and delayed diagnosis of uterine cancer being reported by some women. While the number of complications have been small, they are significant, the agency says.

Focused ultrasound surgery is another treatment you may want to consider. An MRI scanner helps doctors locate fibroids and focus high-frequency sound waves on them to destroy them. So far, ultrasound surgery appears to be a useful, non-invasive treatment, however its long-term effectiveness is not known, and since it is not yet a standard treatment, your health insurance may not cover it.

  • Endometriosis. There's quite a variety of treatments for endometriosis , a painful condition in which the tissue that lines the uterus grows into neighboring areas. You can try drug therapy (including GnRH and progesterones); oral contraceptives may also relieve cramping and pain. Some gynecologists also recommend adding fish-oil supplements or sardines to your diet to reduce menstrual cramps. If these approaches don't work, you may want to have a surgeon remove the abnormal growths. Your surgeon may also use a tiny device called a laparoscope to look at the cysts and lesions, which can then be removed or vaporized with a laser.
  • Dysfunctional uterine bleeding. Women with excessive or protracted menstrual bleeding related to ovulation problems can be treated with a surgical procedure called dilation and curettage, or D & C. The cervix is dilated and the uterine lining scraped out. Another option is drug therapy, in which progestins, oral contraceptives, or nonsteriodal anti-inflammatory drugs (NSAIDs) such as ibuprofen may be used. Another approach is to destroy the uterine lining in a process called endometrial ablation. It can be done through laser surgery or a new procedure known as "uterine balloon therapy." In this technique, a balloon is filled with liquid and inserted into the uterus through the vagina; then the liquid is heated, eliminating the uterine lining.
  • Chronic pelvic pain. Drug therapy, using NSAIDs or oral contraceptives, for instance, is one option. In addition, some women have reported relief with the use of biofeedback, acupuncture, or relaxation techniques, though no studies have been done to confirm the effect.
  • Prolapsed, or "dropped," uterus> For this condition, in which weakened pelvic muscles have allowed the uterus to "relax," you can have a pessary placement, which is an office procedure. A device called a pessary is inserted into your pelvic area to hold the uterus in place.

References

Mayo Clinic. Uterine Fibroids. June 2009.

Mayo Clinic. Chronic Pelvic Pain. February 2009.

National Women's Health Information Center. Uterine Fibroids. May 2008.

Rhodes JC, et al. Hysterectomy and sexual functioning. JAMA 1999 Nov 24;282(20):1934-41.

Brigham Narins, Editor. World of Health:573-4. The Gale Group 2000.

Poma PA. Nonsurgical management of genital prolapse. A review and recommendations for clinical practice. J Reprod Med 2000 Oct;45(10):789-97.

Dayal M, et al. Noncontraceptive benefits and therapeutic uses of the oral contraceptive pill. Semin Reprod Med 2001;19(4):295-304.

FDA Clears Device to Treat Fibroids. FDA Talk Paper T02-48. November 26, 2002.

National Womens Health Information Center. Hysterectomy. July 2006.

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