Alternatives to Hysterectomy

Hysterectomy is the second most common surgery performed on women in the United States. Each year, more than 600,000 women undergo hysterectomy, a procedure in which the uterus is removed. Sometimes the ovaries are taken out as well. It is performed in the operating room at a hospital and generally requires an overnight stay of one to two nights and a few weeks to two months of recovery time at home.

Hysterectomy may be recommended for many different reasons, including gynecologic cancer, fibroid tumors, endometriosis, abnormal vaginal bleeding, and chronic pelvic pain. Uterine prolapse, a condition in which the uterus descends into the vagina due to weakening of its support structures, is also a common indication for surgery to remove the uterus.

Some of these conditions can now be treated with procedures other than hysterectomy. As technology has developed, other options have become available for the management of gynecologic problems. Many of these new techniques allow for a much more rapid recovery time and an excellent chance for improvement in a patient’s symptoms.

Endometrial ablation

In endometrial ablation, the doctor treats the lining of the uterus by destroying a thin layer called the endometrium. The endometrium is the inner portion of the uterus that is shed each month during menstruation. This procedure is performed by a gynecologist. It is usually done as an outpatient and the patient is able to go home the same day. Depending on the type of procedure used, up to 50% of patients treated with this technique may have no menstrual flow for up to five years, and up to 90% have improvement in their menstrual flow.

An endometrial ablation can be completed in many ways, and at least five different instruments have been approved by the Food and Drug Administration (FDA) to perform this surgery. Successful removal of the lining of the uterus can be accomplished using many different techniques, the most common of which are:

• Hysteroscopy with rollerball electrocautery. A telescope placed into the uterus and with electricity applied to a small ball mounted on the end of the telescope.
• Fluid filled balloon (Thermachoice©). A thin balloon is inserted in the uterus and filled with superheated water.
• Bipolar electrocautery (Novasure©). A mesh device with electricity introduced into the uterus. A computer is used to measure when the lining of the uterus has been fully treated.
• Sometimes the doctor may give a patient some medication to thin the lining of the uterus prior to performing the procedure in order to increase the chance of a successful outcome. Newer procedures like the Novasure© do not require medical therapy in preparation for surgery.

An endometrial ablation should not be used with women who may want to become pregnant. It is used only in the treatment of abnormal bleeding, and is not indicated for use in patients with uterine prolapse, endometriosis, pelvic pain, or gynecologic cancers.

Uterine artery embolization

Uterine artery embolization (UAE) is primarily used for the treatment of uterine fibroids, which are growths of smooth muscle that can cause abnormal bleeding, pain, or fertility difficulties. With this procedure, which is performed by an interventional radiologist, a small catheter or tube is inserted into an artery in the groin under local anesthesia. The catheter is then guided up into the arteries supplying blood to the uterus, and small particles are injected to block blood flow in those arteries. The patient usually stays in the hospital overnight.

Research shows that UAE can shrink the size of fibroid tumors and decrease the size of the uterus, reducing symptoms associated with a large uterus such as pressure on the bladder or rectum. UAE is also associated with a reduction in menstrual bleeding. Up to 85% of patients can experience an improvement in their symptoms.

Conception and childbearing after UAE have not been fully studied, so patients desiring more children should carefully consider before proceeding with UAE. UAE does not completely remove all fibroid tissue; therefore, it is possible for a patient still to require a hysterectomy at a later date. UAE is not indicated for use in patients with uterine prolapse, endometriosis, or gynecologic cancers.

Myomectomy

Similar to UAE, myomectomy is used for the treatment of uterine fibroids. Myomectomy involves the surgical removal of individual fibroids by a gynecologist, either through an incision in the abdomen or telescopes called a laparoscope or hysteroscope (described further below). If an incision is made in the abdomen to perform the procedure, the patient will have to stay in the hospital for one to two days.

A woman may still pursue childbearing after myomectomy. A myomectomy can cause internal scarring that leads to infertility, however, and any subsequent babies may need to be delivered by cesarean section. Because the uterus is not removed, more fibroids may develop later, and surgery could be needed again in 20-40% of patients.

Laparoscopy

Laparoscopy is the use of a camera and instruments inserted through small incisions in the abdomen. The technique can be used for the removal of fibroid tumors, scar tissue, endometriosis, and even small ovarian masses. The treatment of these conditions is performed by a gynecologist, and the patient is usually able to go home the same day. Removal of fibroids, scar tissue, or endometriosis using laparoscopy can result in an improvement in symptoms, either temporarily or long-term. Some patients, however, may require more surgery if their symptoms return at a later date and further treatment is needed.

Hysteroscopy Hysteroscopy is the use of a camera and instruments inserted through the cervix to perform surgical procedures in the uterus. This procedure is mostly used for the management of abnormal uterine bleeding, and often includes a dilation and curettage (D&C). Hysteroscopy can be used for the removal of fibroid tumors or other small growths within the uterine cavity, which may result in an improvement in bleeding. But similar to other procedures, sometimes these conditions can recur and need future therapy.

There are many different reasons a doctor may recommend a hysterectomy. For some of these conditions, such as certain gynecologic cancers, very few non-surgical treatment options exist. For others, there may be alternatives to hysterectomy available. Be sure to talk with your doctor about your condition and what alternatives may be appropriate for you.

Dr. Welsch is a board-certified obstetrician/gynecologist in private practice with the Jackson Clinic. He has served on multiple national committees with the American College of Obstetricians and Gynecologists (ACOG) and has most recently been appointed to the Committee on Practice Management. He is a member of the Ethics Committee at Jackson- Madison County General Hospital and also serves on the boards of the Augustine School and the Jackson-Madison County Library Foundation.