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Do You Really Need A Hysterectomy?

Now there are alternatives—and less radical procedures

If your doctor is recommending a hysterectomy, don’t sign the consent form before exploring all the alternatives.

According to the National Women’s Health Network, hysterectomy is the second most commonly performed surgical operation in the U.S. (after Cesarean delivery), with more than 600,000 hysterectomies performed each year. Many physicians and women’s health advocates argue that 75 to 80 percent of those surgeries are not necessary. Many women don’t know there are alternatives or less-invasive options, like laparoscopic surgery. Why hysterectomy?

Laparoscopic hysterectomy
For women aged 35 to 54, the most common reasons for a hysterectomy are fibroids, endometriosis, and abnormal bleeding; after age 55, the most frequent reasons are uterine prolapse or cancer. However, there are new treatments for fibroids and bleeding that can help women avoid a hysterectomy.

Even the largest fibroids can be removed surgically; others can be destroyed by freezing or cutting off their blood supply with lasers, electrocautery, or tiny plugs in blood vessels (uterine artery embolization). Abnormal bleeding can be halted by various means of destroying the uterine lining. Prolapse can usually be corrected surgically without removing the uterus.

There are times when hysterectomy may be unavoidable, however; some women who have endured years of pain and bleeding do choose hysterectomy. But even when the diagnosis is cancer, there are still choices to consider, and some younger women with early cervical cancer may be able to preserve both their uterus—and their fertility.

Less-radical surgeries

A total hysterectomy involves surgical removal of the uterus and the cervix. If the uterus is removed but the cervix is left in place, the surgery is called subtotal or supracervical hysterectomy. When the fallopian tubes and ovaries are also removed, the words bilateral salpingo-oophorectomy are added to the name of the procedure. In a radical hysterectomy, the surgeon not only removes the uterus, tubes and ovaries, but also the upper part of the vagina and some surrounding tissue and lymph nodes.

Radical hysterectomy is usually reserved for women with gynecological cancer. If the diagnosis is fibroids, even if there are multiple fibroids, the uterus does not need to be removed, insists Ernst G. Bartsich, MD clinical associate professor of obstetrics and gynecology at the Weill Medical College of Cornell University. “If there are a lot of fibroids and the uterus is greatly enlarged, and a woman has completed childbearing, just the top of the uterus can be removed. There’s no reason to do a hysterectomy.”

Radical hysterectomy is done through an abdominal incision. If just the uterus is being removed, the surgery can be done through a vaginal incision. Abdominal hysterectomy has a four- to five-day hospital stay and a six- to eight-week recovery. Vaginal hysterectomy usually involves a two-day hospital stay, and a two- to four-week recovery. But there are other reasons for choosing less-radical surgery.

Removing risk?

For one thing, unless you have a family history of ovarian cancer, there’s no reason to remove the ovaries. Back in the 1960s, it was believed that the ovaries stopped working after a hysterectomy, and removing them prevented the possibility of ovarian cancer. Even though it’s now known that the ovaries continue to make small amounts of important steroid hormones after menopause, half of all hysterectomies involve removal of the ovaries and tubes.

“There are still those who believe the ovaries should be removed in women after age 40 if the uterus is being removed. But the incidence of ovarian cancer is not high enough to justify the routine removal of the ovaries in a premenopausal woman,” insists Dr. Bartsich. “Even if women are not having periods, they are still making steroid hormones essential for their well-being. So the hormonal status of the woman should always be checked beforehand. There are many biochemical interactions that are not well understood, and if the ovaries are still functional, their removal amounts to a castration.”

In fact, removing the ovaries in a woman in her 40s and even 50s greatly increases the risk of osteoporosis and coronary disease, and brings on an abrupt menopause with more severe symptoms.

Keeping sexual function

Unless you have invasive cervical cancer, there’s also no reason to remove the cervix.

“The cervix is essential for the support of the vagina, bladder, bowel and the rectum. By removing the cervix, the surgery takes longer, and increases the risk for bleeding and injuries to the bladder and ureter,” says Dr. Bartsich. After removal of the cervix, the vagina and bladder may prolapse, and a woman may experience a lessening of vaginal lubrication and sexual sensation.

The cervix is also an important nerve center, Dr. Bartsich notes. A key group of nerves (the Frankenhauser plexus) merges behind the uterus and cervix , and the muscles and nerves that run through the cervix itself are felt to be important in sexual response. “There’s a parallel with the problems that occur in men after a radical prostatectomy. If important nerves are cut, a man becomes impotent. A woman can become impotent, too.” Some studies say women report feeling better after a hysterectomy, and that their sex lives even improve. But Dr. Bartsich stresses that it’s important to know whether pain and bleeding had interfered with a woman’s sexuality before the surgery.

The laparoscopic alternative

According to the American College of Obstetricians and Gynecologists (ACOG), 74 percent of hysterectomies are performed abdominally, and only 26 percent are done vaginally.

Now there’s an even less-invasive alternative—laparoscopic supracervical hysterectomy (LSH). Using a trocar (a narrow, tube-like instrument), a tiny telescope (a laparoscope) is inserted through the navel to allow the surgeon to view the internal organs on a video monitor. Small surgical instruments are inserted through two or three additional trocars, and the uterus can be removed in small pieces through one of the incisions, explains Thomas L. Lyons, MD, at the Center for Women’s Care and Reproductive Surgery in Atlanta.

LSH requires only a one-day hospital stay, and recovery takes seven to 14 days. Patients resume normal activities more quickly with fewer complications, says Dr. Lyons. “Our patients who have had LSH have less bowel and bladder dysfunction postoperatively.” In addition to less post-op pain, there’s less trauma and scarring to the vagina, so patients resume their sex lives sooner. LSH can be used to treat abnormal bleeding, fibroids, endometriosis, and some ovarian cancers.

Preserving fertility

There’s also a new option for some younger women with cervical cancer who want to have children. It’s called laparoscopic vaginal radical trachelectomy (LVRT). LVRT was actually developed a decade ago in France, but interest in it has recently increased.

What you can do
Traditionally, cervical cancer patients have been treated with radical hysterectomy. However, in LVRT, the lymph nodes around the uterus are removed in a laparoscopic procedure and if the cancer hasn’t spread, only the cancerous cervical tissue is removed through a vaginal incision, leaving the uterus intact. The surgeons then place a drawstring-like suture around what remains of the cervix, closing off the uterus. LVRT takes about two hours and requires a two- to three-day hospital stay. If a woman becomes pregnant, the baby is delivered by Cesarean.

Lynda Roman, MD, co-chief of gynecologic oncology at the University of Southern California Comprehensive Cancer Center, says LVRT is best for selected women with early-stage cervical cancers less than 2 centimeters (about an inch) in size. The journal Cancer reported last year that among 47 procedures done in France between 1987 and 1996, there were only two recurrences, both in women with large cancers. Of the 25 women who wanted to become pregnant, 13 succeeded.

A report in the November 2001 Obstetrics and Gyneclogy says some women can even preserve fertility with just a cone biopsy procedure to remove only the cancerous tissue.

This article originally appeared in the December 2001 issue of Women's Health Advisor.

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