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How To Know If A Hysterectomy Is Right for You

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Originally posted on Women's Voices for Change.

Dear Dr. Pat,

I am 51 years old and have been told that I need a hysterectomy. I have fibroids that are the size of a grapefruit and heavy menstrual periods. The bleeding has always been heavy, but it's now heavier and the heavy days are longer. I bleed enough that I have to wear a pad and a super tampon and change every three hours during the first three days of the period, then just a pad changed four times a day for another five days. I do not have any bleeding at other times. I had a pelvic ultrasound and this showed that my fibroids have not grown in size, but there are many small ones, including one that is growing into the cavity of the uterus. I am in decent shape (for my age) and don't have any other medical problems except that I am now tired more than usual. The gynecologist told me that I am anemic and that my iron levels are low. My blood count shows that I have a hemoglobin of 9 and my iron level is only 45. I had two C-sections and had a hard time recovering from these surgeries. I want to feel better, but I don't want to have this big surgery and the anesthesia and recovery if I can avoid it. I feel that if I can wait until menopause, then I won't need this surgery. My gynecologist said that the only sensible thing to do is to have a hysterectomy. She told me there weren't any other treatments that made sense because of my age. Should I have a second opinion or are there treatments other than hysterectomy that I should discuss with my gynecologist?

Thank you,

Dear Emily,

You do have a reason for fatigue with low red blood cell count and low iron levels.  And I am certain that you would like menopause to begin tomorrow with eight days of bleeding every month!

This is what I suggest you discuss with your gynecologist. First, rule out other common causes of fatigue. Check a thyroid panel, diabetes tests and basic autoimmune tests, which are common causes of fatigue. In addition, ask for basic bleeding tests to make sure that your prolonged bleeding does not have some other cause. If these tests are normal, then I do suggest that a less invasive, less risky and less expensive procedure be tried before a hysterectomy.

Hysterectomy remains the second most common major surgical procedure performed on women in the United States after Cesarean section. This is an interesting fact since there have been various advances in methods of managing non-malignant disorders of the pelvic organs that should have significantly lowered this alarming number over the past 20 years. At present, one third of all women will have undergone a hysterectomy by age 60. Approximately 600,000 hysterectomies are performed each year at an annual cost exceeding $5 billion. Adverse outcomes are possible with hysterectomy and can include mortality risks that exist with all major surgeries (which have been reported in the range of one to six per 1,000 in hysterectomy), extended recovery time, premature menopause (if the ovaries are removed) and its adverse hormonal effects, urinary incontinence, vaginal prolapse, as well as impacts on sexual functioning and consequent social life.

The most common indication for hysterectomy is the presence of enlarging or symptomatic fibroids. Fibroids, also known as myomas, are generally benign smooth muscle tumors (fewer than one in 1,000 tumors removed is a malignant leiomyosarcoma) arising from the uterine muscle. They may deform the uterus by growing very large and outward or cause other symptoms by growing into the uterine cavity.

Options other than hysterectomy for the management of fibroid tumors of the uterus include:
  1. Watchful waiting with monitoring for and treatment of anemia. This is not an option for you anymore since you are symptomatic.
  2. Since the bleeding is most likely from the fibroid extending into the uterine cavity, removing just this fibroid may solve your problem. You should discuss a procedure known as a hysteroscopy with your gynecologist.  This procedure allows the surgeon to introduce a small tube with a fiberoptic system in it through the vagina and into the cervical opening and from there into the uterine cavity.  The surgeon can visually examine the entire uterine cavity with this device. The growth can be removed in small pieces by cutting it with a very thin electrical loop. The tissue that is removed from the endometrial cavity is sent for pathologic evaluation to determine if it is, indeed, benign.
  3. If the uterine cavity is normal, the surgeon can also perform an endometrial ablation. This is a minimally invasive surgical procedure that destroys the endometrium, the lining of the uterus, and can decrease the amount of menstrual flow and in some cases may produce total loss of menstrual bleeding. The options of removal of the fibroid or ablation of the endometrium have an excellent chance of controlling your heavy bleeding associated with fibroids.
  4. If surgery is unsuccessful in controlling your heavy bleeding, then you have hormonal options to consider. The placement of a progestin-containing IUD (Mirena) often decreases heavy bleeding, even in patients with a moderately increased uterine size due to fibroids.  Another less popular hormonal option is the use of a hormone known as danzol that causes a "temporary menopause." It is less popular because patients often do not like the side effects.
You may need a second opinion if your gynecologist is not skilled at this kind of surgery or if there is too little time in his or her practice for thoughtful options to be considered and evaluated. Obviously, if these methods do not work, then you may have to undergo more extensive surgical treatment. However, myomectomy (removal of the fibroid tumors) using a laparoscopic techinque is an option to consider before hysterectomy.

The important information for you, Emily, is that menopause will solve this problem permanently, and the average age for menopause is 51.

The takeaway for you in your conversations with your gynecologist is this:
  • Make sure that the bleeding and uterine growths are not caused by a malignancy.
  • Then begin with the least invasive procedures that have been shown to work in the treatment of heavy bleeding with fibroids.
  • Be informed and encourage your gynecologist to work with you in order to have the least invasive treatment possible to diminish the heavy bleeding and get your energy back.
Most important, each patient is an individual with a unique set of symptoms and clinical findings and should be treated as such. And while two different patients may be suffering from the same condition, they should not necessarily be treated in the same manner. Each patient needs to sit down with her gynecologist and consider all positives and negatives of each treatment for her specific condition.

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