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Andrea Price,
M.D., F.A.C.O.G. 
"Do You Really Need
That Hysterectomy?"
When I first
arrived in the rural heartland from the big city a couple of years
ago, one of the very first things I noticed was the sheer volume
of patients who had hysterectomies performed…and at a very
young age. It seemed as if the majority of women in their late
30's who had finished childbearing had no uterus. After a year
I nearly forgot what a cervix looked like and when I ran across
a woman over the age of 40 who had managed to retain her uterus,
my nurse and I literally would get excited. It seemed as if the
most common reason for removing a uterus was the identical reason
people give for wanting to climb Mt. Everest, or even the reason
the chicken crossed the road…because it was there!
OK, I admit
it. I may be exaggerating just tiny a bit, but only to illustrate
my point that there still exists an old school of thought among
some medical professionals and lay people who believe, "if
you are finished childbearing, the uterus and ovaries serve no
purpose other than causing annoying monthly bleeding, and being
a reservoir for the potential development of cancer years down
the line". Therefore, many women are being needlessly hysterectomized
at the first sign of pelvic pain, a small fibroid tumor, or a
few irregular periods, when they could have been very successfully
treated using conservative uterus saving measures. Unfortunately,
many of these women soon find out that the uterus was indeed there
for a reason.
The
function of a uterus
Pelvic
support
In addition to being the baby carriage, the place where a baby
matures, develops and grows over nine months, the uterus serves
the following functions. First and most importantly, the uterus
is a part of the pelvic support structure. To put it simply, the
uterus plays a major role in holding pelvic organs in their proper
positions. The bladder, the ovaries and the vagina are all supported
by ligaments attached to the uterus that must be cut when a hysterectomy
is performed. When these ligaments are cut there is not much left
to support these organs. This leaves the bladder, the rectum and
the vagina much more likely to fall down over time, and at a younger
age than in women who have not had a hysterectomy. Normally, as
a woman ages the pressures of childbearing and gravity contributes
to the tissues no longer being as strong as they once were. How
many of you have noticed that after the birth of that second or
third child, occasionally you had to suddenly had to cross your
legs and squeeze very tightly while coughing, laughing hard, or
jumping up and down in that hip-hop aerobics class, in order to
keep from accidentally leaking urine? This occurs more frequently
once the uterus is removed. The loss of support often leads to
incontinence far more severe than occasional slight urine leakage.
Incontinence or loss of bladder control can be a very embarrassing
problem requiring constant usage of pads and diapers, or worse,
social isolation.
Sexual
gratification
In addition to pelvic support there is also mounting evidence
that the uterus may play a major role in sexual gratification.
Now that I have your attention here's the real "skinny".
While most women feel pain when the cervix is "bumped"
when penetrated deeply during sexual intercourse, many women find
this sensation to be pleasurable, contributing to enhanced sexual
excitement. The uterus may also contract during orgasm, which
further heightens sexual pleasure. For many women, after the removal
of the uterus, sex will never be quite the same. However, this
does not hold true for all women.
Many women
feel that being free from worries about uterine and cervical cancer
and free from symptoms of "female problems" is well
worth the compromise. For example, if you are suffering from severe
pelvic pain from endometriosis, uncontrollable heavy bleeding
due to a fibroid, or discomfort from your uterus falling down
into your vagina, a hysterectomy may be just what is needed to
allow you to comfortably have sexual intercourse again, and enjoy
it!
Cultural
considerations
In many Asian, African, Hispanic and African American cultures,
the uterus is viewed as the essence of a woman's femininity. To
remove the uterus is almost tantamount to taking away her "womanhood",
and this in itself can be devastating.
What about the ovaries?
Another factor
a woman must take into account when considering a hysterectomy
is whether or not to have her ovaries removed. Unless you are
post-menopausal (past the "change of life"), your ovaries
are still producing estrogen, which protects from bone loss, heart
disease and keeps the vaginal skin thick, moist and healthy. The
ovaries also produce small amounts of androgens or "male
hormones" which are largely responsible for a woman's sex
drive. Androgens are our body's own built-in source of Viagra
[smile]. Normal, functioning ovaries should never be removed simply
because a hysterectomy is being performed. This is a serious consideration
to be thoroughly discussed with your gynecologist.
Hysterectomy
alternatives
While it
is beyond the scope of this column to go into detail about each
type of treatment available, here is a brief overview of a few
common problems and possible alternative treatments:
Fibroid
Uterus - A fibroid is a benign tumor made of muscle tissue
in the wall or lining of the uterus. In many cases a myomectomy
(cutting out the fibroid tumor) can be performed rather than removing
the entire uterus. Some myomectomies can even be performed through
the laparoscope (belly button surgery). A new treatment called
uterine artery embolization (UAE) is being performed at some medical
centers. This procedure involves injecting material into the main
blood vessel that supplies a fibroid tumor causing the tumor to
"die" or degenerate. If you are near menopause, it is
possible to use a drug called lupron to temporarily shrink the
fibroid and relieve symptoms until menopause is completed. Once
you are menopausal, fibroids will continue to shrink on their
own ultimately becoming inactive.
Dysfunctional
Uterine Bleeding (DUB) - This is heavy, irregular, or uncontrollable
bleeding. The first line of treatment for this condition involves
using hormones to control bleeding. If you are a person who cannot
take hormones, or you tried hormonal treatment and it failed,
ask about endometrial ablation using Thermachoice. This safe,
easy to perform procedure destroys the lining of the uterus using
extreme heat for a few minutes. Eighty-five percent of women who
undergo endometrial ablation by this method see significant
improvement or a complete cure of any abnormal bleeding.
Chronic
Pelvic Pain
- This is pain in the pelvis that does not respond to conservative
treatment such as pain relievers and birth control pills. One
option is called trigger point injection. The doctor carefully
examines the patient trying to identify a "trigger point",
or the area where the pain originates. The doctor will then inject
the area with numbing medicine and/or steroids to provide relief.
There is also a surgical procedure that is often done which involves
cutting the nerves to the pelvic organs, which may alleviate pain.
You may also be referred to a chronic pain clinic or pain specialist
who is specially trained to treat all types of chronic pain. Also,
many people have successfully used acupuncture or hypnosis as
a means to control pain.
What
can I do if I am not a candidate for any of these treatments?
If you are
not able to have any of the above treatments, then you may require
a hysterectomy. However, in lieu of a traditional abdominal or
vaginal hysterectomy, there is a less intrusive method available.
" Supracervical
hysterectomy - A traditional hysterectomy involves removal of
the cervix along with the uterus. In a supracervical hysterectomy
only the body of the uterus is removed and the cervix remains
intact. The advantage of this method is that the main support
ligaments to the vagina and bladder are not cut, thus leaving
less of a chance for vaginal and bladder support problems (including
incontinence) later. Often this surgery is performed through the
laparoscope (belly button) and you may go home the same day or
the next morning.
This surgical
method is a good option to consider if you must have a hysterectomy
and you have a history of normal PAP smears. This procedure is
not appropriate if the cervix is abnormal and needs to be removed.
Conclusion
While there
are many legitimate reasons for a woman to have her uterus removed,
we are fortunate to live in an era where there are many new and
alternative treatment options available, allowing more choices
when it comes to reproductive health. A woman need not jump to
the extreme of a hysterectomy without exploring all uterus saving
options available to her. The best advice I can give is to educate
yourself about your particular diagnoses, ask plenty of questions,
and if you are at all uncomfortable or unsure, seek a second opinion.
Remember,
to empower thyself is to love thyself.
andi@WomenOfColorOBGYN.com
www.WomenOfColorOBGYN.com
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