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Hysterectomy

Marcy Holmes, NP, Certified Menopause Clinician

For women considering hysterectomy

An update on new options and alternatives

By Marcy Holmes, NP

One of the most frequently asked questions women have asked about their health is some variation of “Do I need a hysterectomy?” Or, “I’ve been told I need a hysterectomy. What are my alternatives?” If you are struggling with heavy bleeding or fibroids — two common problems leading to hysterectomy — you may feel that surgery is your only choice. But you should know that it’s not. Many women have had great success with alternatives to hysterectomy and, when surgery truly is required, with cutting-edge techniques that are the least invasive possible.

It’s likely that you already know a few women who’ve had a hysterectomy — about a third of American women have one by age 60! For some it is a relatively care-free experience, but for others, entry into surgical menopause is fraught with severe hormonal symptoms and dependence on hormone replacement therapy. Women who opt for elective surgery are sometimes unprepared for the debilitating side effects they experience. Weighing the benefits versus the risks of hysterectomy with your practitioner, in light of your own health history, is something every woman must do for herself when faced with this decision. The more you know, particularly about alternatives, new technology and procedures, the better equipped you’ll be to make the right choice for you.

So let’s take another look at this topic and see what’s new.

Understanding the basics

Let’s start by reviewing the anatomy, so we are clear about what’s involved, and what’s at risk. The uterus (“uter” is Latin for “bag”) is also known as the womb. It is a pelvic organ suspended by ligaments between the bladder and rectum connected to the vagina with a cervix. In Chinese, the word for uterus means “palace for the child,” a better description by any standard.

Image of uterus, ovaries and fallopian tubes

The fallopian tubes carry eggs from the ovaries to the uterus. The uterus can be positioned toward the front or back of the pelvis (anteverted or retroverted). The lining, or endometrium, of the uterus swells with each menstrual cycle — becoming engorged in preparation for the implantation of a fertilized egg. The body sheds this lining with a period if that doesn’t happen. If implantation does occur, the uterus grows for nine months to accommodate the fetus’s growth, then shrinks back to pre-baby size after delivery and the process starts all over.

This elegant dance is orchestrated by the complex crosstalk between your sex hormones, predominantly estrogen, progesterone, and testosterone. During your cycling years, your ovaries are responsible for producing most of your body’s estrogen and progesterone. This is important information to know when considering a hysterectomy, so that you are clear on what may happen when organs are removed.

While it may seem easier to remove your reproductive organs in one fell swoop, particularly if you have been struggling for years with heavy bleeding or painful fibroids, new insight into the aftermath of total hysterectomy (including the ovaries) reveals that many women feel wrecked without the natural hormonal wash from their ovaries. So we advise every woman who has the choice to approach a hysterectomy with great forethought, and to seek a second opinion. This may be met with resistance by your doctor, or with prejudice grounded in years of misperception.

The historical misperception of the uterus

A woman’s body and mind have always seemed mysterious to male thinkers (and thanks to legends of Eve, highly suspect). The hidden sexual organ of the uterus has amazed philosophers and physicians from early times. Pre-modern medicine thinkers gave the uterus the power to get angry, move, and cause other serious problems.

The term hysteria (Latin for uterus) comes directly from the belief that the uterus could travel about the body and produce a state of confusion, manifest as irrationality and wild fits of fainting, crying, and laughing. Hysteria was considered a form of mental instability that, funnily enough, occurred in both sexes in times of stress. To this day, the medical term globus hystericus describes the sensation of having a lump in one’s throat from too much emotion.

In Victorian times, if a woman’s temperament could not be “controlled” by loosening her corset or being kept in a quiet place with a cold compress applied to the head and neck, it was common for her reproductive organs to be removed. (For a short time the other cure prescribed was genital massage!) Can you imagine a world where the medical solution to certain male behavior would be removal of the penis and testes? More interesting details abound in Sherwin Nuland’s The Mysteries Within. Only within the last century has it been recognized that the brain has primary control over a woman’s emotions, and that the removal of her reproductive organs can often cause more problems than it solves.

Common reasons for elective hysterectomy

Hysterectomy is the second-most common major surgery performed on women in the United States. (The most common is cesarean section delivery.) Each year, more than 600,000 women undergo hysterectomy. While some progressive doctors claim that up to 90% of hysterectomies are unnecessary, more conservative estimates put that number between 20–30%.

There are several reasons why women are advised to consider an elective hysterectomy. The most common are heavy bleeding, large fibroids, endometrial polyps, endometriosis, and other endometrium issues. Some women just want one for comfort, or for a prolapsed uterus (a condition in which the pelvic organs drop). More dire indications include cancers of the uterus or ovaries — conditions that truly merit immediate surgery. But the latter are relatively rare and leave a woman little choice, so this discussion is geared toward women who are considering surgery for less clear-cut reasons.

Heavy bleeding

In conventional medicine heavy bleeding is termed “dysfunctional uterine bleeding” because it is assumed that the loss of blood is not healthy or functional for a woman. However, if we look at it from a perspective that takes into account our natural processes, we see that the body is trying to do what it is supposed to — shed the uterine lining. What may be more useful for us to identify as “dysfunctional,” or imbalanced, are the environmental and lifestyle factors affecting our hormones and sending the uterus mixed messages. Sometimes these influences lead to a state of estrogen dominance, and in other cases the menses may be out of sync, leading to overall hormonal imbalance. In either case, tuning in and paying attention to what the body and mind need can restore balance naturally. Also, what is dysfunctional for one person may not be for another, and the term is somewhat subjective by nature, so it should be discussed with an informed provider.

Having reached a state of hormonal imbalance, a woman’s body can get stuck, and even her best efforts to restore balance can take several months. The nuisance of having to change pads hourly, double up on tampons, wash extra linen, and time activities around heavy flow leads some women to the end of their gynecological rope. When women in this situation ask for a hysterectomy, most doctors in America will respond by scheduling surgery. But in our book, surgery should never be the first, or even the second, recourse in the face of heavy bleeding. No matter what, an old dictum from surgery generally applies: bleeding eventually stops when a woman goes through menopause.

Heavy bleeding often occurs around perimenopause and in many cases can be effectively addressed with many natural measures before pursuing surgery. In most cases, a woman with dysfunctional uterine bleeding can be offered a trial of non-surgical intervention such as “medical management” of dysfunctional bleeding prior to referral for “surgical management.” This cautious approach is generally safe, as long as the lining of her uterus has been appropriately evaluated with an endometrial biopsy or D&C if necessary, and as long as her red blood count remains adequate.

Many women have experienced excellent results for their heavy bleeding by using high-dose bioidentical progesterone, in the form of creams or oral tablets, along with other supportive supplements. Lifestyle and dietary changes that reduce stress and increase core nutrition are also highly effective in this arena.

Many bleeding issues reflect irregularities of the endometrium, so the symptoms are strongly influenced by the monthly ebb and flow of estrogen as well as progesterone. Because of this, these problems often respond extremely well to a natural rebalancing of hormones through diet and lifestyle changes, and a natural approach should be given a trial before advancing to surgical intervention. Surgery is no small matter, and the removal of organs can lead to further problems that are just as bothersome, only different. And, just as heavy bleeding dissipates with menopause, so too do conditions of the endometrium.

Postmenopausal bleeding

Note that post menopausal bleeding is a different matter, and any type of bleeding that occurs after menopause should be immediately evaluated by your healthcare provider. Women with postmenopausal bleeding are often referred for vaginal ultrasound so the endometrium within the uterus can be evaluated and measured. If the endometrial stripe is above a certain width, endometrial biopsy is recommended. Certain drugs such as tamoxifen for breast cancer can cause endometrial thickening, and women on tamoxifen who have thickened stripes should be seen by providers familiar with this side effect.

Adenomyosis

Persistent heavy bleeding that does not stem from a discretely identifiable source such as fibroids, and which does not respond to medical management, is often a result of adenomyosis of the uterus. In the medical community adenomysis is sometimes referred to as endometriosis interna. In this condition, which is sometimes mistaken for uterine fibroids, the glandular endometrial lining of the uterus invades the bulk of the uterine muscle wall.

While many women who have adenomyosis have no symptoms, it can cause the uterus to grow 2–3 times its normal size and be accompanied by severe menstrual cramping. It can sometimes be identified by ultrasound, or more definitively by MRI, and confirmed by pathology after hysterectomy, but technically it is categorized as a benign condition.

Adenomyosis may fail to respond to the influence of progesterone under medical management. If you have exhausted all natural measures and still have persistent heavy bleeding, you may want to enquire further about this potential diagnosis. Endometrial ablation is one alternative to hysterectomy now available, along with the Mirena IUD; either may be considered in certain cases.

Fibroids

At least 40% percent of hysterectomies performed are for fibroids. (Fibroids technically are not part of the endometrium.) No one knows exactly what causes them, but they are definitely a nuisance. They are very real and women’s concerns about them should not be dismissed as just fretting. We think their growth is probably fueled by estrogen but are not sure yet about the details.

Fibroids are quite common: at least one in five women over age 35 has them. Many women think that if they have fibroids they will eventually need a hysterectomy. This just isn’t true. Some doctors recommend a hysterectomy for patients with fibroids even when they have no bleeding or pain! This is like cutting off your nose to spite your face.

Many women deal successfully with their fibroids through diet, lifestyle and supplements — as well as acupuncture, if they are painful. We recommend the book Women’s Bodies, Women’s Wisdom, which includes a wonderful section on treating and living with fibroids without invasive surgery. See our fibroid article for more information on causes and natural treatment for fibroids.

Fibroids can cause bleeding and pain or discomfort, and can grow in some, but certainly not all cases. A fibroid’s size is referenced by comparing it to the gestational age of a fetus — for example, a 5-month size fibroid — or to a piece of fruit (orange or melon-sized). Women can have multiple fibroids of various sizes and shapes. Some fibroids change very little over time, and many women are unaware they have them. A healthcare provider can often feel them while doing a pelvic exam and will order an ultrasound if they feel it is warranted.

An ultrasound will measure the fibroid and better assess it. You may be referred for repeat ultrasounds to be sure the fibroids aren’t growing too large or too rapidly over time. Your doctor may also order a CT scan or an MRI if additional information is needed. Fibroids are very rarely cancerous and do not routinely need to be biopsied. But be aware that any kind of dysfunctional uterine bleeding, even if it may be caused by known fibroids, mandates that an endometrial biopsy be performed to rule out potentially more threatening, co-existing issues.

Polyps

Uterine polyps or endometrial polyps are irregularities of the inner uterine lining (something like fleshy skin tags, only on the inside). Polyps can be a source of irregular bleeding and a nuisance, but they are not usually cancerous. However, they can change over time.

Polyps of the uterine lining can sometimes be difficult to visualize on regular ultrasound, but a “sono-hyst” (sonohysterography) or saline-infused ultrasound may help define the nature of a polyp more accurately. Fragments suggestive of polyps can also be identified by endometrial biopsy.

Most endocervical polyps can be removed through the vagina, with no interference to the uterus, but uterine/endometrial polyps are generally removed via the D&C with hysteroscopy method, which is slightly invasive but certainly less traumatic than a hysterectomy.

Endometriosis

Endometriosis is a condition that is generally more irksome than dangerous. Many women who have endometriosis are unaware of its presence until they try to become pregnant. Endometriosis can cause fertility problems, but it’s more notorious for causing irregular spotting, bleeding, and pain. For women with severe endometriosis, the pain can be debilitating, especially around their period.

Acupuncture can be quite helpful for pain management. If fertility is an issue, massage techniques such as integrative manual therapy (IMT) and Clear Passages could be investigated. Laparoscopy is often used in more severe cases for definitive diagnosis and treatment. For more detailed information on natural treatments for endometriosis, see our article.

If your decision to have a hysterectomy is an elective one, consider yourself lucky. You can take the time to fully research your choices and determine how best to help yourself before you commit to surgery.

Different kinds of hysterectomy procedures

Many women of our mothers' generation didn’t know just what a hysterectomy entailed. Today, there are several degrees of hysterectomy and techniques used to perform them. If you are considering hysterectomy, it is wise to learn about the specifics of each kind and discuss them in advance with your practitioner.

Total hysterectomy

Image of total hysterectomy In a total hysterectomy, the entire uterus and cervix are removed (ovary status is officially referred to separately). Total hysterectomy can be done abdominally (abbreviated TAH), with an incision typically made along the bikini line. In an emergency situation, a vertical incision is made through the abdominal wall from the belly button to the pubis. TAH can also be performed through the vagina, with no large incision through the belly.

The most sophisticated techniques use laparoscopy to assist the hysterectomy procedure. In laparoscopic hysterectomy, the organs are visualized and manipulated through a laparoscope, and the uterus is removed either through the vagina (laparoscopically assisted vaginal hysterectomy, or LAVH) or through a small incision in the abdomen. The incisions are very small (~½”, beneath the belly button and on the lower pelvis/abdomen, beneath the bikini line).

This surgery lends itself to faster recovery, with far less disruption of the bowel and pelvic floor architecture. It is best performed by a laparoscopic specialist, as not all surgeons are skilled at this. The choice here depends on the reasons for doing the surgery, the patient’s anatomy, and the surgeon’s preference. If you have a preference, clearly communicate this to your surgeon.

Image showing total hysterectomy and bilateral salpingo-oophorectomy

While doing a hysterectomy, a surgeon may also take the ovaries and fallopian tubes. This is called a bilateral salpingo-oophorectomy, or BSO. (Together with a total abdominal hysterectomy this is referred to as a TAH/BSO.) There are many important considerations to make before consenting to this surgery, primarily the artificial onset of menopause due to loss of your natural sex hormones. Again, the decision depends on the individual nature of a woman’s condition and her doctor’s choices. If this is the only option available to you, be assured that it is possible to regain your hormonal balance with the help of some good support measures and a healthy lifestyle.

Young women who must undergo a BSO usually do need to consider appropriate estrogen replacement for numerous health benefits.

Partial hysterectomy

In a partial or subtotal (supracervical = above the cervix) hysterectomy, the ovaries and/or cervix are left intact. These procedures, too, can be performed either abdominally, vaginally, or laparoscopically. Unfortunately, many women aren’t even told about these options. Some doctors remove the cervix automatically as a precaution against cervical cancer.

Many women have seen that the benefits of retaining their cervix (more sexual enjoyment and sounder inner pelvic architecture) outweigh the relative risks. For one, evidence exists that an intact cervix may actually benefit proper Pap smear technique. If you do choose to keep your cervix, you will need to continue regular annual screenings and Pap tests.

Image showing partial(supracervical) hysterectomy

Another option is a laproscopically-assisted supracervical (partial) hysterectomy (LASH, or LSH). This allows women to try to keep their ovaries (no BSO), if at all possible, but this is case-dependant as well. Again, not all doctors are skilled in these newer techniques. Those who are often specialize in endometriosis treatment, as well. You may have to seek them out in your local area or be willing to travel elsewhere to have your procedure.

We also recommend considering your options on preparing yourself for surgery. To start you can sign up for a few sessions of acupuncture, and use Peggy Huddleston’s book and audiocassette, Prepare for Surgery, Heal Faster, to decrease your recovery time and improve your outcome.

Alternatives to hysterectomy

If you have the option to forego a hysterectomy, you should know that along with hormonal support and lifestyle changes, there are many alternatives to explore that treat heavy bleeding, endometriosis, fibroids, and polyps. Current treatment options include:

Success rates of these techniques vary according to the patient, so it’s important to support whatever method you pursue with the healthiest lifestyle choices you can. Many women respond beautifully to the nutritional measures provided with our Hormonal Health Package, and many report how the approach and Nurse–Educators have helped them make a rapid recovery from a variety of procedures — including hysterectomy!

Looking ahead

While heavy bleeding or a diagnosis of fibroids can be alarming, it is rarely necessary for a woman to jump right into surgery. Checking out other possibilities along the way may well steer you in an entirely different direction.

Because hysterectomy and fibroids are so common, studies into other options are continuously underway, and new techniques are being developed and researched in many parts of the world. Although the results of these innovations are mixed, the encouraging news is that these less invasive techniques do work for some women.

Unfortunately, for unclear reasons, no truly scientific, randomized study has yet been done to fully evaluate these various hysterectomy alternatives, their side effects, risks and benefits. Nor are any such studies currently being planned, though some observational studies on UAE (the surgery Dr. Condoleeza Rice had in 2004) have been done, comparing outcome satisfaction, failure rates, and cost compared to traditional hysterectomy methods. Visit the UAE Fibroid Registry at the SIR website for more information.

What can you consider now?

What we do know is that for many women hysterectomy is a choice, not their destiny. Exploring the wealth of other natural and less invasive alternatives is always a valid course of action — as is surgery, if it comes to it. It’s also true that some women feel wonderful after a hysterectomy and have no side effects.

If you do decide on surgery, we suggest preparing yourself for surgery in advance to increase your chances of a positive experience. Whether you opt for a nonsurgical alternative or you’re awaiting your OR date, investigate the measures you can take right now to boost your nutrition, reduce your recovery time, and balance your hormones.

Related to this article:

References & further reading on hysterectomy options

 

Last Modified Date: 04/20/2011

& Marcy Holmes, Certified Menopause Clinician