A hysterectomy is a surgical procedure to remove a
woman’s uterus. “Do I need a hysterectomy? What are my alternatives?” These are
common questions for women struggling with heavy bleeding or fibroids, or one of
the other problems that may lead to hysterectomy. Women may feel that surgery is
the only choice but in a lot of cases, there are other options. Many women have
great success with alternatives to hysterectomy and even when surgery is required,
new techniques are often much less invasive than they used to be.
It’s likely that you already know women who’ve had hysterectomies — about a third
of American women have one by age 60. For some it is a relatively easy experience,
but for others the aftermath of surgical menopause is made worse by severe hormonal
symptoms and eventual dependence on hormone replacement therapy (HRT). Since hysterectomy
is considered elective surgery for some women, they are sometimes unprepared for
the debilitating after-effects.
If you are faced with this decision, you will want to weigh the benefits versus
the risks of hysterectomy with your practitioner, in light of your own health history.
The more you know, particularly about alternatives, new technology and procedures,
the better equipped you’ll be to make the right choice.
Before you have a hysterectomy: understand the basics
The uterus, or womb, is a pelvic organ suspended by ligaments between the bladder
and rectum and connected to the vagina with the cervix.
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 menstrual period if that doesn’t happen. If implantation does
occur, the uterus expands for nine months to accommodate the fetus’s growth, then
shrinks back to size after delivery and the process starts all over.
This process is orchestrated by the complex crosstalk between your sex hormones
— mostly estrogen, progesterone and testosterone. Before menopause, your ovaries
produce most of your body’s estrogen and progesterone. This is important to think
about when considering a hysterectomy because of what may happen when any of those
organs is removed.
If you have been struggling for years with heavy bleeding or painful fibroids, it
may seem simpler to have all your reproductive organs removed. But we urge you to
get more information first. That’s because we now know that often, total hysterectomy,
including removal of the ovaries, leaves many women feeling wrecked due to loss
of their natural ovarian hormones. So if you have a choice about having a hysterectomy,
ensure that the most recent information and insight about hysterectomy are being
applied to your case. Even if this is met with resistance by your doctor you should
probably seek a second opinion prior to being scheduled for hysterectomy surgery.
The history of hysterectomy
The term hysteria (Latin for uterus) comes directly from the belief that the uterus
could produce wild fits of fainting, crying and laughing. Hysteria was considered
a form of mental instability. In Victorian times, if a woman’s temperament could
not be “controlled,” it was common for her reproductive organs to be removed. Only
within the last century have we recognized that the brain controls our emotions,
and that taking out a woman’s reproductive organs often causes more problems than
Common reasons for elective hysterectomy
Hysterectomy is the second-most common major surgery performed on women in the United
States. Each year, more than 600,000 women undergo hysterectomy with a conservative
estimate that between 20–30% of them are medically unnecessary.
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 want a hystectomy to be more comfortable,
or they have a prolapsed uterus, a condition in which the pelvic organs drop. But
it’s different with more serious indications, including cancers of the uterus or
ovaries. These conditions merit immediate surgery. In these relatively rare cases,
a woman does not truly have a choice and hysterectomy is a life-saving solution,
offering reassurance and peace of mind.
But most women may want to consider their options before scheduling surgery.
Conventional medicine brands heavy bleeding as “dysfunctional uterine bleeding”
because it’s assumed that the loss of blood is not healthy and serves no purpose
for a woman. However, the body, as part of a natural process, is trying to do what
it is supposed to: shed the uterine lining. And it’s also true sometimes that what
is dysfunctional for one person may not be for another
Often, environmental and lifestyle factors affect our hormones and send the uterus
mixed messages. These can, for example, lead to a state of estrogen dominance or
cause the menstrual cycle to be out of sync, leading to overall hormonal imbalance.
Tuning in and paying attention to what your body needs can restore balance naturally.
Even with the best efforts, it can take several months for a woman to restore balance.
Heavy bleeding is miserable and uncomfortable, with the added nuisance of having
to change pads or tampons frequently, wash extra bed sheets and limit and time activities
around heavy flow. When women in this situation ask for a hysterectomy, most doctors
in America will say yes. But usually, surgery shouldn’t be the first or even the
second option for heavy bleeding. No matter what, 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 try surgical intervention such as “medical
management” of dysfunctional bleeding before “surgical management.” This cautious
approach is generally safe, as long as the lining of the uterus has been appropriately
evaluated with an endometrial
biopsy or D&C if necessary, and as long as the red blood count remains adequate.
Many women with heavy bleeding get excellent results by using high-dose bioidentical
progesterone, as creams or oral tablets, along with other supportive supplements.
Lifestyle and dietary changes that reduce stress and increase core nutrition are
also highly effective.
Bleeding issues often reflect irregularities of the endometrium with symptoms strongly
influenced by the monthly ebb and flow of estrogen as well as progesterone. These
problems often respond well to a natural rebalancing of hormones through diet and
lifestyle changes. You may want to try this before turning to surgical intervention
partially because organ removal can lead to different problems.
Postmenopausal bleeding is different — any bleeding that occurs after menopause
should be evaluated immediately by your healthcare provider. You may be referred
for vaginal ultrasound so the endometrium within the uterus can be evaluated and
measured. If the endometrial stripe is greater than a certain width, endometrial
biopsy is recommended. Certain drugs, such as tamoxifen for breast cancer, can cause
Persistent heavy bleeding that doesn’t have an identifiable source such as fibroids,
and that does not respond to medical management, is often a result of adenomyosis
of the uterus (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, accompanied by severe menstrual cramping. It
can sometimes be identified by ultrasound, or more definitively by MRI, and confirmed
by pathology after hysterectomy, though it’s technically categorized as a benign
If you have exhausted all natural measures and still have persistent heavy bleeding,
you may want to ask about adenomyosis as a potential diagnosis.
Endometrial ablation is one alternative to hysterectomy now available, along
with the Mirena IUD, and either may be considered in certain cases.
At least 40% percent of hysterectomies are for fibroids though fibroids are not
technically part of the endometrium. No one knows exactly what causes them, but
they are definitely an issue for many women. Their growth may be fueled by estrogen
but we don’t know for sure yet.
At least one in five women over age 35 has fibroids. Many women think that having
fibroids will eventually lead to having a hysterectomy but this isn’t necessarily
true. Some doctors may recommend a hysterectomy for fibroids even when there is
no bleeding or pain. Surgery is likely not needed in this scenario.
Many women deal successfully with their fibroids through diet, lifestyle and supplements
— as well as acupuncture, if there is pain. 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 cases.
A fibroid’s size is compared 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, and some change very little
over time, with many women unaware of them. A healthcare provider can often feel
them during a pelvic exam and will order an ultrasound if warranted.
An ultrasound measures the fibroid and helps assess it. You may be referred for
repeat ultrasounds to be sure the fibroids aren’t growing too large or too rapidly.
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 usually mandates an endometrial
biopsy to rule out potentially more threatening, co-existing issues.
Uterine polyps or endometrial polyps are irregularities of the inner uterine lining,
sort of like fleshy skin tags, only on the inside. Polyps can be a source of irregular
bleeding but they are not usually cancerous. However, they can change over time.
Polyps of the uterine lining may be difficult to see on regular ultrasound, but
a “sono-hyst” (sonohysterography) or saline-infused ultrasound may help visually
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, without affecting the
uterus, but uterine-endometrial polyps are generally removed via the D&C with hysteroscopy
method — slightly invasive but still less traumatic than a hysterectomy.
Endometriosis is a condition that is generally more troublesome than truly health-threatening.
Many women who have endometriosis don’t know they have it until they try to get
pregnant. Endometriosis can cause fertility problems, but is even more notorious
for causing irregular spotting, bleeding and pain. If you have severe endometriosis,
the pain can be debilitating, especially around your period.
Acupuncture can be quite helpful for pain management. If fertility is an issue,
you can try massage techniques such as integrative manual therapy (IMT) or Clear Passages therapy.
Laparoscopy is often used in more severe cases for definitive diagnosis
and treatment. See our article for more detailed information on
natural treatments for endometriosis.
If your decision to have a hysterectomy is an elective one, take the time to fully
research your choices and determine how you might be able to try a natural approach
before you commit to surgery.
Different kinds of hysterectomy procedures
Many women of earlier generations didn’t know exactly what a hysterectomy entails.
Today, there are several different types of hysterectomy, as well as additional
techniques used to perform them. If you are considering hysterectomy, learn about
the specifics of each kind and discuss them in advance with your practitioner.
In a total hysterectomy, the entire uterus and cervix are removed and ovary status
is officially referred to separately. Total hysterectomy (TAH) can be done abdominally
with an incision typically made along the bikini line. In an emergency, a vertical
incision is made through the abdominal wall from the belly button to the pubis.
TAH can also be performed through the vagina, without a large incision through the
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.
While doing a hysterectomy, a surgeon may also remove the ovaries and fallopian
tubes with a bilateral salpingo-oophorectomy (BSO, or together with a total abdominal
hysterectomy, TAH/BSO.) There are many considerations to make before consenting
to this surgery, starting with 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 option available
to you, be assured that it is possible to regain hormonal balance with the help
of some good support measures and a healthy lifestyle. You can talk it over with
your doctor later if you need additional help.
Young women who must undergo a BSO usually should consider appropriate estrogen
replacement for numerous health benefits.
In a partial or subtotal — supracervical = above the cervix — hysterectomy, the
ovaries and/or cervix are left intact. These procedures can be also performed abdominally,
vaginally or laparoscopically. Unfortunately, many women aren’t told about these
options and sometimes the cervix is removed automatically as a precaution against
You should definitely talk this over with your doctor, and the surgeon performing
your hysterectomy, if they’re different. Many women have seen that the benefits
of retaining the cervix — more sexual enjoyment and sounder inner pelvic architecture
— outweigh the relative risks. An intact cervix may actually benefit proper Pap
smear technique so if you choose to keep your cervix, continue
regular annual screenings and Pap tests.
Another option is a laproscopically-assisted supracervical (partial) hysterectomy
(LASH, or LSH). This allows women to try to keep their ovaries (no BSO), if possible,
but this is case-dependent. Try to find a doctor skilled in these newer techniques,
many of whom specialize in endometriosis treatment.
We also recommend preparing yourself for surgery. You can sign up for a few sessions
of acupuncture, and use Peggy Huddleston’s book and CD, Prepare for Surgery, Heal Faster
to decrease your recovery time and possibly improve your outcome.
Alternatives to hysterectomy
If you have the option to forego a hysterectomy, there are many alternatives that
work with hormonal support and lifestyle changes to relieve and treat heavy bleeding,
endometriosis, fibroids and polyps. Current treatment options include:
Success rates of these techniques vary, so it’s important to support whatever method
you pursue with the healthiest lifestyle choices you can make. Many women get excellent
results with the nutritional guidelines that come with our
Hormonal Health Programs, and also use our Nurse–Educators to help them
recover from a variety of procedures — including hysterectomy.
Heavy bleeding or a diagnosis of fibroids can be distressing and scary but it is
rarely necessary for a woman to jump right into surgery. Checking out other possibilities
may steer you in an entirely different direction, so if possible, take the time
to evaluate all options.
Because hysterectomy and fibroids are so common, studies into other treatment options
are underway, and new techniques are being developed and researched in many parts
of the world. Results so far are mixed, but these less invasive techniques do work
for some women.
No scientific, randomized study has been done to fully evaluate these various hysterectomy
alternatives, their side effects, risks and benefits. Some observational studies
on UAE have been done, comparing outcome satisfaction, failure rates, and cost compared
to traditional hysterectomy methods.
Your choices today
For many women hysterectomy is a choice. Exploring the other natural and less invasive
alternatives is valid — as is surgery, if it comes to that. It’s also true that
some women feel wonderful after their hysterectomies and have no side effects. Whether
you opt for a nonsurgical alternative or some version of hysterectomy, consider
boosting your nutrition and taking steps to balancing your hormones.
1 Farquhar, C., & Brosens, I. 2006, Mar 22 [Epub ahead of print].
Best Pract. Res. Clin. Obstet. Gynaecol. Medical and surgical management
2 Ohanlan, K., et al. 2006, July 7; [Epub ahead of print] Total laparoscopic
hysterectomy for uterine pathology: Impact of body mass index on outcomes. Gynecol.
3 American College of Obstetricians and Gynecologists Committee on Gynecologic
Practice. 2006. ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel
intrauterine system. Obstet. Gynecol., 107 (6), 1479–1482.
4 Society of Interventional Radiology. March 2006. URL: http://www.sirweb.org/refSpec/GR_PDFs/UFE_Grand_Rounds.pdf
Society of Interventional Radiology
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