Is It Necessary to Remove My Uterus?
By Alicia Armeli

NecessarytoRemoveUterus

In the United States alone, 400,000 hysterectomies are done annually with 68% performed to treat benign conditions like abnormal uterine bleeding and fibroids.1 With numbers this high, it raises the following question, Is a hysterectomy medically necessary for fibroid treatment?

“While hysterectomy is an option for women suffering with symptomatic fibroids, it’s completely unnecessary,” says Dr. John Lipman MD, Medical Director and Interventional Radiologist at the Atlanta Interventional Institute in Atlanta, Georgia, and a pioneer developer of uterine fibroid embolization (UFE). “If you have cancer, hysterectomy is completely appropriate,” he emphasizes. “But fibroids are benign tumors.”

Yet, ironically, statistics show that hysterectomy continues to be the second most common surgery in the U.S. performed on women of reproductive age.2

Three types of hysterectomies exist and, depending on the reason for surgery, can also include the removal of the ovaries and fallopian tubes. A radical hysterectomy removes the uterus, cervix, and surrounding tissue that hold these structures in place. A total hysterectomy removes the uterus and cervix, whereas a partial or simple hysterectomy removes the uterus but leaves the cervix intact.3

Hysterectomies can also be performed differently. For example, an abdominal hysterectomy is an open procedure with large incisions and a slow recovery time that can last between four to six weeks4—and, for some women, could take up to eight weeks.5

A hysterectomy can also be performed through the vagina or laparoscopically—a type of surgery that makes small incisions in the abdomen and then uses slender instruments to help guide the surgeon in removing the uterus. This technique avoids the need for a larger incision, as seen in an abdominal hysterectomy3 and has a recovery time of about three to four weeks.4 However, as Dr. Lipman points out, this is performed in the minority of cases.

Although one technique may be considered less invasive than another, each has its own set of risks and complications both during and after surgery. “With any surgery there are risks of bleeding, infection, and adhesions,” Lipman explains. “The risks and recovery time of UFE are much lower than surgery. Our patients go home the same day with just a Band-Aid and are back at work typically one week after the procedure.”

Multiple studies have indicated potential post-procedural complications such as bladder dysfunction following all three types of hysterectomies.6,7  A five-year follow-up study published in the British Journal of Obstetrics and Gynecology found persistent vaginal bleeding to follow partial hysterectomy.7 Other possible complications can include constipation, pelvic pain, sexual dysfunction, and depression.7,8

Despite the potential consequences seen in the majority of women, some gynecologists still believe hysterectomy is best and should be recommended more often to pre- and perimenopausal women. The authors of a paper entitled, Should We Recommend Hysterectomy More Often to Pre-Menopausal and Climacteric Women? contend that benefits associated with having a hysterectomy outweigh potential risks of living with a postmenopausal uterus.9 Authors Erik Qvigstand and Anton Langebrekke wrote, “We argue that hysterectomy should be considered with myomas (uterine fibroids) and/or abnormal uterine bleeding if [women] have no desire for pregnancy and are aged above 40 years.” They added, “minimally invasive techniques…will never be 100% successful, and many women will require retreatment.”

“While some women will require retreatment, this is the exception,” Dr. Lipman disputes. “Ninety percent of women who undergo UFE will find relief from their symptoms and in women treated who are over 40 years of age, the majority will make it to menopause without any additional therapy.”

Furthermore, the benefits to a woman keeping her uterus may outweigh the retreatment risk. “The uterus is important for women beyond childbearing,” Dr. Lipman continues. “It’s important for them physically—women having hysterectomies are seen to experience bone loss, as well as experience psychological and sexual obstacles. Some women see losing their wombs as losing their womanhood and struggle with this.”

Albeit Qvigstad and Langebrekke’s second argument is true, that there’s never a total guarantee with any medical procedure, studies show that less-invasive techniques like UFE are promising for the majority of women suffering from fibroids.

According to a study published in the American Journal of Obstetrics and Gynecology,10 a reintervention hysterectomy following uterine fibroid embolization (UFE) was performed in approximately 28% of women who saw no relief in heavy bleeding. But upon further analysis, the authors of the study found that only women with higher body mass indices experienced unsuccessful UFE. The results of this study mirror other studies that found long-term improvement of heavy bleeding in nearly 75% of women who underwent UFE.11

With effective and minimally invasive techniques like UFE available, the question still remains, Why are so many women still opting to part with their wombs? The truth is that many women are unaware of alternatives to surgery, prior to hysterectomy.

Over a decade ago, a Yale University study showed only 5 percent of gynecologists were suggesting UFE as a treatment option.12 Another study revealed many women who underwent UFE had learned about it from family, friends, the media, and researching online—but not by gynecologist referral.13 Today referral statistics have improved but still have a long way to go.

Earlier this year at the 40th Annual Society of Interventional Radiology Meeting, Dr. Lipman presented data from his research revealing that out of 234 women who later underwent UFE to treat their fibroids, 57 percent of these women were told surgery was their only option and weren’t informed of UFE as a potential treatment.

“It’s 2015 and most women today who suffer from uterine fibroids and go to their gynecologist may not hear about UFE,” says Dr. Lipman. “A woman has the right to know all of her options. UFE is safer, less invasive, less expensive, and has a much shorter recovery time than surgery. But most importantly, a woman finds the relief she is looking for and gets to keep her uterus.”

If a woman is experiencing fibroid symptoms such as heavy bleeding, pelvic pain, and increased urinary frequency, the best action she can take is to seek out medical advice from physicians who work in a collaborative fashion. Detailed counseling from medical professionals regarding the effects of every procedure should be an integral part of each care plan. Creating such a dynamic has been show to improve overall patient care and satisfaction, says a study published in the Journal of Minimally Invasive Gynecology.14

“A woman should see her gynecologist and have a thorough exam to see if she does indeed have fibroids,” encourages Dr. Lipman. “If she does, then her gynecologist will give her a range of treatment options. Once she has her gynecologist’s recommendation, she should then seek out an interventional radiologist who has expertise in UFE and get an additional opinion. Once she’s presented with all the tools and information she needs, she can weigh the pros and cons and decide what’s best for her.”

ABOUT THE AUTHOR Alicia Armeli has a Master of Science in Nutrition and Whole Foods Dietetics (MSN/DPD) and is a registered dietitian nutritionist, a certified dietitian, and a holistic life coach. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR John Lipman is Medical Director and Interventional Radiologist at the Atlanta Interventional Institute in Atlanta, Georgia, and a pioneer developer of UFE. With his extensive UFE experience and by actively participating in clinical research trials, Dr. Lipman strives to help the public and other physicians become better informed about uterine fibroids and all treatments available.

REFERENCES

  1. Corona, L. E., Swenson, C. W., Sheetz, K. H., Shelby, G., Berger, M. B., Pearlman, M. D., Campbell, D. A., Delancey, J. O., & Morgan, D. M. (2015) Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. American Journal of Obstetrics & Gynecology, 212(3): 304.e1-7. doi:10.1016/j.ajog.2014.11.031
  2. National Women’s Health Network. (2015). Hysterectomy. Retrieved July 14, 2015, from https://nwhn.org/hysterectomy?gclid=CMzggab63cYCFYU5aQodVJwPxQ
  3. The American Congress of Obstetricians and Gynecologists. (2015). Hysterectomy. Retrieved July 14, 2015, from http://www.acog.org/Patients/FAQs/Hysterectomy
  4. Office on Women’s Health, US Department of Health and Human Services. (2014). Hysterectomy. Retrieved July 17, 2015, from http://womenshealth.gov/publications/our-publications/fact-sheet/hysterectomy.html
  5. Royal College of Obstetricians and Gynaecologists. Recovering Well: Information for you after an abdominal hysterectomy. Retrieved July 22, 2015, from https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/abdominal-hysterectomy-recovering-well.pdf
  6. Maneschi, F. (2014). Urodynamic study of bladder function following nerve sparing radical hysterectomy. Journal of Gynecologic Oncology, 25(3):159-161. doi:10.3802/jgo.2014.25.3.159
  7. Andersen, L. L., Zobbe, V., Ottensen, B., Gluud, C., Tabor, A., & Gimbel, H. (2015). Five-year follow up of a randomised controlled trial comparing subtotal with total abdominal hysterectomy. British Journal of Obstetrics and Gynecology, 122(6):851-857. doi:10.1111/1471-0528.12914.
  8. Goktas, S. B, Gun, I., Yildiz, T., Sakar, M. N., & Caglayan, S. (2015). The effect of total hysterectomy on sexual function and depression. Pakistan Journal of Medical Sciences, 31(3):700-705. doi:10.12669/pjms.313.7368
  9. Qvigstad, E., & Langebrekke, A. (2011). Should we recommend hysterectomy more often to pre-menopausal and climacteric women? Acta Obstetricia et Gynecologica Scandinavica, 90: 811-814.
  10. van der Kooij, S. M., Hehenkamp, W. J. K., Volkers, N. A., Birnie, E., Ankum, W. M., & Reekers, J. A. (2010). Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology, 203:105.e1-13.
  11. Scheurig-Muenkler, C., Koesters, C., Powerski, M. J., Grieser, C., Froeling, V., & Kroencke, T. J. (2013). Clinical long-term outcome after uterine artery embolization: sustained symptom control and improvement of quality of life. Journal of Vascular and Interventional Radiology, 24(6):765-771. doi:10.1016/j.jvir.2013.02.018
  12. Yale University. Section of Vascular and Interventional Radiology. (2001). Women would rather switch than fight with gynecologist over uterine fibroid embolization. Retrieved July 23, 2015, from http://yaleir.vasculardomain.com/images/uploaded/yale/switch_ufe.cfm
  13. Lvoff, N. M., Omary, R. A., Ryu, R. K., Chrisman, H. B., Resnick, S. A., Vogelzang, R. L., et al. (2002). The role and effect of gynecologists in referring patients for uterine artery embolization; Abstract presented at the 27th Annual Scientific Meeting of the Society of Cardiovascular and Interventional Radiology (SCVIR). Baltimore, MD.
  14. Zurawin, R. K., Fischer, J. H., & Amir, L. (2010). The effect of a gynecologist-interventional radiologist relationship on selection of treatment modality for the patient with uterine myoma. Journal of Minimally Invasive Gynecology, 17(2):214-221. doi:10.1016/j.jmig.2009.12.015