Hysterectomy
Hysterectomy
Know the Facts
Most of us wouldn't knowingly choose an operation that triggers early menopause. We wouldn't knowingly choose an operation that accelerates the aging process and makes us vulnerable--a full decade earlier--to heart disease, osteoporosis and urinary incontinence. Yet that's exactly what more than a half-million American women do every year when they schedule hysterectomies.
The tragedy is that the surgery may not be necessary.
"I'd say 80 percent of hysterectomies not done for cancer can be avoided," says Herbert A. Goldfarb, M.D., clinical instructor of obstetrics and gynecology at New York University School of Medicine in New York City and author of The No Hysterectomy Option. They're done to solve problems for which other solutions exist.
Thirty percent of the 567,000 procedures performed annually are done to eliminate fibroids, harmless estrogen-dependent growths that pop up in half of all women of reproductive age and that regress on their own at menopause, according to research from the National Center for Health Statistics.
Just over 19 percent are done to eliminate endometriosis, a condition in which clumps of the uterine lining drift outside the uterus and take up residence in the abdominal cavity.
Nineteen percent are done for reasons that include bleeding between periods, pelvic pain and obstetric complications.
About 16 percent are done to correct a prolapsed or droopy uterus, a common consequence of several pregnancies.
Only 15 percent of all hysterectomies are done to treat cancer or precancerous conditions. Yet except for cancer, says Dr. Goldfarb, "there are effective treatments for most of these problems without cutting out the female organs."
Instant Menopause
Why are so many hysterectomies done in non-life-threatening situations?
"Many doctors have been taught in medical school that the uterus has no purpose beyond being a receptacle for a fetus," says Dr. Goldfarb. So when gynecological problems arise in a woman in her thirties or forties when childbearing is complete, removing the uterus seems to be a "neat and tidy solution--the panacea for all pelvic problems," says Dr. Goldfarb.
The problem is that it's not--not when it thrusts women into old age before their time.
There are four types of hysterectomy. A partial hysterectomy removes most of the uterus, leaving the cervix intact. A total hysterectomy removes the entire uterus, including the cervix. A total hysterectomy with a bilateral salpingo-oophorectomy also excises the fallopian tubes and ovaries. And a radical hysterectomy removes all the above plus the upper part of the vagina and some lymph nodes.
Which operation a woman has depends on which problem a doctor is trying to solve and how he has been trained.
All forms of hysterectomy are major surgery, says Dr. Goldfarb. But the one in which the ovaries are removed--representing about half of all hysterectomies--is probably the toughest because it instantly deprives the body of its major source of the hormones estrogen and androgen.
Androgen is what gives us our sex drive. So without the ovaries, women experience a significant loss of libido, says Dr. Goldfarb. And estrogen is that magic elixir that keeps our skin soft, the vagina lubricated, our arteries flexible, our bladder openings taut and our bones strong. It can even contribute to a peaceful night's sleep.
Normally, the ovaries begin to slow their production of estrogen around age 35. Month by month, year by year, the amount of estrogen slows to a trickle, usually cutting off completely three to five years after menopause.
But when the ovaries are removed and the entire body is suddenly deprived of estrogen, the body overreacts. "Hot flashes are hotter, longer and more frequent" than they would be during the gradual withdrawal of estrogen that naturally occurs, says Dr. Goldfarb.
What's more, the sudden absence of estrogen instantly accelerates various problems that a woman wouldn't expect for another decade. The bone-thinning process that leads to osteoporosis occurs twice as fast, and a study at Harvard Medical School involving 121,700 women indicates that those who had their ovaries removed doubled their risk of heart disease--unless they took estrogen supplements.
Talk, Don't Cut, First
Women should never agree to a hysterectomy until they are fully informed about the alternatives to and consequences of the surgery, adds Nora W. Coffey, president of Hysterectomy Educational Resources and Services (HERS), a Bala Cynwyd, Pennsylvaniabased nonprofit consumer group that offers information on hysterectomy alternatives to women around the world.
A study at Cornell University Medical College in New York City indicates that more than half of all second opinions on hysterectomy find that the procedure is inappropriate. And it is not an innocuous procedure. About one in seven women who have the operation needs repeat surgery for complications due to the operation.
So before you schedule an operation that could age your body and increase your risk of disease, consider these options.
Seek support. Even though there are millions of women who have had hysterectomies, many faced it alone--unnecessarily. But if you're considering this procedure, you can get help from HERS. "We offer free counseling about the alternatives to hysterectomy that many women may not know about as well as counseling to women who have undergone hysterectomies," says Coffey.
Check with another specialist. Maybe the problem really isn't your uterus. In a study of 200 women with normal-size uteruses referred to a San Diego clinic, researchers found that 80 percent of the women who were told they should have hysterectomies to alleviate their chronic pelvic pain actually had gastrointestinal or other non-gynecological problems. "You can have your uterus removed and still have pain," says Francis Hutchins, M.D., clinical associate professor of obstetrics and gynecology at Thomas Jefferson University Hospital and vice chair of gynecology at Graduate Hospital, both in Philadelphia. So if you have pelvic pain, have a thorough evaluation for various causes before you assume the cause is gynecological, says Dr. Hutchins.
Exercise your pelvic muscles. Rather than having a prolapsed uterus removed, try exercising it, says Dr. Hutchins. Ligaments supporting the uterus frequently get weak after childbearing. But Kegel exercises, particularly when combined with an estrogen cream vaginally applied, can help increase the tone of the supporting ligaments.
To build both the uterus and the ligaments, simply tighten your muscles for several seconds as though you were holding urine and then release. Do the exercise up to 20 times a day, says Dr. Hutchins.
Ask about a scrape. If your problem is abnormally heavy bleeding--which can result from fibroids, hormonal problems or other causes--ask your doctor about scraping away a portion of your uterine lining to control it. This procedure, which stops heavy bleeding by "cleaning out" the part of the uterus that has a rich blood supply, is done in two ways:
* Dilation and curettage (D & C) is a procedure in which the cervix is dilated and the uterine lining is scraped and removed with a long spoon-shaped instrument.
* Endometrial ablation is a newer procedure that uses a hot coiled instrument called a resectoscope to destroy the lining of the uterus. There's less pain and faster recovery than with a hysterectomy, but it can lead to infertility, and studies show that it's completely successful only about half the time.
Planning for the Aftermath
Experts say you shouldn't rush into a hysterectomy without complete information on side effects, recovery time and the physical and emotional changes you can expect.
If a hysterectomy is necessary for you, here's how to make the most of it.
Ask about a vaginal hysterectomy. In many hysterectomies, the uterus can be removed through the vagina rather than through an incision that's four to six inches long across the abdomen. When a laparoscope is used to help this procedure, it is called a laparoscopic assisted vaginal hysterectomy (LAVH). LAVH leaves no visible scar and can sometimes be handled on an outpatient basis, says Joseph Gambone, D.O., associate professor of obstetrics and gynecology at the University of California, Los Angeles, UCLA School of Medicine.
LAVH requires a well-trained surgeon, so when getting referrals from your primary physician, ask for surgeons who are board-certified in gynecology and obstetrics and who have experience in this procedure, advises Dr. Hutchins. And don't be shy about interviewing more than one surgeon. Keep talking until you find one with whom you're comfortable.
Fight for your body. Some doctors who perform hysterectomies advocate removing ovaries as a preventive measure against ovarian cancer. But unless you have cancer or a family history of the disease, don't be talked into it: A woman's lifetime chances of dying from ovarian cancer are only about 2 in 100, says Dr. Gambone. Meanwhile, removing your ovaries without adequate hormone replacement therapy can double your risk of developing osteoporosis and heart disease--the number-one killer of women.
Ask about low-dose estrogen. If you must have your ovaries removed, estrogen replacement therapy (ERT) is the best way to protect against heart disease and symptoms of osteoporosis, says Dr. Hutchins. But ask your doctor about the lowest possible effective dose, since ERT may increase your risk of breast cancer and other conditions, says Dr. Goldfarb. Fortunately, doctors believe that by combining estrogen with progestin (another female hormone), you may be able to reduce your cancer risk.
Start a regular walking program. If a family history of cancer makes you a bad candidate for ERT, it's essential that you get regular exercise and plenty of calcium in order to slow the bone loss that can lead to osteoporosis. Australian researchers found that a brisk 30-minute walk at least three times weekly helped slow the rate of bone loss in postmenopausal women when coupled with 1,000 milligrams of supplemental calcium each day.
That's because weight-bearing exercises such as walking help build bone mass. Exercise is also a great way to keep your heart healthy, since estrogen deprivation can change the way your body processes cholesterol and can cause hardening of the arteries.
Include your partner. If you're considering a hysterectomy, talk with your partner and consider including your partner in discussions with your gynecologist about its effects. With the uterus gone, women will notice changes in their orgasms. The earth-shaking contractions that affect the uterus at climax will be missing, although other tissues will still be just as volatile. Including your partner in a discussion of how your physical sensations may change may prevent future problems in the bedroom, says Dr. Hutchins.
