Love Thyself

Do you really need that hysterectomy?

by  Andrea N. Price, M.D.   

(c) Copyright, 2001, Dr. Andrea N. Price

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

q       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.

q       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! 

q       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:

q       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.

q       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.

q       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.

q       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.