Hysterectomy Doctors Exploring Alternatives To Controversial Surgical Treatment
More than a generation after American women began rebelling against routine hysterectomies, removal of the uterus remains a common and controversial surgery. While the number of hysterectomies in this country has declined from a peak of 740,000 in 1975, it is still high at about 560,000 each year - twice the rate in England and three times the rate in Sweden.
The good news is that women’s demand for less radical treatments, coupled with managed care’s demand for less costly ones, is spurring development of alternatives to hysterectomy. Physicians are finding ways to selectively destroy uterine tissue or uterine tumors using minimally invasive technology that reduces the need for anesthesia and recovery time.
The procedures - some still experimental - are not without risks, complications and limitations. But for women determined to avoid a hysterectomy, the options are growing.
Women’s health advocates have “heightened the medical community’s awareness of the need for alternatives to hysterectomy,” said Mark B. Woodland, an obstetrician-gynecologist at Pennsylvania Hospital, “and we’ve developed a lot of good alternatives.”
Hysterectomy is major surgery, requiring general anesthesia, several days of hospitalization and four to six weeks of recuperation. In a simple hysterectomy, the uterus and cervix are taken out through the abdomen or vagina. In a total hysterectomy, the fallopian tubes and ovaries are removed as well.
Critics say hysterectomy not only ends a woman’s fertility and exposes her to the dangers of major surgery, but it may reduce her sex drive and energy level and create urinary problems. Some research suggests it may even increase the risk of cardiovascular problems.
“I haven’t talked to a single woman who wouldn’t turn the clock back if she had known the consequences of hysterectomy,” said Nora W. Coffey, who founded Hysterectomy Education Resources and Services in Bala Cynwyd, Pa., outside Philadelphia, after her own hysterectomy 19 years ago at age 36.
Others counter that most women who resort to hysterectomy find it improves the quality of their lives but agree that right through the 1970s doctors treated the uterus as expendable, even unimportant, in women who were finished with childbearing.
“When a woman had completed her family and had any significant gynecological problem, hysterectomy was the answer,” said Brian Walsh, chief of surgical gynecology at Brigham & Women’s Hospital in Boston.
Only 8 percent to 12 percent of hysterectomies are clearly necessary to treat cancer or other lifethreatening diseases. Most often, the operation is performed to treat benign tumors of the uterus called fibroids. These estrogen-sensitive growths, which occur in about 40 percent of women over 35, usually have no symptoms and shrink on their own after menopause.
But depending on their size, number and location, fibroids can cause bleeding and pain and, in rare cases, can obstruct other organs, such as the bladder or bowels. Drugs that can temporarily shrink fibroids have unpleasant side effects.
Occasionally, hysterectomy is done to relieve pelvic pain or abnormal bleeding that is not related to fibroids and that doesn’t respond to hormonal therapy. Hysterectomy also may be done to treat uterine prolapse, in which the uterus descends into the vagina, or severe endometriosis, a painful, recurring condition in which bits of uterine lining migrate to other areas of the abdomen, where they adhere and cause scarring.
As women have pushed for less radical treatments, so have cost-conscious health insurers.
“We had incentives under the traditional (fee-for-service) system to operate on people,” said Francis L. Hutchins Jr., a Bala Cynwyd gynecologist who specializes in treating fibroids. “We’re now hearing the mandate of managed care to be more efficient in our use of resources.”
Many new treatments involve the use of laparoscopes or hysteroscopes - telescopelike instruments that can be equipped with lights, viewing lenses, lasers, scalpels or electrocautery devices. These scopes are inserted into the uterus through tiny incisions in the abdomen or through natural body openings - thus avoiding the need for major abdominal incisions - and then used to diagnose and treat bleeding, fibroids, cysts and other problems.
Among the alternatives to hysterectomy:
Myolysis. A laparoscope with an electrical needle destroys small blood vessels feeding fibroids, which gradually shrink as they die. Montclair, N.J., gynecologist Herbert Goldfarb, who introduced the technique six years ago, says it is suitable for fibroids near the uterine surface.
He first shrinks the fibroids with drugs called GnRH antagonists.
Uterine balloon therapy. To treat excessive bleeding, a slim tube, or catheter, with a balloon attached is inserted into the uterus, where the balloon is filled with a sterilized liquid. Then a heating element raises the liquid temperature to 189 degrees, destroying or “ablating” the uterine lining, called the endometrium. This technique, being tested in 13 U.S. hospitals, including Brigham & Women’s, is considered safer than older methods that use lasers or electrocautery to ablate the endometrium.
All forms of endometrial ablation render the uterus incapable of childbearing. Sometimes the bleeding recurs.
Uterine artery embolization. In this experimental fibroid treatment, a catheter is inserted through a small groin incision into the femoral artery, then threaded up to the uterine artery. Plastic particles as fine as sand are injected into the catheter. These particles lodge in tiny blood vessels, cutting off blood to the fibroids, which then shrink over the next several months. Robert Worthington-Kirsch, a radiologist at City Avenue Hospital, and Hutchins are pioneering the embolization procedure for fibroids. However, it has long been used to stop postpartum and postsurgical hemorrhage.
Hysteroscopic resection. A hysteroscope is inserted through the vagina and fibroids are gradually shaved out, layer by layer.
Myomectomy. Fibroids are cut away without removing the entire uterus. Depending on size and location, the fibroids may be extracted through an abdominal incision or using by a hysteroscope or laparoscope.
While state-of-the-art approaches can spare women from hysterectomy, they require specially-trained, skilled practitioners. Richard Tureck, director of reproductive surgery at the University of Pennsylvania Medical Center, has seen what can go wrong with endometrial ablation, for example: “We’ve seen so many disasters come here (for repair) after the uterus is perforated or the bowel burned.”
The best medicine, he and others say, is for women to carefully evaluate the risks and benefits of all options, including hysterectomy.