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Alternatives to Hysterectomy(Uterus removal)

Posted by : Prince, 01 Jun 2011 12:46 PM
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By:
Dr Ashwini Bhalerao-Gandhi
MD, DGO, DFP, FCPS, DNB, FICOG
Consultant Gynecologist,
P.D.Hinduja Hospital, Mumbai
For any queries, Email us at info@hindujahospital.com

Hysterectomy is a very commonly advised surgery for women in perimenopausal age group. Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive system. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of tissue resembling the uterine lining tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and three forms of cancer (uterine, advanced cervical, ovarian).

The decision to have a hysterectomy should not be taken lightly. There are medical conditions that require treatment - cancer, prolonged heavy bleeding to the point of severe anemia, or incapacitating pain. As with most decisions, the woman should carefully consider the pros and cons of hysterectomy as they relate to her particular medical situation and emotional well-being. On one hand, she should weigh the degree of discomfort that her gynecologic problem presents to you, the ways in which it interferes with her health, both emotionally and physically. On the other hand, weigh the potential risks of the operation, including the possible physical as well as the emotional side-effects of having a hysterectomy.

According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60. There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade. In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are removed in about 20% of hysterectomies. We do not have accurate statistics in India.

Hysterectomy has like any other surgery certain risks and side effects. During surgery excessive bleeding may occur. After surgery wound complications may result. Other problems like urinary tract infection are also common.

Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for vaginal or laparoscopically assisted vaginal procedures. Time for full recovery is very long and practically independent of the procedure that was used.

The average onset of menopause in those who underwent hysterectomy is 3.7 years earlier than average even when the ovaries are preserved. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% women, some of them even require hormone replacement treatment. Surprisingly, a similar or slightly weaker effect has been also observed for endometrial ablation which is often considered as an alternative to hysterectomy.

There are many newer alternatives to traditional hysterectomy. Which one is suitable for a particular patient needs to be properly assessed.

1) Uterine Artery Embolization - Uterine artery embolization (UAE) is a radiological procedure recently introduced as an alternative treatment for symptomatic uterine fibroids. The American College of Obstetrics and Gynecology cautions about its potential for infection and other serious complications requiring emergency surgery.The radiologist introduces a catheter, usually through the right femoral artery, into each of the two uterine arteries, which supply blood to the uterus and, in turn, to the fibroids. A solution containing small particles is injected into the uterine arteries. The particles occlude the branches of the uterine arteries (blood outflow) and thereby drastically reduce blood supply to the uterus and the fibroids. The procedure is usually done under edation and local anesthesia.

Outcome and Success Rate - Six months after UAE the average fibroid is reduced in size by 40-60%. Reportedly, UAE reduces uterine bleeding and symptoms related to uterine size such as urinary frequency and pelvic pain. Recent studies found that 22% of patients undergoing UAE required hysterectomy or myomectomy. The reasons for the hysterectomy were continued heavy bleeding, pain and bulk related symptoms.

2 ) Myolysis for Uterine Fibroids - Myolysis is the destruction of fibroids (necrosis) by different methods, including coagulation of the tumors with bipolar or unipolar electric electrodes or laser beams. The procedure may destroy large portions of the uterine muscle. Consequently, a pregnancy following myolysis is ill-advised.

3) Endometrial Ablation- Endometrial ablation destroys the endometrial lining to a varying extent (depending on technique and skill). These techniques include hot water balloon, cryo-ablation (freezing the endometrium), laser ablation, roller ball cautery and electric loop resection of the endometrium.These procedures are quite effective for the treatment of true functional uterine bleeding (bleeding due to hormonal imbalance without the presence of any anatomical abnormality), but in the presence of sub-mucous fibroids, endometrial ablation usually fails (unless effective myomectomy is also performed at the same time). Ablation also fails when the bleeding is caused by deep adenomyosis.

4) MRI-Guided Focused Ultrasound Surgery for Uterine Fibroids - The patient lies on her back and ultrasound waves are focused with the guidance of Magnetic Resonance Imaging into the center of a particular fibroid. The treatment is limited only to those fibroids where the focused ultrasound energy does not traverse bowel or bladder on its way to reach the fibroid. (Otherwise, the bladder or bowel may sustain damage.) The focused ultrasound energy is continued long enough to produce thermablation of the center of the sonicated fibroid. This volume will become necrotic and eventually shrink. The procedure is still in its early stages of evaluation and long-term results and complications are unknown.

5) Uterine Balloon Therapy - It is a procedure to reduce excessive menstrual bleeding. Unlike hysterectomy, which takes out the entire uterus, the procedure just destroys the lining of the uterus by the use of heat.

In most cases, bleeding during a period will be reduced to moderate or light flow. Some women may experience spotting; a few may experience no bleeding at all. Clinical data has shown that up to 15% of patients may not respond to this therapy and may require additional treatment.

6) Transcervical resection of endometrium (TCRE)- It may be called a TCRE for short. We pass a thin telescope, called a hysteroscope, through vagina and cervix into the uterus. We pass another instrument, called a resectoscope, through the hysteroscope to remove the endometrium. The resectoscope has a loop of wire at the end, which cuts using an electric current called diathermy.

If the endometrium is completely removed, the patient will have no further periods. If only a small amount of the endometrium remains, periods should be light.

Most women, about 85%, are pleased with the result after four years. Some of the remaining women will need a repeat TCRE or even an operation to remove the uterus.

7) Hysteroscopy / D&C / Polypectomy During a hysteroscopy, the gynecologist inserts a thin telescope with a video camera called a hysteroscope in the woman's uterus. The hysteroscope is passed from the vagina through the cervix into the uterus. The uterus is filled with a liquid or a gas (carbon dioxide) to allow for visualization of the endometrial cavity. When an operative port is combined with the hysteroscope, very small instruments may be used within the uterine cavity to perform a variety of surgical procedures.

Polypectomy is a surgical procedure to remove polyps (benign growths that rarely turn into cancer) from the endometrial lining of the uterus. Because of limitations of the D & C procedure to visualize and grab the polyp for removal, polypectomy is more often performed through hysteroscope.

8) Gonadotropin-releasing hormone agonist injections – These injections interact with the gonadotropin-releasing hormone receptor to elicit its biologic response, the release of the pituitary hormones FSH and LH. It will lead to medical menopause.

Women with menorrhagia, endometriosis, adenomyosis, or uterine fibroids may receive GnRH agonists to suppress ovarian activity and induce a hypoestrogenic state.

9) MIRENA® (levonorgestrel-releasing intrauterine system)

Mirena® (levonorgestrel-releasing intrauterine system) consists of a T-shaped polyethylene frame (T-body) with a steroid reservoir

Low doses of levonorgestrel can be administered into the uterine cavity with the Mirena intrauterine delivery system. Initially, levonorgestrel is released at a rate of approximately 20 μg/day. This rate decreases progressively to half that value after 5 years. Mirena has mainly local progestogenic effects in the uterine cavity. Morphological changes of the endometrium are observed, including stromal pseudodecidualization, glandular atrophy, a leukocytic infiltration and a decrease in glandular and stromal mitoses.

Mirena is indicated for intrauterine contraception for up to 5 years. Thereafter, if continued contraception is desired, the system should be replaced. Mirena is recommended for women who have had at least one child. This can be used for relief of heavy periods.

Most of the above mentioned alternatives are available in India. The cost depends on many factors

type of procedure chosen, type of hospital, experience and seniority of the gynaecologist, class of bed etc.

Cost may be equivalent to hysterectomy or more than that. Many patients get confused after hearing about different alternatives. A method which is suitable for a patient may not be suitable for another patient. Your gynecologist can explain pros & cons of different methods as applicable to your particular situation. The best possible alternative can be chosen after discussing your symptoms, evaluating your investigations and findings of the clinical examination. No modality is superior or inferior. All have their advantages as well as disadvantages. Please have faith in your for selecting the right option for you.

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