Women frequently voice the concern that they may need a hysterectomy
to solve problems with menstrual flow. Many have family and friends that
have had surgery, and they would like to avoid it if possible.
Fortunately, there are now other options. Dr. Dein outlines the choices
that are now available for treatment. — Beverly
Vaughn, MD, Medical Coordinator, Menopause and You
Reasons for Hysterectomy
Hysterectomy, which is the surgical removal of the uterus,
remains one of the most common operations performed in America
today. Reasons for hysterectomy include excessive bleeding, pelvic
pain, fibroid tumors, uterine prolapse, and cancer. While many of
these indications remain entirely valid, modern advances now offer
doctors and patients alternatives to this surgical procedure. This
article discusses alternatives to hysterectomy for two major conditions:
menorrhagia, or excessive vaginal bleeding, and uterine
Options for Managing Menorrhagia
As with any medical problem, the most important part of choosing the
appropriate therapy for excessive bleeding is for your doctor to begin
with a careful history, physical examination, and testing in order to
determine the cause. Reasons for bleeding can usually be divided into
three categories: mechanical (e.g., fibroids or polyps), hormonal (e.g.,
excessive estrogen or anovulation), and neoplastic (i.e.,
A workup should include a sonohysterogram, which is a specialized
ultrasound that images the interior of the uterine cavity. This can
determine if there is a polyp or fibroid present within the cavity.
Polyps can nearly always be removed with a simple D&C (dilation and
curettage) procedure, which may in turn eliminate the bleeding problem.
Fibroids within the cavity may be removed with a hysteroscopic
resection, which again may be curative, and thereby avoid the need for
It is important that a simple office endometrial biopsy be performed to
rule out precancerous or cancerous lesions. Precancerous cells may be
treated with hormones in women who wish to retain their fertility, but
they are usually treated with a hysterectomy. Cancer of the uterus still
nearly always requires surgery.
If the reason for bleeding is felt to be a hormonal imbalance, the
traditional treatment has been the use of birth control pills or natural
and synthetic progesterone. There is a new technique now available which
eliminates many of the problems inherent with the use of systemic
hormones, namely a progestin-secreting IUD called Mirena.
The Mirena IUD has been used by over two million women over the last ten
years. It is a small T-shaped plastic device that is approximately the
size of a quarter. This IUD is inserted by your doctor through the
cervix into the uterus. This is done in the office without the need for
anesthesia. The Mirena releases a small constant dose of the progestin
Levonorgestrel. The effect over time is to thin out the lining of the
uterus and counteract the stimulatory effect of estrogen. With a
thinner, more stable uterine lining, a woman will bleed less and may
even stop bleeding altogether. The advantages of the Mirena are that it
is not only a treatment for excessive bleeding, but also a very
effective form of birth control as well; it is fully reversible in
case pregnancy becomes desirable; and it lasts for five years. Since
there is no estrogen in this device, it is appropriate for women who are
breastfeeding or following treatment for breast cancer.
One of the most exciting new innovations to decrease the need for
hysterectomy is a minor surgical procedure called an endometrial
ablation, usually performed in the physician’s office. Uterine bleeding
comes from the endometrium—the fluffy glandular lining of the inside of
the uterine cavity. Endometrial ablation surgically destroys (ablates)
that lining. Endometrial ablation has been performed for many years, but
it was a difficult, long and potentially dangerous procedure. The new
technologies of endometrial ablation have lowered the operative time to
50 to 90 seconds and have virtually eliminated the risks.
Modern endometrial ablation utilizes one of three major
technologies: a heated, fluid-filled balloon; an electrically conductive
mesh; or an intrauterine infusion of super-heated water. The mesh, or
NovaSure system, is the newest technique. NovaSure uses a
small, gold-foil mesh that is inserted into the uterus after a brief
dilation of the cervix. A light general anesthetic is given, although
some physicians perform this in their office with a local cervical
block. The mesh device is attached to a computer-driven controller that
applies a very precise amount of electrical energy to the endometrium.
Safety measures will prevent the machine from operating if a small hole
is present in the uterus. After 50 to 90 seconds, the feedback
mechanism on the controller indicates that the endometrium is completely
ablated, and the mesh is then removed. Results have been dramatic with
this new technology. Approximately 60% of women will not bleed at all
after this procedure, and 92% will have significant improvement of
their bleeding. Women who continue to bleed heavily can be re-treated or
may be candidates for hysterectomy. Side effects are few, and patients
go home after one to two hours. Return to work is usually within a few
Options for Treating Uterine Fibroids
There are two techniques available to treat fibroid tumors without
hysterectomy: myomectomy and uterine artery embolization.
Myomectomy is the surgical removal of fibroids and can be accomplished
hysteroscopically, if the fibroids are within the uterine cavity, or by
laparoscopy or traditional laparotomy. A hysteroscope is a lighted
instrument that is passed through the vagina into the uterus. Myomectomy
has the advantage of fully removing the fibroids, while preserving the
Uterine Artery Embolization (UAE)
A second technique is the new procedure of uterine artery embolization
(UAE). UAE is performed by an interventional radiologist and is similar
in technique to cardiac catheterization. A small incision is made in the
groin, and a catheter is inserted through the femoral artery into the
uterine artery. Small plastic particles are then injected into the
artery, clogging it, and reducing the blood flow to the uterus. Fibroids
then die and shrink in size over time. Fibroids shrink an average of 39%
after three months, and 52% by six months. Occasional serious
complications occur, but complication rates are low.
In sum, there are many available techniques that may reduce or eliminate
your need for a hysterectomy. As always, your best resource is your
health care provider. Individual attention to your condition, needs, and
desires will help choose the course that is right for you.
This article is part of the Menopause and Youlibrary,
a web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own health care practitioner with your
specific concerns and questions.
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