Alternatives to Hysterectomy

December 14, 2007

Non-surgical Alternatives to Hysterectomy

Removing the womb will certainly resolve problems with bleeding, fibroids, pain related to the uterus, and pelvic heaviness related to prolapse of the uterus. But many women would prefer to not lose any of their anatomy if they can help it. Conservative treatments have enjoyed varying degress of success.

Endometriosis has, as its final treatment, hysterectomy. But endometriosis is a tragic disease affecting fertility in those eager to achieve pregnancy. For this reason the big gun, Lupron, or Lupron + surgery (without hysterectomy) may be followed with non-cyclic birth control pills to control the disease until ready to aggressively seek pregnancy. Fibroids can be surgically removed from the uterus, preserving it. Pelvic prolapse can be corrected with a uterine suspension (although this is a lousy operation that fails consistently). Irregular bleeding can be controled with birth control pills, DepoProvera shots, or other hormonal manipulation.

What is a Fake Hysterectomy?

The uterus does two things: It bleeds once a month (ideally) and it carries a baby (hopefully less frequently than once a year).

When babies are no longer desired, the uterus is still an extremely important organ to a woman, because the monthly cycles are a reassurance that everything is working properly hormonally. A normal period can be anywhere from every twenty-one to thirty-six days (although every twenty-one could be tiresome), and last from two to five days or so. The further away on either end of these parameters the duration or frequency extends will present problems to social, sexual, and day-to-day life.

One of the most common reasons for hysterectomy (removal of the womb) is heavy and/or frequent bleeding to the point that it interferes with lifestyle. Heavy bleeding can cause pain and cramping bad enough to miss work, having a financial penalty as well. Anemia can result when a patient's bone marrow cannot keep up with making enough blood to compensate for that lost. When things get bad enough that something must be done, hysterectomy is the most agressive and final way to go.

Rarely, about once a year in my practice, a woman will present to the emergency room with hemorrhage requiring an emergency hysterectomy and transfusion. In the past women suffered or died from these complications. Now, she can just have a little hysterectomy.

Wait a minute! "Little" hysterectomy? Hysterectomy is one of the most common procedures done in the U.S. today, most of the time performed on otherwise healthy, non-elderly women who do well. But we still have to remember it is not just a "little" operation. A woman can still die from such an operation. Our bodies are dynamic systems, each one unique, each one with subtle variations of anatomy. Any surgery will pose a different presentation to a surgeon, and he or she must be well trained to handle these variations as well as handle surprise complications that can arise from blood loss, infection, or damage to other structures during the course of the surgery. In other words, no one has just a "little" hysterectomy. It is always serious business. In these days of undergoing surgeries under epidural anesthetics and pain relief with lingering medications and powerful anti-inflammatories, we've been lulled into a false sense of security when patients are discharged from the hospital on post-op day two or three. And it is true that most obstetrician-gynecologists have had very low complication rates. But a woman cannot be guaranteed before surgery that she has any special protection from complications. Therefore, hysterectomy should be performed when it is clearly necessary or indicated.

Prohibitive sexual pain, heavy bleeding, debilitating cramping, and anemia are all problems that could benefit from hysterectomy, and this operation does provide a final resolution to these problems. But what if a woman does not want or cannot afford in time or money the very operation that would be helpful to her? There is never a good time to have a hysterectomy--or any surgery for that matter. Even though the operation may be necessary, a woman is looking at down time of a month and a financial impact on her family. The down time impacts more than work; it takes a very important family member away from the household goings-on and from her husband, children, or friends. Those few weeks represent a big chunk of time in the phantom zone.

Yes, a hysterectomy will fix a problem arising from the uterus, but there are alternatives that can mitigate the sacrifice and danger of an abdominal operation. Laparoscopic hysterectomy is now performed by most GYN surgeons. Patients usually get out of the hospital the next day, and the recovery time is reduced to about a week to ten days. Hormonal manipulation (see above), which should be tried first, is sometimes successful in taming the response of the uterus to an aggressive cycle, pushing a patient into the tolerable zone of discomfort.

Even with Vaginal (some call "blind") Hysterectomy and Laparoscopic Assisted Vaginal Hysterectomy (LVAH), in spite of leaving the hospital within a couple of days, still the recovery may not be complete for three or four weeks. Who has this kind of time? Probably not you.

Unfortunately for some women, conditions sometimes push them into a hysterectomy procedure for which their busy lives can't stop. In the past it was just too bad: A woman just stopped her life, disrupted her work, school, and family, and did what was necessary. But then came a new wrinkle to the old problem.

Endometrial Ablation

Endometrial ablation became popular as an out-patient procedure that used electrocautery to eliminate that layer of the uterus that sloughed each month with the menstrual period. And so bleeding that warranted hysterectomy was also eliminated. A small wire loop was passed vaginally, under anesthesia, through a thin, lighted scope (hysteroscope) into the mouth of the womb (cervix) . There were no incisions. The electrified wire loop (resectoscope) shaved away the lining that was causing the bleeding. This was followed by a small roller-ball-like device that singed all of the surface area that was shaved. The scope was removed, the patient awakened, and all of her plans resumed the very next day. There were the advantages of hysterectomy without the hysterectomy. Sounded great. Did I mention the problem with this type of endometrial ablation?

Some women died from it.

Big problem.

I was taught how to do endometrial ablation by faculty from Harvard and UCLA. These are people who have performed the procedure hundreds and hundreds of times without any complications. It seems that the reports of patient deaths and complications involved doctors not adequately trained or who were careless. This is interesting, because it seems ANY surgery in the hands of someone not properly trained or careless could cause death and injury. It could have been that endometrial ablation had gotten a bum rap. Part of the training in this procedure requires one to know when fluid or gas used to distend the inside of the womb is accidentally leaking into the body through a sneaky sinus or vent in the uterine wall. It can be easily recognized and the procedure left incomplete for a "touch up" at a later time.

Carelessness can cause fluid to rush into the body, diluting the blood, and a resulting drop in sodium (hyponatremia) can lead to the cardiac arythmias that cause death. Careful monitoring of fluid going in with fluid being evacuated through the same scope will tell a gynecologist when things are getting uneven. Simple arithmetic. With this precaution in mind, the procedure is just as safe as any other surgery. Another complication, burns through the wall of the uterus which might in turn burn bowel, can be prevented with the right training and care.

Bum rap corrected. So with a clear conscience, we began talking about a procedure that is a true advance--allowing a woman needing a hysterectomy for heavy, prolonged, or abnormal bleeding to have an out-patient procedure that eliminates the actual cause of the problem. She keeps her womb and returns to her routine after the anesthetic is washed out of her system. The procedure would also help those who were poor risks for conventional hysterectomy--those who had been bumped because of obesity, diabetes, or other medical conditions. Although the procedure did not replace hysterectomy, it was offered, with the proper precautions, as another option for many and a necessity for others.

Then...It became less popular. Even though people only died at the hands of bad math, still the procedure had a black cloud over it that caused it to fade away. Gynecologists loved the idea of ablation of the endometrium but didn't feel like having to possibly explain to a jury a weird complication of a new procedure that took the life of a healthy woman during an elective procedure.

"If they could only make this procedure completely safe..."

Enter ThermaChoice.

Uterine Balloon Therapy (UBT)

ThermaChoice was a new method that kept the advantages of endometrial ablation without the fears of mortality--justified or not. This new development and technique, called Uterine Balloon Therapy (UBT), was invented solely to prevent hysterectomies in women who suffered with unmanageable periods and who no longer desired fertility. It was also invented for the gynecologist, still a big fan of the concept of endometrial ablation, but afraid of death from hyponatremia.

For a woman who presents with heavy, prolonged, and/or too frequent periods, possibly anemic and for whom hormonal therapy has failed, we may be backed into a corner of either offering her surgery or nothing at all. But (UBT) makes it possible to avoid a hysterectomy.

What happens in this technique is that from a vaginal approach (no incisions) a small balloon is inserted into the uterus where it is inflated with heated water which damages the endometrial lining (the source of all the bleeding) to the point at which it can't regenerate. The balloon is then withdrawn after about eight minutes. The machinery has been designed with many redundant safety measures. The balloons are about $650, and at that price you get what you pay for--a balloon that won't pop (test after test after test, in extreme conditions dozens of times more severe than what the procedure needs).

UBT is 85% successful in either making periods normal or (more likely) eliminating periods altogether.Like the older endometrial ablation described above, some women may need a second helping of this procedure, but with return to work the next day, we're still way ahead of what hysterectomy would involve. And hyponatremia is out of the loop altogether.

Besides the convenience, safety, and financial frugality of this procedure, it also gives those women who were poor surgical risks another option. Women who have lung or heart disease, diabetes, or an obesity problem that would make a major surgery more risky than beneficial can now treat their problem.

In these modern medical times of cost-containment, there are continuing concerns about complications due to cutting corners in treatments and diagnostics. Managed care companies, HMOs and PPOs, have had the difficult job of balancing what's best for the patient with what's fiscally responsible for the employers who have to pay the premiums for their employees. Nowhere has this been more true than in women's health care. But managed care should love this, because it gives them a cost containment vehicle that also provides an adequate treatment for the patient. Just the hospital stay itself for a hysterectomy can run $6,000 to $12,000. When compared to a two-hour stay at a surgicenter for an eight-minute procedure, the savings is not only in money, but in recuperation and in return to normal life. Everyone wins.

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