New Research on Alternatives to Total Hysterectomy

In an age when so many once private topics are out in the open, many women are still very reluctant to talk about hysterectomies, perhaps because of the potential emotional implications of losing the womb, the organ that in some ways defines feminine identity. But it is a surprisingly common operation. By the time they reach age 60, nearly a third of all American women will have had their uteruses removed, making hysterectomy the second most frequently performed major surgical procedure (after Caesareans) for women of reproductive age.

Although it's commonly thought of as an operation for older women, the average age of women getting hysterectomies is actually 42, which means that many younger women have the procedure. That can be particularly devastating if they haven't yet had but want children. In the past, doctors have been divided over whether to also remove a woman's ovaries if she hasn't reached menopause, especially if the reason for the hysterectomy is endometrial cancer that is confined to the inside of the uterus.

But two recent studies indicate that there are good reasons to keep the ovaries. A study published earlier this month by researchers at Columbia University College of Physicians and Surgeons found similar five-year survival rates in 402 women age 45 and younger with stage one endometrial cancer whose ovaries were preserved and 3,269 similar women whose ovaries were removed.

Keeping the ovaries may have long-term health benefits as well. Until women reach natural menopause (the average age is 51), estrogen produced by the ovaries protects against heart disease and thinning bones. A 2007 study also found that women who have their ovaries removed before menopause are at increased risk of developing dementia and other memory problems.

Nearly 600,000 hysterectomies are performed annually in the United States, according to the Centers for Disease Control (CDC), a rate that is down from a peak of 740,000 in 1975. The U.S. still has one of world's highest hysterectomy rates, however, and in recent years, major medical organizations have worked hard to educate both doctors and patients on alternatives to surgery, as well as ways to minimize the surgery's long-term effects.

A total hysterectomy means that the uterus and cervix are removed. In a partial hysterectomy, only the portion of the uterus above the cervix is taken out. In both cases, the ovaries and fallopian tubes may or may not remain. Some doctors believe that saving the cervix reduces the risk of future sexual or urinary problems, but recent studies suggest that's not the case. Still, the issue remains somewhat controversial.

Besides cancer, other problems that can lead to hysterectomies include fibroids, benign growths in the uterus that can cause pain and heavy bleeding; endometriosis, a condition in which the tissue lining the inside of the uterus grows outside on the ovaries or other organs in the abdominal cavity; and uterine prolapse, when the uterus moves down into the vagina.

If your doctor suggests a hysterectomy for you, here are some questions to ask, suggested by Dr. Denise Jamieson, medical officer in the division of reproductive health at the CDC and chair of the American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice:

1. What are my other options? If you are considering a hysterectomy because of bleeding problems, your doctor should be knowledgeable about the current range of nonsurgical options and be able to discuss which makes the most sense for you. There are IUDs and hormone treatments that can help, as well as more limited surgical procedures (myomectomies and embolizations) that remove the fibroid tumors causing the bleeding but leave the uterus intact.

2. If more limited treatments aren't appropriate, what type of hysterectomy is best? Women may be presented with a range of surgical options depending on their specific clinical situation. A total abdominal hysterectomy involves an abdominal incision and requires an overnight hospital stay. Complete recovery takes up to eight weeks. A vaginal hysterectomy leaves no abdominal scar and patients usually go home more quickly than after an abdominal hysterectomy, sometimes on the day of surgery. Laparoscopic and robotic surgeries—performed with small incisions to the abdomen—are usually performed on an outpatient basis. Your doctor should be familiar with all these options and discuss them with you. If your doctor has only limited knowledge, ask for a referral to someone who has a wider range of experience.

3. What are the complications, risks and likely success rates for each type of procedure? Although laparoscopic and robotic procedures are becoming more popular, it's not clear that these are better. "We are doing more laparoscopic and robotic surgeries without carefully evaluating the benefits of one type over the other," says Jamieson. Some surgeons simply prefer one procedure over another because they've had more experience with it, according to Jamieson. It's important to find a doctor who can objectively compare the different methods.

4. Ask if your surgeon is experienced with the kind of surgery you want. If he or she is not, be sure to ask for a referral to someone who is.

5. Will my ovaries be removed as well? Women who have not yet reached menopause should discuss whether it's a good idea for them to keep their ovaries in order to preserve natural estrogen production, strong bones and better sexual function. Jamieson said the American College of Obstetricians and Gynecologists generally recommends that premenopausal women keep their ovaries, if possible. It's important to understand that after a hysterectomy, pregnancy is no longer an option. While it's possible to have eggs harvested and embryos frozen, these procedures are expensive and complicated, and not to be taken on lightly. They may also mean a potentially life-threatening delay in surgery.

No matter what the reason for the hysterectomy, it is a serious, and permanent, decision. For more information, check out these resources from the American College of Obstetricians and Gynecologists and the National Women's Health Information Center.

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