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Alternatives to Hysterectomy

I. Facts

a. Hysterectomy is 2nd most commonly performed major operation in United States, 600,000 per year.

b.Approximately one in three women will have this operation during their lifetime, usually before the age of 60.

c. Most common indications:

i.Fibroid uterus
ii.Abnormal uterine bleeding (heavy menstrual flow) iii.Endometriosis/chronic pelvic pain iv.Pelvic organ prolapse

d. Morbidity associated with hysterectomy; Death = 0.1-0.2%

i. Increase with age of patient
ii. Increase with medical complications
iii. Increase with difficulty of procedure
iv. Increase with association with pregnancy

e. Causes of death

i. Blood clot to lungs
ii. Cardiac arrest size
iii. hemorrhage
iv. Infection
v. Injury to adjacent organs

1. Bladder
2. Bowel
3. Uterus

II. Alternatives

a. Alternatives to hysterectomy can provide excellent treatment outcomes for many women. In general, these alternatives are underutilized. For some women, alternative treatments fail and hysterectomy provides the best approach.

b. For women who require hysterectomy, the laparoscopic approach affords the benefit of less postoperative discomfort, shorter hospital stay, and quicker recovery.

c.Morbidity associated with alternative approaches depend on:

i. Type of approach

ii. Nature of illness

iii. Physical, medical condition of patient
iv. Experience of physician v.
v. Patient's perspective and future desires

III. Fibroids

a. Definitive therapy = total abdominal hysterectomy
b. Expectant management
iii. Less radical surgical therapy

1. Endoscopic removal
2. Myolysis
3. Myomectomy
4. Uterine arterial embolization
5. Hormonal therapy
6. GnRHa therapy iv. Recurrence rates = 10-30%

IV. Subsequent hysterectomy = 20-25%

e. Heavy menstrual flow (menorrhagia)

i. 15-20% of healthy women experience debilitating menorrhagia

ii. Past therapy recommended = vaginal hysterectomy

iii. Alternatives today an option as nearly 50% of uterine specimens obtained at hysterectomy for menorrhagia are disease free on pathologic examination

iv. Less radical surgical therapy

1. Medical therapy

a. NSAIDs

b. Progestins

c. Oral contraceptives

d. GnRHa

2. Surgical therapy

a. D & C

b. Endometrial ablation

i. Recurrence rate = 25-30%

ii. Reoperation rate = 10-20%

iii. Subsequent hysterectomy = 20%

iv. Contraindications

1. pelvic malignancy

2. future fertility

3. acute pelvic infection

4. large fibroids

5. large uterus

c. Hysteroscopic resection of polyps/fibroids

f. Endometriosis/chronic pelvic pain

i. Abdominal inspection for assessment of extent of disease

ii. Definitive therapy = Total abdominal hysterectomy with bilateral salpino-oophorectomy, appendectomy, excision of remaining adhesions or implants of endometriosis

iii. Conservative approach

1. Medical therapy

2. Laparoscopic surgery

3. Presacral neurectomy

g. Pelvic organ prolapse

i. Operative approaches

1. abdominal hysterectomy with bladder suspension

2. vaginal hysterectomy with sling procedure

3. vaginal repair

ii. Nonoperative approaches

1. pessaries

2. exercises

3. estrogens in menopausal women

Robert B. McWilliams, M.D.

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