Posts from — June 2010

I urge you all to check out the entire content on Women\’s Voices for Change, an online resource for grown women and the people who love them.

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty\’s Prolapse Problem

(c) Lauri Romanzi 2010

Vaginal rejuvention, a mystical term with many facets, new darling of cosmetic surgery and battle cry of the “anti-medicalization of female sexuality” crusade, is a marketing term with no formal medical definition, this despite the American College of Obstetrics and Gynecology 2007 Clinical Practices Bulletin on the topic that was rife with both admonishments against some, and guarded approval of other, procedures advertised under this “VR” label. Some 3 years after the ACOG bulletin, concern and confusion reign on as the definition of vaginal rejuvenation continues to mutate.  

As a reconstructive pelvic surgeon and urogynecologist, I’ve been dealing with “Vaginal Rejuvenation” requests of all types since the term went public. As far as I can tell, the public’s interpretation of vaginal rejuvenation falls into three groups, listed here in order of increasing controversy and decreasing volume of safety & efficacy data:

Procedures to correct prolapse and incontinence

Procedures to alter the appearance of vulvar structures

Procedures alleged to enhance female sexual gratification

For a perspective-setting preview, consider reading this 2009 review of vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, here:

NAFC Quarterly Update Vaginal Rejuvenation & Childbirth Planning

These 2 articles, written for the National Association for Continence quarterly newsletter, dovetail nicely. As it turns out, much of what patients consider “vaginal rejuvenation” has a lot to do with childbirth-related changes in pelvic floor anatomy and function. As a contributor and member of NAFC (National Association For Continence, www.nafc.org), I share this fantastic online resource for information on pelvic floor disorders.  While the NAFC focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing up-to-date information on sex and well being to the public.

THE INSIDE SCOOP ON VAGINAL REJUVENATION

UPDATE 2010

Vaginal rejuvenation is a tenaciously fashionable concept, still with no strict medical definition. Yes that’s right, things vaginal continue to be fashionable. And, as with fashion, much is left to creative interpretation.

For many women, the childbearing, peri- and post- menopausal years come with pelvic, sexual, urinary, rectal or vaginal problems. Vaginal laxity, pelvic prolapse, poor bladder control, vaginal dryness, sexual pain, or waning sexual response can truly affect how you feel about yourself and your ability to enjoy your life. In medicine, we use “quality of life” questionnaires to measure the affect of such symptoms on health‐ mental health, ability to work, play, travel, enjoy sex, and feel normal and intact as a woman. If things aren’t right, you have options. These options, under the newly minted term “vaginal rejuvenation”, continue to spark controversy, raising concerns about safety, efficacy, and medical ethics.

With those options come obligations. Your obligation includes examining your motivations, taking stock of the overall impact of the condition(s) on your quality of life, and obtaining several medical or surgical opinions before you start any therapy or sign up for any surgery.  The doctor’s obligations include sorting out whether your condition(s) warrant physical, medical or surgical therapies or some combination thereof, and to help you understand what the risks, benefits and alternatives are for your personal mix of issues and symptoms.

Vaginal rejuvenation skipped onto the medical stage a few years ago, with no formal medical definition, in response to increased demand for  cosmetic alteration of gynecologic structures, most commonly the labia minora (inner vaginal lips). It has since come to mean any variety of procedures and treatments, many with an established record of use for generations, and others with no established history, little to no safety or efficacy data, and no predictable result.

“Vaginal Rejuvenation” for pelvic organ prolapse, vaginal laxity, and incontinence

Women with vaginal laxity, prolapse or  incontinence  might not know what “prolapse” or “incontinence” truly mean, but all women instinctively understand the notion of vaginal rejuvenation.

For a new mother, vaginal rejuvenation may mean improving pelvic muscle tone, and vaginal snugness with Kegel muscle exercises in a formal postpartum rehabilitation program of biofeedback (think “vaginal video games”) and pelvic floor electrical stimulation. For a 43 year old tennis‐playing mother of 3, it could mean minimally invasive surgery for “exert and squirt” type urinary incontinence (stress incontinence), with “perineoplasty” to restore the perineum (connective tissue between vagina and anus) back to normal, “rejuvenating” bladder control and vaginal snugness to pre‐baby condition. Or uterine resuspension, bladder lift, rectum reinforcement (rectocele repair), perineoplasty and a minimally invasive sling for combined prolapse and stress incontinence – what I call “the blue plate special.”

Vaginal Rejuvenation Traditional Medical Terminology

Vaginal muscle fitness = Pelvic Floor Rehabilitation a.k.a. Kegel Exercise

Lift a dropped bladder = Anterior Colporrhaphy*

Tighten a vagina permanently widened by childbirth= Perineoplasty

**Fix a bulging rectum = Posterior Colporrhaphy

Repair a leaky bladder = Urethral Sling or Urethral Bulking Injections

Restore anal control = Anal Sphincteroplasty

Lift a dropped uterus = Uterine Resuspension, aka Hysteropexy

***”Vaginoplasty” = creation of a vagina (often using  loop of intestine) in a woman born with congenital absence of the vagina, or creation of a vagina in a woman whose vagina is scarred shut from disease (fistula, radiation effect, infection, radical pelvic cancer surgery). More recently, under the marketing concept of vaginal rejuvenation, it has come to mean any combination of procedures from any of the basic three categories (prolapse/incontinence, cosmetic, sexual enhancement) for women without congenital or acquired obliteration defects of the vagina.

*Also referred to as “anterior repair”

** Also referred to as “posterior repair”

***On “vaginoplasty”, in the realm of “vaginal rejuvention” for women born with normal vaginal anatomy, this procedure, commonly attached to the word laser, as in “Laser Vaginoplasty” or “Laser Vaginal Rejuvenation”, carries no description in any medical or surgical textbook or peer review journal.  As of June, 2010, neither “laser vaginoplasty” nor “laser vaginal rejuvenation” are now or ever have been taught in any surgical or gynecological residency training program, nor in any urogynecology, female urology, plastic surgery, or other reconstructive surgical subspecialty fellowship training program. If you want to know about laser vaginoplasty, patient choice is restricted to consultation with a doctor who paid to be trained by the founder of the laser vaginal rejuvenation procedure. These doctors pay a fee to spend several days learning the procedure(s). The fee includes the franchise purchase, after which purchasing physician participates in an exclusive, robust webmarketing network restricted to purchasers of the franchise, the only doctors who may perform the laser vaginal rejuvenation procedures. These franchise-purchasing physicians are under contractual obligation that forbids discussing or otherwise disclosing the actual technique to anyone who has not purchased the franchise, including colleagues or the press. As such, and despite patient satisfaction testimonials on the franchise physician websites, there is no scientific, peer reviewed data in any peer reviewed medical journal documenting the actual technique, efficacy or safety of laser-based vaginal rejuvenation procedures

For some women, “rejuvenate” = “relubricate” (see When rejuvenate = relubricate). Vaginal dryness, poor lubrication and reduced clitoral sensitivity, common symptoms after menopause, are easily remedied with low‐dose vaginal estrogen therapy, treating the target areas without giving your body a full dose of estrogen.

With “vaginal rejuvenation” in the public lexicon, many women with prolapse or menopause-related vaginal dryness or problematic urinary incontinence eagerly seek out a little rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” , “vaginal atrophy” or “incontinence.” For women over 50, the risk of severe pelvic organ prolapse or urinary incontinence are about 5%, and this increases in women who are overweight, or who have birthed children, particularly large babies and long pushing stage of labor.  A recent study of over 3000 women ages 50‐61 showed 6% with symptomatic, high‐grade prolapse.  Some estimates show 50% of women who’ve born children will have variable degrees of pelvic organ prolapse, from asymptomatic to gravely symptomatic.  By 2050, the number of women with urinary incontinence is expected to increase by 46%, and those with pelvic organ prolapse by 55%, with the number of American women with at least one pelvic floor disorder increasing from 28.1 million in 2010 to 43.8 million in 2050.

Whether you call it prolapse repair, incontinence therapy, or vaginal rejuvenation, pelvic floor disorders condition and related treatments (with “laser vaginal rejuvenation” the exception) come with generations of experience documented in medical and surgical texts and reams of data in myriad peer-reviewed medical journals.

“Vaginal Rejuvenation” to alter the appearance of the vulva and vaginal opening

Reduce and remodel inner labia = labiaplasty

Restore the hymen to a virginal state = hymenoplasty or “revirgination”

Reduce wrinking of outer labia = labial filler injections (of fat, collagen or other filler)

Labiaplasty reduces and remodels large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Women requesting labiaplasty reduction and recontouring of the inner labia minora is often  report physical discomfort from labial catching, chafing, rubbing and folding in clothing or with sexual or other vigorous activities like tennis, yoga, running and biking. Women’s current propensity to depilitate all vulvar hair and wear thongs, the ad infinitum wearing of jeans formerly reserved for the under-30 set, intertwine with inevitable yet subtle changes in inner-outer labial consistency and relative size and natural age related vulvar wrinkling, resulting in unprecedented complaints of physical discomfort from this artificially increased labial exposure. I find many such patients adamantly unwilling to restore Mother Nature’s natural labial cushion that comes from full-growth pubic hair, full crotch underwear, and pants that aren’t painted on. I tell every labiaplasty patient every time, and 9 times out of 10, this (self-selected and therefore biased) group opts for the labiaplasty operation over nature’s blueprint.

The role of enculturation cannot be underestimated. On the other end of the labial alteration spectrum, from a region of the world more famous for rite-of-passage female genital mutilation than female sexual gratification, comes the regionally popular central African practice of labial elongation, believed to enhance female orgasm, female ejaculation, and sexual satisfaction for both male and female sides of the coital equation: Rwandan women enhance gratification with \”labial elongation\”

Hymen restoration involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures requiring virginity at the altar, but gaining popularity here in the States from women seeking “revirgination”. This procedure meets with much scrutiny, given the inherent cross-cultural and socio-ethical issues involved.

Labial bulking of the outer labia reduces age-related wrinkling as the body’s youthful fat pads diminish not only in the vulva, but also in the cheeks, hips, extremities and around the joints. These fat pads are well understood by cosmetic surgeons, who commonly plump up  facial cheeks made hollow by age-related loss of facial fat, often using liposuctioned fat from the patient’s own buttocks, abdomen or thighs. Popularized by these same cosmetic surgeons, women with age-related fat pad volume loss in the labia majora reportedly undergo similar bulking filler injections into the labia majora in cosmetic surgery offices.

As with rhinoplasties, lip enhancements, cheek and buttock implants, liposuction and all other cosmetic procedures, these “not medically necessary” labial alteration procedures are not covered by insurance. The physician is obligated to evaluate patient motivations, and to do their professional best to avoid performing them on women addicted to cosmetic procedures or suffering from body dysmorphia, both contraindications to cosmetic procedures.

A woman seeking labiaplasty for severe congenital asymmetry or labia that routinely catch, tear or chafe with sporting or sexual activities are not the same as patients responding to cruel comments from an unworthy sexual partner or insecure because they “don’t look like the women in porn movies”. Labiaplasty procedures are included in surgical texts, with techniques and data published in peer reviewed medical and surgical journals. Much controversy surrounds labial and hymenal procedures, taken as yet another sign of the increased medicalization of female sexuality, with “female sexuality as a newly minted profit center for unethical surgeons and greedy pharmaceutical corporations” as the banner-head under which such protests march. (see Professor Leonore Tiefer)

The controversy rages on, hitting fever pitch with the next category of rejuvenation procedures:

“Vaginal Rejuvenation” to enhance sexual gratification

Clitoral unhooding

G-Spot amplification (a.k.a. the G-shot)

Sub-clitoral bulking injections

This category of VR procedures carry significant risks, with sparse to no efficacy data published in peer reviewed medical or surgical journals.

Clitoral unhooding reduces or removes the skin folds over the clitoris. As an anatomy instructor at Weill Cornell Medical College, I consider clitoral unhooding an inherently risky procedure, given its proximity to the clitoral nerves and the small and vulnerable clitoris.

G‐spot amplification, another “sexual enhancement” procedure involves an injection of collagen or other bulking agent (same fillers used for facial wrinkles) into the front vaginal wall. The theory behind such an injection is to create a temporary (as collagen always absorbs and disappears) bump beneath the Grafenberg’s spot to enhance sexual response.

Sub-clitoral injections underneath the clitoris using filler bulking agents such as collagen or hyaluronic acid are purported to “lift” the clitoris, increasing exposure of the sensitive clitoral glans, allegedly to enhance sexual sensitivity.  This poorly documented procedure continues to flirt around the Upper East Side of Manhattan, offered primarily in cosmetic surgical offices.

Each of these sexual enhancement procedures carries the risk of scarring, pain, infection and numbness. Benefits are unclear, as the miniscule amount of peer-review data currently available used non-validated patient questionnaires administered by the surgeons themselves as opposed to blinded reviewers, and did not include objective measures of nerve function and other measures of genital function and sensitivity.

What say the gynecologists?

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these vaginal rejuvenation cosmetic and sexual enhancement procedures in Bulletin #378,  finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” while reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” the mystery-shrouded, copiously marketed laser vaginal procedures, and clitoral unhooding, until each procedure garners the necessary peer review safety, efficacy, and technique disclosure warranted by medico-ethical standards of clinical acceptability.

For synopsis ACOG bulletin: ACOG committee opinion #378 on cosmetic gynecology

What say the plastic surgeons?

Nothing, really.

from American Society of Plastic Surgeons: ASPS weighs in on vaginal rejuvenation, sort of

There are a number of different vaginal rejuvenation procedures that can be performed by board-certified plastic surgeons. Here, an ASPS Members Surgeon explains the reasons why women may seek out procedures such as this. Learn more about cosmetic procedures.

Note: Some of the procedures and technologies presented in the following videos may be under investigation and presented for research and educational purposes. More scientific study may be needed to determine efficacy and success rate. The American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Educational Foundation (PSEF) do not endorse the procedures or technologies presented nor do the statements of the individual physicians represent the opinions, positions, or recommendations of the ASPS or PSEF.

From The American College of Surgeons, The American Society of Aesthetic Plastic Surgeons and the American Academy of Cosmetic Surgeons: Zero.

Except for ASPS saying “we can do it”, these non-gynecologic surgical societies, whose vaginal rejuvenating members aggressively online advertise cosmetic gynecologic procedures, provide no medico-ethical professional statements for us to consider, despite the widespread adoption of things gynecologic into the plastic surgeon’s arena. This “plastic/cosmetic surgeon as vaginal rejuvenator” phenomenon spawned a competitive explosion in the marketing of “vaginal rejuvenation”, replete with page after page of graphic, genital BEFORE AND AFTER images, something gynecologic surgeons had never previously adopted into office, online or related marketing practice. Given the robust vaginal and vulvar enthusiasm demonstrated by many plastic and cosmetic surgeons, you’d expect their professional societies to weigh in on the ongoing vaginal rejuvenation debate with something more than “we can fix your vagina and we have the images to prove it”  regarding this controversial corner of medicine.

If you’re interested in cosmetic “vaginal rejuvenation”, begin a conversation with yourself about your motivations and perspective: Cosmetic Gynecology Personal Perspective Litmus Test

While doctors, medical societies and health advocates rage on in the debate about what is and what is not acceptable vaginal rejuvenation, each patient is fairly clear about her individual rejuvenation goals. Vaginal rejuvenation is whatever you need it to be‐ Kegel exercise to improve vaginal muscle tone, bladder control and orgasm; vaginal estrogen for lubrication and clitoral sensitivity; prolapse operations to resuspend the dropped uterus, bladder and rectum; perineoplasty to restore vaginal snugness after childbirth; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone, each available as needed to get your pelvic life back on track. The cosmetic procedures to alter the labia or hymen, and to a greater extent, the operations promising sexual ehancement, carry relatively escalated levels of scrutiny due to concerns about the medicalization of female sexuality, and the variable dearth of data regarding both safety and efficacy.

REFERENCES OF INTEREST

Medicalization of Sexuality:

Professor Leonore Tiefer Home Page

Forecasting pelvic floor disorders:

Pelvic floor disorders 2010 – 2050

Labiaplasty technique:

Labiaplasty overview and link to technique monograph

Labiaplasty technique

Clitoral unhooding and mixed genital plastic surgery:

Female cosmetic genital surgery

Multicenter study of female genital plastic surgery

Hymen restoration:

Should doctors do virginal reconstruction for adolescent girls? Cultural considerations cannot be ignored,

Reconstructing the hymen: mutilation or restoration?

Hymen reconstruction:ethical and legal issues

Perineoplasty:

Vaginal laxity and post-perineoplasty images

Perineoplasty in women with sensation of a wide vagina

Combined anal sphincteroplasty and perineal reconstruction for fecal incontinence in women.

Kegel muscles and sex:

female orgasm: role of pubococcygeus muscle

vaginal contractions in female orgasm

The Science of Sex circa 1982

Orgasm mechanics the same in women and men

I recently read an article you were featured in for Glamour magazine and sparked me to find out more about your practice.  I am a 25 y/o female in a committed, sexual active relationship.  With past partners I have experienced vaginal pain during intercourse and this partner is no exception.  No matter how much foreplay, lubrication, positions, etc we try, I still experience pain.  I want to be able to enjoy sex with my boyfriend, but it’s hard to do when it is physically painful every time.  Help!

 Dear Glamour reader,

Your symptoms can be treated – the trick is to figure out how many issues are contributing, and how best to formulate your personal recipe for successful resolution of your sexual pain. For instance, if stiff levator (Kegel) muscles are part of the problem, it is important to figure out if the muscles are the cause of your symptoms, or if the muscles are stiff and sore because of another source of pain in or around the vagina that also hurts, with the muscles reacting to the pain and then themselves becoming a secondary source of pain. Confused yet?

You may have vestibulitis, you may have vaginismus, you may have a urethral diverticulum, you may have yet another urogynecologic condition contributing to your pain. The key to successful treatment is evaluation and management by the right team, which may include a gynecologist who specializes in vestibulitis, a urogynecologist, a pain management anesthesiologist, and a pelvic floor physical therapist.

If you’re in a large metropolitan area, this mix of clinicians will be easy to find, time consuming, but easy. If you are in an area without a lot of specialists, you may need to travel to get the care that you need to put your pelvic life on a normal track.

Most importantly, it is NOT in your head. (It’s in your vagina) Be tenacious. Screen the offices over the phone with questions like “Does Dr. XYZ take care of patients with sexual pain, vestibulitis, levator hypertonus and vaginismus?” If the answer is yes, GO THERE.

Thanks for sharing your story.  Please keep us posted.

Dr R

i need your help. i have problems with fistula, thank you. I am from Kosova.

Hello Kosova,
Fistula is a terrible problem. You will be best served at a University-based medical clinic in urogynecology, urology or colorectal surgery. If you are able to travel to New York, please notify us at contact@urogynics.org or by calling 0012129354343.  Please keep in touch.

Dr Romanzi

(c) Lauri Romanzi, 2010

As a relentless advocate for avoiding hysterectomy unless you will truly benefit from the surgical removal of your uterus, I am here to share information about the benefits of  hysterectomy when it’s done for all the right reasons.

My favorite “don’t need a hysterectomy” message is  about uterine resuspension for treatment of uterine prolapse, a condition that accounts for about 16% of benign hysterectomies in the States, being the third most common indication for hysterectomy after fibroids and dysfunctional bleeding. Since uterine resuspension fixes uterine prolapse just as well as hysterectomy-based repairs, there is no need to undergo hysterectomy for prolapse.

But what if you’re suffering with a condition for which hysterectomy truly can make a difference?

Is there any such thing as a Happy Hysterectomy?

The Female Pelvis

Fibroids, adenomyosis, dysfunctional bleeding and endometriosis are the biggest players in this “do I or don’t I” hysterectomy arena. Let me help you understand something most of you already intuitively know – one woman’s hysterectomy blessing is another woman’s hysterectomy nightmare. What turned your neighbor’s life into a happy healthy place might not work so well for you.

According to a  beautifully designed and implemented research project recently published in the bible of gynecologic research, ”Obstetrics and Gynecology”, whether you’ll celebrate or regret your hysterectomy depends on how much headache your uterine condition is causing in terms of pain, painful sex, heavy bleeding, pelvic pressure, and fatigue from the anemia caused by heavy bleeding, combined with how you feel about your uterus, and how you feel about hysterectomy.

With the right mix of severe, recalcitrant uterine problems in the setting of unsuccessful non-hysterectomy therapies, and a laissez-faire attitude toward the role of your uterus in your version of womanhood, a hysterectomy may turn out to be best thing you ever did. But when the clinical/personal mix leaves you feeling like less of a woman and wondering why you signed up to remove an organ that plays a crucial role in your feminine identity, you may well regret your hysterectomy.

Sometimes the best clinical research just makes a lot of sense.

The March 2010 issue debuted the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA).  Taking 10 years to complete, this team of researchers from California’s Kaiser Permanente HealthCare System painstakingly kept track of over 1400 women with benign (non-cancerous) uterine and other pelvic problems as they decided to undergo hysterectomy, undergo alternatives to hysterectomy, or decide not to decide by foregoing treatment in favor of TIME, the unsung heroine of benign uterine problems. If you can hang in there until menopause starts, most likely your uterus will calm down and the symptoms will … just… slowly… stop.

At the beginning of the trial, women were asked how they felt about  the

“benefits of not having uterus”

• lack of menstruation,
• uselessness of uterus once childbearing complete,
• no more birth control concerns

the

“value of the uterus ”

• sexual function
• feeling complete as a woman

and

“hysterectomy concerns”

• feeling older
• violated
• sad about loss of fertility resulting from hysterectomy

Over the ensuing decade, these self-rated attitudes were compared to symptom impact on each woman’s overall quality of life and sexual function as she dealt with her gynecologic disorder.

Guess what they found? Among the women who chose hysterectomy, those who felt that the benefits of not having a uterus outweighed the value of having a uterus and hysterectomy concerns, or for whom the underlying condition had major impact on quality of life and sexual function (pain in daily life, uncontrollable bleeding, painful sex, constipation, irritable  bowel, overactive bladder, urinary incontinence and the like) and for whom non-hysterectomy therapies did not work who did not want to wait for natural menpause to but the brakes on the condition, reported that hysterectomy improved quality of life in a major and regret-free fashion,  including, when applicable, their sex lives.

Women for whom the underlying condition was not associated with severe impact on quality of life and sexuality, and who rated the value of having a uterus and hysterectomy concerns higher than benefits of not having a uterus were more likely to regret the hysterectomy.

Over the past 25 years many a gynecologic staple indication for hysterectomy now comes with non-hysterectomy options. Conditions include fibroids (extremely common benign smooth muscle tumors of the uterus that can make for heavy or irregular periods, pelvic pressure, colorectal and urinary difficulties, infertility and enlarged abdomen), adenomyosis (spongy super-thickening of the lining of the uterus that can cause heavy and irregular periods), and endometriosis (abnormal location of uterine lining tissue outside of the uterus itself where it does not belong, often implanting on the tubes, ovaries, intestines and other pelvic organs causing pelvic pain, scarring and infertility). These options include hormone suppression with birth control pills or hormone-containing IUD (intrauterine contraceptive device), endometrial ablation using controlled cautery of the lining of the uterus so that it doesn’t bleed very much, (http://www.nlm.nih.gov/medlineplus/ency/article/000903.htm), or shrinking fibroids using  uterine artery embolization, a radiologic procedure that threads a tube into the uterine artery through the groin, injecting embolic material that blocks bloodflow to the fibroids. (http://www.nlm.nih.gov/medlineplus/ency/article/007384.htm).

So now we’ve got choices, and they often work quite well. It used to be wait for menopause, take harsh hormones, (look up Danazol for endometriosis when you have a chance), clean out the uterus with a D&C, and if none of that worked, your options were restricted to toughing it out or hysterectomy.

Besides these new therapies, it is important to understand that not every condition needs treating. Mild endometriosis may never cause a problem short of a tendency to painful periods, or it can be as brutal as a cancer, socking onto every organ in the pelvis, ruining your fertility and making you feel like your belly’s on fire. Fibroids can be cute little nubbins scattered here and there with nary a clinical impact, or they can be gigantic super-ball-consistency uterine tumors the size of your head.  Dysfunctional bleedng tack a few extra days on to your period, or it can be a  hemorrhagic pad-soaking, anemia inducing tsunami that knocks the wind out of your life every month.

In the SOPHIA trial, of the 1400 women participating fully for the entire 10 years, only 207 (14.6%) chose hysterectomy- ”These women were more likely to report symptomatic fibroids and that they did not want to become pregnant” at the beginning of the study”. ” Women who reported higher levels of pelvic problem impact on sex or who had higher (mental stress) scores were more likely to choose hysterectomy as were women wtih higher scores on the “benefits of not having a uterus” scale and lower scores on teh ‘hsterectomy concerns” scale.  63.9% of the 207 women who chose hysterectomy were very satisfied with the results. but nearly 22% were only  somewhat satisfied, about 7% were ambivalent, with the remaining, about 8%, frankly dissatisfied.  The majority of women who used uterine artery embolization and endometrial ablation did not go on to hysterectomy, highlighting the growing role of these effective, uterine-preserving operations for conditions traditionally treated with hysterectomy.

The authors further state “Perhaps the most noteworthy are our findings regarding the significant role of women’s attitudes toward their uterus and hsyterectomy in their decision making regarding and satisfaction with this surgery.”, and “We cannot comment, however, on the extent to which these attitudes were elicited by or shared with physicians.”

Here’s the deal, if the condition is benign but truly ruining your life, and you really like your uterus, find a gynecologist who shares your perspective, and try the all appropriate non-hysterectomy therapies. For those of you who’ve already done everything BUT the hysterectomy, and the fibroids/bleeding/pain is DRIVING YOU NUTS, a hysterectomy just might make your life a lot better.

The Aging Ovary

HEADS UP: for most non-medical people, hysterectomy = remove the uterus and ovaries. The medical definition of hysterectomy, however, is removal of uterus only, ovaries LEFT IN PLACE.  Your ovaries make almost all of your sex hormones. And even if you’re menopausal, there may be some good  reasons to leave your ovaries right where they are until age 75 or so – see

http://www.ncbi.nlm.nih.gov/pubmed/20226402,

http://www.ncbi.nlm.nih.gov/pubmed/17513923,

http://www.ncbi.nlm.nih.gov/pubmed/16055568.

Really need a hysterectomy?  Make it a happy one, keep your ovaries.

I have the privelege of contributing my literature reviews to the Journal of Sexual Medicine (JSM). Below you’ll find my JSM synopsis of the SOPHIA trial:

Predictors of Hysterectomy Use and Satisfaction. Kuppermann M, Learman LA, Schembri M, Gregorich SE, Jackson R, Jacoby A, Lewis , Washington AE. Obstet Gynecol 2010 Mar, 115(3):543-551. This prospective observational Study of Pelvic Problems, Hysterectomy, an Intervention Alternatives (SOPHIA) monitored 1420 women over a 10 year period, to describe the natural history of the choice to choose or forego hysterectomy in premenopausal participants with benign clinical conditions for which hysterectomy was one management alternative. Baseline evaluation included pelvic symptom profile, quality of life scoring, sexual function and hysterectomy and uterus-related attitudes, in addition to use of Western and alternative medicine therapies. Hysterectomy and uterus related attitude evaluation included “benefits of not having uterus” (lack of menstruation, uselessness of uterus once childbearing complete, no more birth control concerns), “value of uterus (sexual function and feeling complete as a woman) and “hysterectomy concerns” (feeling older, violated, and sad about loss of fertility resulting from hysterectomy). Participants were English, Spanish or Chinese speaking women ages 31-54 at enrollment in trial. Over the 10 year period, 207 (14.6%) underwent hysterectomy, some of whom received up to 8 years of follow-up before end of trial. Approximately 64% of these hysterectomy women were very satisfied, with ~22% somewhat satisfied, and the remaining 15-16% neither satisfied or unsatisfied, ~7% of whom were dissatisfied to varying degrees. Women satisfied with hysterectomy had higher QOL and / or sexual function impact from the condition for which hysterectomy was performed, in addition to higher scores on the “benefits of not having a uterus” and lower scores on the “value of having a uterus” and “hysterectomy concerns” questions. The authors describe a greater likelihood to undergo and be satisfied with the outcome hysterectomy in women reporting greater pelvic problem impact on sexual function and pelvic problems overall, underscoring “the importance of determining the extent to which symptoms interfere with QOL and sexual function when counseling patients about hysterectomy and its outcomes”. The majority of women who underwent alternative therapies such as endometrial ablation and uterine artery embolization, did not go on to hysterectomy. The data clearly demonstrate the conclusion that “women’s attitudes toward their uterus and hysterectomy play a primary role in the decision to undergo and personal satisfaction with the outcome of hysterectomy” for benign conditions. Level of Evidence: IIa

The uterus comes with dual support, one robust uterosacral ligament on each side, holding it in place at the top of the vagina.

Repeat after me… Resuspend – Do Not Remove.  Hysterectomy is not a cure for prolapse, Hysterectomy is a cure for having a uterus.  There are three basic categories of uterine resuspension:

#1: Suspend the uterus to one or both adjacent sacrospinous ligaments

Sacrohysteropexy: Resuspend with an "artifical uterosacral ligament" graft

  For more details click on the role of Kegel exercises in uterine prolapse, click this interview link:

Dr. R for Sweet Talk on the Spot – Prolapse Part 2

And if you absorb nothing else, retain this: When it comes to prolapse, the uterus is a victim, not a perpetrator. Prolapse occurs because the ligaments supporting the uterus gave way, not because the uterus is heavy.  Uterine resuspension (hysteropexy) works just as well as do prolapse repairs where the uterus is removed (hysterectomy).  Durability is essentially the same. There is zero advantage to removing the uterus to repair prolapse. However, if you have prolapse and also suffer a separate,  good reason to consider hysterectomy, such as severe fibroids or endometriosis or high personal risk for gynecologic cancers, there may be a true benefit to removing the uterus at the time of prolapse repair.  Otherwise, lift that uterus up into normal position with a resuspension procedure and get on with your life! 

To find a surgeon to do your uterine resuspension in your area,  visit http://www.mypelvichealth.org/FindaProvider/tabid/75/Default.aspx and ask your regional specialists if they are comfortable and experienced with uterine resuspension for uterine prolapse.