Category — Hysterectomy and Alternatives to Hysterectomy

(C) Lauri Romanzi, 2010

Pelvic organ prolapse, the medical term for vaginal bulges caused by damage to the connective tissues supporting the organs above and around the vagina (the uterus, bladder, rectum and vaginal opening), is a silent epidemic affecting women worldwide. Common terms include dropped bladder, dropped uterus, rectocele and vaginal laxity. Recent estimates using US Census population projections anticipate a 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth. Prolapse can even cause depression.

Childbirth contributes to most prolapse conditions, however genetics, medical disorders such as connective tissue disease, diabetes and obesity, and lifestyle habits have all been shown to contribute to pelvic organ prolapse risk. I’ve had many young women in their 30’s with prolapse who’ve never been pregnant, or found themselves suffering a dropped bladder after an easy and quick delivery of their first normal (or even low) weight baby. Even cesarean section is no guarantee against pelvic organ prolapse, with 5% of women in one recent study suffering severe, palpable and visible prolapse even though they delivered by cesarean section before going into labor. The role of Kegel fitness and Kegel exercise in the prevention of treatment of pelvic organ prolapse is just recently getting the research attention it deserves, and Kegel exercise may well play a role in prevention and treatment of prolapse. But for certain, if you suffer prolapse that looks like the image below, no amount of pelvic floor Kegel exercise, or any other kind of exercise, will pull your parts back into place.

Prolapse surgery often comes with a recommendation for hysterectomy, but the latest trends highlight new techniques that fix the prolapse just as well without removing the uterus. When the uterus prolapses it can be resuspended by one of several techniques, and the surgery holds up just as well as when a hysterectomy is included in prolapse repair surgery. This uterine resuspension concept is an exciting new option that allows many women to undergo prolapse repair surgery without removing any organs.

While many women with prolapse believe just one single body part is out of postion, most commonly, prolapse involves hernia-type displacement of several organs. When the bladder drops, formally called a cystocele (siss-toe-seal), it is often accompanied by a rectal bulge, called a rectocele (wreck-toe-seal).  Laxity at the vaginal opening, called a perineocele (pear-in-ee-oh-seal) results when the perineum loses connective tissue bulk as a result of childbirth.  Uterine prolapse is called, well, uterine prolapse. But behind a prolapsed uterus, it is common to find an internal small intestine hernia called an enterocele (en-tare-oh-seal).

When you put all these prolapse possibilities together at their absolute worst, it looks like this:

Courtesy WomensVoicesForChange.org

My role as guest blogger gives me the opportunity to demystify this deeply troubling malady.  For more information, check out this first of 2 posts on pelvic organ prolapse done for my friends at Sweet Talk on The Spot:

Dr R covers Prolapse, Part 1 for Sweet Talk on The Spot

To review Dr R’s book on prolapse, see www.plumbingandrenovations.com

If you have any questions, send in your comments on this post or post your own question to Ask Dr R.

(C) Lauri Romanzi, 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

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