Category — Hysterectomy and Alternatives to Hysterectomy

Uterine Prolapse – The Facts

Uterine prolapse affects 30% of ALL women, so there’s a good chance that it will touch you or someone you know. But before you can comprehend uterine prolapse, you need to have a basic understanding of a woman’s pelvis.

The vagina is the foundation of female anatomy, while the cervix sits above the vagina, and the uterus above the cervix. Connective tissue called uterosacral ligaments hold the uterus and cervix in place.

When it comes to uterine support, it's all about the uterosacral ligaments...

As the primary support system for the entire female pelvis, the uterosacral ligaments are extremely important! Uterine prolapse occurs when collagen fibers in these ligaments stretch or weaken, causing the cervix and uterus to drop down to the vaginal canal. If it drops far enough, it’s possible to feel and see the cervix, which looks like a small pink donut.

Although this is not usually painful, a woman may experience feelings of heaviness or pulling in the pelvis. Other symptoms of uterine prolapse may include painful sex, low backache, frequent urination, or even vaginal bleeding, although the converse is not always true, i.e; every women with frequent urination or low back pain or vaginal bleeding does not necessarily suffer uterine prolapse, as there are many reasons, prolapse among them, for each of these conditions. Your gynecologist can help sort out whether or not you are suffering uterine prolapse.

Like I said, it's all about the ligaments

A number of things can contribute to uterine prolapse. Women who give birth vaginally are more likely to experience thinning and stretching of the supportive uterosacral ligaments,especially those who experience long labors or deliver big babies. Prolapse is also more likely in women over 50, because muscle tone and onnective tissue integrity decreases with age.

Research also suggests that some women may be genetically predisposed to uterine prolapse. In other words, you can’t always PREVENT uterine prolapse, but you CAN learn about treatment options.

One effective treatment choice is a pessary, which is a vaginal support made of rubber, plastic, or silicone. A doctor fits a woman’s pessary to her body to hold the prolapse comfortably in place.

Surgery is another option, which, unlike a pessary, actually REPAIRS the prolapse. As with all surgeries, complications, including but not limited to recurrence of prolapse, are possible so make sure you understand both the risks and the benefits if you are considering prolapse surgery.

According to US Dept of Health data, one in nine cases of uterine prolapse is severe enough to warrant surgery. The good news is that uterine prolapse IS fixable without resorting to hysterectomy, so if you’re suffering uterine prolapse, understand that you don’t have to choose between hysterectomy or pessary, you have the option of uterine resuspension, hysterectomy-type prolapse repair, or pessary support.

To learn more about this and other pelvic floor conditions, visit Dr R video on HealthGuru.com.

NOV 23, 2010

(c) L Romanzi 2010

The Step-Sisters of Fistula – Minimally Invasive Uterine Resuspension- Hysteropexy C’est Arrive au DR Congo.

The Stuff of Prolapse *image courtesy of "Women of the Shadows"

It is difficult to express how impressed I am during each and every Harvard Humanitarian Initiative mission (www.hhi.harvard.edu) by the  skilled, motivated, and wise  pelvic floor – fistula surgeons at Panzi Hospital in Bukavu, DRC.  On these many fistula-repair missions, I’ve come to understand that one of the most important ways to add value to colleagues upon whom we descend in our zealous compulsion to fix every woman with a fistula, is to realize that, in addition to the tragic, fashionable and international charity-funded fistula women found in every developing nation on the planet, there are women in these same villages suffering equal stigma, ostracism, divorce and abandonment as their fistulous sisters because they suffer incontinence of urine or stool, or waddle about in a state of severe pelvic organ prolapse. The prolapsing cervix can look a lot like the head of a penis, and many’s the woman accused of infidelity by the husband to whom she birthed all the children and for whom she’s carried all the loads of wood, water and supplies on her head that caused the prolapse in the first place. As if she had a single ounce of energy with which to seek out and fornicate with a man other than her husband – peeleeze.  Anyhow, this sort of tragi-comic mythology surrounds many medical and surgical conditions when the people suffering said conditions do so without the benefit of education and absolutely zero comprehension of internal anatomy. You have a fistula because you are possessed by evil spirits, you have prolapse because you cheated on your husband, you died from hemorrhage after your clitoris and labia were cut off ritualistically to transform you into a marriageable chattel because you were committing the ultimate sin of pleasuring yourself to the always dangerous female orgasm. Things like that.  Feel free to throw the conditions and myths into a hat to play the game of “mix and match”. It’s all the same, as are the personal ramifications – you’re divorced, thrown out of your house, often permanently separated from your children, and excommunicated from your village, this being the only home you’ve ever known and the only people that ever mattered to you since the day you were born.

The uterosacral/cardinal ligament complex holds the uterus in place

Unlike the condition of fistula, prolapse and incontinence don’t “go away” with modern medicine, new world economics or robust personal health and wealth. Even the well-healed at the Hampton Classic include wealthy ladies who are wetting their pants and wishing their parts would stay all up in there where they belong. While fistula vanished with the advent of ether anesthesia in the mid-1800’s, rendering vaginal fistula nearly obsolete in Europe and North America well in advance of the 1900 centennial, (the world’s first fistula hospital was in New York City, torn down when rendered obsolete by access to Cesarean section, replaced by the still present Waldorf Astoria Hotel on Park Avenue), prolapse and incontinence continue to plague even the wealthiest, best educated, most fashionable of women on the planet.  But fistula virtually disappeared as anesthesia made Cesarean section the cornerstone of optimal obstetrical practice and stellar reduction in Euro-American maternal mortality and morbidity statistics, because fistulas come from obstructed labors, and no one in a developed nation is allowed to suffer through a 2 week labor resulting in a dead baby and a destroyed, fistulous vagina. We just do a Cesarean if it’s taking too long. The luxury of quick, routine, easy access to Cesarean section remains unavailable to the majority of women in Sub-Saharan Africa and other impoverished nations.

So this time, rather than play the “American fistula heroine” game, I decided to back it up into the unglamorous territory of plain old US/European style pelvic floor disorders, these being pelvic organ prolapse and urinary incontinence. While these un-funded (they’re not on UNFPA’s radar at all) women have no international advocate, yet they are equally tortured and punished for these conditions that are beyond their control as is any fistula victim’s.

We started with prolapse patients today. Magically, (there’s a lot of magic in DRC), after being informed that there was only a single prolapse patient, 10 emerged from the ether, each with the most severe form of prolaase, called procidentia. Procidentia (remove the children from the room and erase this link from your laptop history, quickly!) is a total pelvic disaster easily diagnosed by visualizing the cervix dangling between the patient’s thighs, turning the bladder upside down and kinking the urethra and rectum in the process. It’s mortifying.

From Beverly Hills to Bukavu, uterine prolapse is all about the uterosacral ligaments

We started the day with a lecture-discussion where we engaged in robust, healthy debate about current theory and principle held true among international pelvic floor disorder specialists – with the exception of avoiding hysterectomy by utilizing uterine resuspension – in the States, with rare exception, uterine prolapse = hysterectomy unless the woman can find a pelvic floor specialist who understands that the uterus is the victim of prolapse, not the cause.

This notion of preserving the uterus even though it’s falling out my Congolese colleagues understood, given the large number of young women whose lives would be equally destroyed by hysterectomy as they are by the prolapse.  Here at Panzi they use a large abdominal incision to resuspend the uterus by shortening the round ligaments of the uterus, a somewhat dated technique used very rarely inEurope and North America currently because it tends to fail and distorts pelvic and vaginal anatomy. These round ligaments contribute little (or so we believe) to the vector support of the uterus, the starring role of which falls to the ligament pair known as the uterosacral (US) ligaments. These US ligaments are like 2 cables, holding up the uterus and cervix by suspension at the top of the vagina much like a chandelier is held up by cables in the ceiling of a room.

We talked about compartment analysis, evaluating the support of the uterus (Apex), followed by evaluation of the stuff of vaginal prolapse and vaginal laxity below the level of the uterus, bladder for cystocele (Anterior) and rectum for rectocele and perineocele (Posterior), and evaluation of the levator (a.k.a. Kegel) muscles separately. We reviewed the role and evaluation of the Kegel muscles and the support and potential childbirth damage to the all-important and under-appreciated perineal body (connective tissue separating vagina from rectum). We debated and evaluated each continent prolapse patient for occult stress incontinence by filling the bladder, holding the prolapsed parts in proper anatomic position as the might be after surgical reconstruction, and asking the patient to cough and strain to see if urine leaks with abdominal exertion – the finding consistent with stress incontinence. Shocker, just like we find in the States, 40% of these women with bad prolapse and no incontinence symptoms leaked like sieves with full bladders and the prolapse temporarily corrected with vaginal support, and these women will undergo incontinence sling for stress incontinence at the time of their prolapse reconstruction. Tomorrow, in the OR (operating room), the Congolese fistula surgeons of Panzi Hospital (www.panzihospitalbukavu.org) will be the first to perform vaginal uterosacral uterine resuspension (a.k.a. hysteropexy) in Central Africa.

(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