Dr. Judith Reichman TODAY contributor • Profile • E-mail

There was a time when if a woman bled too much, had any pelvic mass, an abnormal Pap, hurt or felt pressure “down there”, she was told that the best way to ensure her gynecologic health was to “take it out”. . . to get a hysterectomy. When I trained at the University of Chicago decades ago, hysterectomies were the most common surgical procedure scheduled in our gynecologic operating rooms.  Hysterectomy is second only to Caesarian deliveries as the most frequently performed major operation in the United States.  Over twenty million U.S. women have had a hysterectomy and 600,000 are performed annually. Four months ago I joined that number. I, too, had a hysterectomy.

What are the reasons most hysterectomies are performed?
The most common symptoms leading to hysterectomies are heavy or irregular uterine bleeding, pelvic pain and pelvic pressure. Most hysterectomies are performed in women between the ages of forty and forty-five. But in the last two years we have actually seen a decrease in overall hysterectomy rates in these relatively young women and an increase (by up to 45%) in women older than age 75 (I fall in between). 

The clinical conditions leading to a hysterectomy vary from annoying to life-threatening, but most hysterectomies are still performed for benign conditions:

• Fibroids — These account for up to 30 percent of hysterectomies. Fibroids are benign growths that appear in up to one-third of women in their forties. (There may be a genetic and/or ethnic tendency to develop these). In most cases they are silent and won’t require intervention.  But if they become very large (like a four-month pregnancy or greater), cause significant pain, pressure and/or abnormal or heavy bleeding, they require therapy. Hysterectomy is the final solution, but there are often alternatives for symptoms of bleeding. These include: birth control pills, anti-hormones (GnRH, which can stop periods and shrink the fibroids)and an intrauterine system that slowly releases progestin (Mirena). There are also new non-invasive procedures such as MRI directed ultrasound to destroy the core of the fibroids and shrink them and minimally invasive techniques in which uterine vessels are embolized in order to block blood flow to the fibroid. Finally, ablation of the lining of the uterus can be performed through an instrument inserted through the cervix. This allows the uterine lining to be destroyed by either cautery, heat, laser or freezing.
  
• Depending on their size, and placement, fibroids can also be surgically removed (myomectomy). This can be performed through a laparoscope (using small incisions in the abdomen), or, if the fibroids “poke through” the endometrium, through a hysteroscope which is inserted through the cervix. If the fibroids are large and a woman wants to maintain her ability to have a pregnancy, myomectomy can be done through an open incision in the abdomen (laparotomy). So why consider a hysterectomy? Fibroids can grow back and do recur (and cause clinical problems) about twenty percent of the time and may then require a repeat procedure or... if “enough is enough” a hysterectomy.

  Now lets get back to the other reasons for hysterectomy:

• Endometriosis — This can cause both abnormal bleeding and chronic pelvic pain and accounts for about 10% of hysterectomies. Endometriosis is caused by the abnormal migration or growth of endometrial cells (which normally line the uterine cavity) onto surfaces of pelvic organs or onto the lining (peritoneum) of the pelvis and abdomen.  These cells bleed; precipitate pain, scar tissue formation and development of blood filled cysts when stimulated by hormones produced by the ovaries during the reproductive years. This condition may then cause severe menstrual pain and diminish fertility.  Hormonal, anti-hormonal, as well as laparoscopic surgeries to excise the abnormal implants or bloody cysts will be the first line of therapy. Hysterectomy is the last resort.
  

Pre-cancerous and cancerous conditions accounts for about 23% of hysterectomies.

• Invasive cervical cancer - The hysterectomy needs to be radical with removal of surrounding tissue, lymph nodes and a portion of the top of the vagina.  But today, with routine Pap smears, HPV testing and appropriate follow-up, the diagnosis of cervical pre-cancer before it becomes “full blown” cancer is common. Pre-cancer ( high grade lesions also called CIN 2 and CIN 3 lesions can be treated with cryo (freezing), laser or removal (conization) of a portion of the cervix, without resorting to hysterectomy. 

• Ovarian cancer — This does mandate a hysterectomy together with removal of the fallopian tubes, ovaries and appropriate lymph nodes. 
  
• Endometrial cancer (Cancer of the lining of the uterus) — This too is an indication for hysterectomy. This condition often “announces itself” with abnormal peri or post-menopausal bleeding. 
  
• Genital prolapse — Which accounts for 10 to 15% of all hysterectomies. This is a condition in which the pelvic ligaments supporting the uterus, bladder and rectum are severely stretched or injured (often due to previous pregnancies and deliveries) so that these organs protrude down or out of the vagina. Prolapse causes a sensation of pulling or pressure and can also create problems with urination and/or bowel movements. A pessary can be inserted to hold up the organs, but many women don’t like the way it feels or the fact that it had to be periodically removed and cleansed. The definitive treatment for a prolapsed uterus is hysterectomy. Additional types of surgery may be needed for bladder or rectal prolapse. 

Women often have a combination of symptoms. In my case, I had recurrent, growing fibroids (I had a myomectomy years ago) and over the past year they caused bleeding and cramping.  In addition I had developed prolapse, probably from my two previous deliveries. (My daughters however, were definitely worth it!)

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