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If a Hysterectomy is not performed

A hysterectomy--removal of the uterus--can be a life-saving operation for women with certain types of cancer or uterine hemorrhage. But in most women a hysterectomy is done to improve the quality of life. These women are relieved of abnormal bleeding, pain or annoying protrusion of the uterus outside the vagina. But it appears that too many hysterectomies are performed. The reason being doctors being accustomed to performing a hysterectomy and women being accustomed to getting one--based on their mother or other female relative having one.

Today with the newer medications, technologies, and procedures being available women have other options to consider especially for noncancerous conditions. Some of these are less invasive, less expensive, pose lesser risk & are associated with a speedy recovery. And some preserve the ability to get pregnant also.

Abnormal Uterine Bleeding:
In women younger than 30 yrs most hysterectomies are done for abnormal bleeding. Abnormal uterine bleeding can occur as frequent, irregular and unpredictable bleeding, lengthy menstrual periods, bleeding between periods, or a heavy flow during periods. This bleeding may be caused by hormonal imbalances, growth of endometrial tissue into the wrong place, fibroids, or other conditions. Sometimes there may not be any identifiable reason for abnormal bleeding. In such conditions medical therapy is the first choice. But when the treatment fails surgical therapy is advised.

Removal or destroying the uterine lining (endometrial ablation) is a viable alternative for these women. The lining can be destroyed with minimally invasive procedures using electrical energy, heat or cold. The result may not be permanent & are not for women who are desirous of future pregnancy.

Endometrial ablation is done using a hysteroscope, a telescope-like instrument that is placed through the mouth of the uterus, and no incisions are needed. A hysteroscope is a thin, fiber-optic tube for viewing and has an attachment to destroy the endometrial tissue. The attachment may be a "rollerball" or wire loop through which electrical heat travels to remove the endometrial lining. Thermal ablation(using heat), cryoablation(using cold) & impedance controlled endometrial ablation are the newer methods of endometrial ablation

A special type of contraceptive coil or Mirena inserted into the womb is also used to reduce the amount of bleeding during the periods in some selected women.

Fibroid uterus:
Overall the most common indication for hysterectomy is fibroids. These are benign tumors that grow on or within the uterus. Most of the time no treatment is needed, but sometimes there is so much discomfort that treatment is required.

Most fibroids are stimulated to grow by estrogen, and without it, fibroids usually shrink. There are medications (GnRH analogues) that will temporarily shrink fibroids by inducing sort of menopause. These injections are expensive & are associated with significant risks and side effects & are generally prescribed only for selected pts. And also fibroids tend to regrow after discontinuing therapy.

The other options include surgically removing only the fibroids (myomectomy), cutting off the blood supply to the fibroids (embolization), and shrinking the fibroids using electric current (myolysis). A myomectomy is a surgery to cut away the fibroids without removing the uterus, so that a woman can maintain her ability to bear children. Myomectomy can be performed in several different ways, depending on the size and location of the fibroids - by opening the abdomen through an incision or through a laparoscope or through a hysteroscope introduced through the mouth of the uterus. Myomectomy is however a major surgery similar to hysterectomy. In uterine artery embolization the vessels carrying blood to the fibroid are blocked by injecting embolic agents to the vessel. This is also not a trivial procedure.

Uterine Prolapse
Uterine prolapse may be improved in some cases with Kegel exercises to strengthen the pelvic floor muscles that support the uterus. Another treatment for uterine prolapse is a pessary, a device placed in the vagina to hold the uterus and bladder in place. For women past menopause, taking hormones can help keep the pelvic muscle tissues stronger. For younger women with prolapse special surgeries preserving the uterus for childbearing is the other option.

Oral contraceptives and other hormone medications may be used to shrink the endometrial tissue that implants outside of the uterus. If medications do not effectively treat endometriosis, the endometrial tissue can be removed by laparoscopy or laparotomy.

Chronic pelvic pain:
Medical therapy includes non-steroidal anti-inflammatory agents (such as ibuprofen), birth control pills, progestins & GnRH analogues. These measures are effective in 70% of cases. In some cases psychotherapy proves to be an effective measure. Hysterectomy, with or without resection of the ovaries, is reserved for the relatively rare cases that do not respond to conservative approaches. Hysterectomy is by no means foolproof and fails to relieve chronic pelvic pain in about 25% of cases.

In most women hysterectomy is an elective procedure. Medicines or limited surgery can be used in some women to treat an underlying condition, and hysterectomy can be postponed or avoided. The decision to proceed with the surgery should be made mutually by the woman and her doctor after careful consideration of the woman's particular medical problem, all available treatment options, and the risks and benefits of each type of treatment.

Dr R Sukhada Rao, MB, M,D (Ob. & Gynaec.),
Consultant Obstetrician & Gynaecologist and Laparoscopic Surgeon,
Dr. U Mohan Rau Memorial Hospital, Chennai.


Updated on 01.12.2004.

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