Hysterectomy uncut

By admin
27 February 2009

Some say it's a procedure overprescribed by scalpel-happy doctors, others say it's a health-seeking solution for modern women.

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We sort fact from fiction and explain what you can expect if you're considering a hysterectomy

By Karena du Plessis

Despite years of extreme menstrual periods characterised by heavy bleeding and pain, 40-year-old Capetonian Gill Evans was still nervous about having a hysterectomy.

"I was calling in sick every month . . . I had tried every option without success," she says. "But even though I'm not planning to have children it still seemed like such an extreme move at the time."

Now, three months post-op, Gill is truly thrilled. "I'm finally getting my life back," she says. "I was so worn out by the pain and ongoing bleeding that I became anaemic and very rundown. Now I'm even planning a holiday away – something I haven't been able to do for years."

A hysterectomy is the removal of a woman's uterus, in some cases with the ovaries and Fallopian tubes. The first operation was performed in Manchester, England, in the mid 1800s to treat uterine cancer. But for some time it was also used to treat psychiatric disorders. The assumption: a woman's uterus was responsible for a range of unpredictable behaviours.

The proposed solution: remove the uterus to ensure a calmer, less "hysterical" female population. Today we know fluctuating hormone levels can influence a woman's moods and behaviour. The availability of more subtle treatments means, however, a hysterectomy is no longer the first port of call. But the procedure still carries a questionable reputation.

South African statistics are hard to come by but according to a US Senate hearing in 1993 the hysterectomy is the second most common major surgical procedure in America (first is the Caesarean section delivery). In fact statistics show that one in three American women has had a hysterectomy by the age of 60.

Although the hysterectomy might have been overused in the past, Dr Tobie de Villiers, president elect of the International Menopause Society (IMS), thinks the so-called hysterectomy "hysteria" is a lot of fuss about nothing.

"The number of hysterectomies has more than halved over the past decade," De Villiers says. His point of view is supported by statistics from other industrialised countries. "New developments in women's health offer many different solutions other than having a hysterectomy," he adds. "But when needed I still wouldn't hesitate to recommend it."

Pick your procedure

A hysterectomy can be performed in different ways and to different degrees. The most common is a complete or total hysterectomy involving the removal of the cervix and the uterus. In a partial or subtotal hysterectomy, the upper part of the uterus is removed while the cervix is left in place. The most extreme version, called a radical hysterectomy, is performed only in selected cases of cancer and calls for the removal of the uterus, cervix, upper vagina and supporting tissues.

The procedure can be performed using various surgical techniques (see box below). Your doctor will advise you on the best option for your particular condition. Of course this is an invasive surgical procedure and not without its drawbacks. Not only will you need to take about six weeks off work but you won't be able to drive for three to four weeks. And if both ovaries are removed, you'll be catapulted into menopause. This means no periods and the possibility of hot flushes, vaginal dryness and weight gain.

De Villiers doesn't support the routine removal of healthy ovaries during hysterectomy at any age. "Even in post-menopausal women the ovaries are hormonally active and produce small amounts of hormones that play an important role in maintaining libido," he explains. "But the decision to leave them in place must be weighed up against the small risk of ovarian cancer later in life."

How is it done?

There's more than one way to perform the surgery. Your options include the following:

Abdominal hysterectomy.

Most hysterectomies are done through the abdomen with a "bikini cut" – a horizontal incision just above the pubic hair, identical to the one made during a Caesarean section.

Vaginal hysterectomy.

Because it's performed through the vagina it leaves no external scars. It's generally quicker, has fewer complications and recovery is more rapid. But a vaginal hysterectomy can be impossible in certain cases, including those in which fibroids have increased the size of the uterus.

Laparoscopic hysterectomy.

Three to five small incisions are made in the abdomen and a laparoscope (a telescope- like viewing instrument) is inserted so the doctor can see the pelvic organs. Generally, the uterus and/or cervix are cut into smaller segments for removal through these small incisions.

This approach is less invasive and involves a much shorter recovery time than the abdominal hysterectomy. The operation is, however, longer and more costly and some medical aids are reluctant to pay for it.

What's it really for?

Hysterectomies are used to treat a number of gynaecological conditions of which persistent bleeding and fibroids are the most common.

Persistent vaginal bleeding. Heavy or irregular periods, as well as those that last for days during each cycle, can be treated through hysterectomy if non-surgical methods don't help to control bleeding.

Fibroids.

Common, non-cancerous growths in, on or within the muscular walls of the uterus, fibroids are often asymptomatic. They can, however, cause symptoms such as heavy, protracted periods, pain and, rarely, infertility.

Endometriosis.

A common condition in which uterine cells grow outside the uterus (usually on the Fallopian tubes, ovaries, outer surface of the uterus or anywhere in the pelvic cavity), endometriosis can cause severe and irregular periods, pain and infertility.

Uterine prolapse (or a "dropped womb").

When the muscles and ligaments supporting the uterus are weakened (by childbirth or muscle strain) the uterus can drop into the vagina. It's more common after menopause and the symptoms can include back pain, pain during sex and incontinence.

Cancer.

A hysterectomy is most commonly performed for cancers of the cervix, endometrium (lining of the womb), ovaries and Fallopian tubes.

Chronic pelvic pain.

If the pain is clearly from the uterus, then a hysterectomy can be an effective last resort – but other causes of pelvic pain should be ruled out before considering the procedure.

Of all the reasons, the two most common causes for a hysterectomy are persistent bleeding and cancer.

Why the cut in numbers?

The number of hysterectomies performed does appear to be decreasing. This is probably due to the increase in other, less invasive options. According to De Villiers, low-dose oral contraceptive pills have played a significant role because they are "very effective in managing bad periods by reducing bleeding and controlling the menstrual cycle". But a hysterectomy is still indicated for certain conditions, including severe cases of menorrhagia (intolerable periods).

Just what constitutes menorrhagia varies from patient to patient. But for some women, like Gill Evans, protracted and irregular bleeding takes its toll emotionally and physically. Depleted iron levels and anaemia are not uncommon, while ongoing bleeding can wreak havoc with your sex life – and life in general.

"In the past doctors were reluctant to prescribe the Pill for menstrual control after the age of 38 because of the increased risk of stroke," says De Villiers. "But today dosages have been dramatically reduced.

"The Pill once contained up to 50 micrograms of oestrogen while now some contain as little as 15 microgram. This makes it safer to use over an extended period and up to menopause. Sometimes this is all it takes to make a period manageable."

Cape Town gynaecologist and obstetrician, Dr Janet Cole believes the Mirena, a progesterone-releasing contraceptive intrauterine device, has also impacted on the number of hysterectomies.

"The Mirena costs around R1 600 compared to the cost of surgery which is around R25 000. It's inserted in five minutes in your doctor's rooms and controls vaginal bleeding extremely effectively," she explains.

"One of the disadvantages is that some medical aids won't pay for the Mirena, and it takes four to five months to settle during which time the patient can experience irregular bleeding and spotting. Also, some women's anatomical structure will prevent the device from being inserted safely – a disappointing fact that might only come to light during the procedure."

Endometrial ablation, during which the lining of the uterus is destroyed using heat or cold, also helps to control bleeding, says Cole. But this isn't the only surgical procedure that may have contributed to the drop in hysterectomies.

Fibroids (together with menorrhagia, the most common reason women resort to hysterectomy) can be eradicated by a myomectomy during which the fibroids are removed while the uterus is left intact. This isn't a new procedure and is done to conserve fertility. Ironically a myomectomy can affect the very fertility doctors are trying to preserve – the fibroids often recur and the procedure can cause adhesions that prevent the Fallopian tubes from functioning properly.

For all the different options there are situations when the best solution remains a hysterectomy. Cancer, large fibroids and, in rare cases, obstetrical haemorrhage are just a few. For the patient with incapacitating menstrual bleeding, a hysterectomy is the only treatment that guarantees the bleeding will stop.

Should you have one?

Having a hysterectomy is a big decision. In addition to weighing up the pros and cons of surgery and the potential physical effects, patients need to consider the emotional impact of this life-changing procedure. Nireshni Govender was surprised to discover that having a hysterectomy triggered a major bout of depression.

"I'd had three natural deliveries, which caused urinary incontinence," says this busy mother of three from Durban North. "I had tried various exercises and medication without much success and finally decided to opt for a hysterectomy."

Her surgery went smoothly and was free of complications but Govender felt strangely ambivalent after the recovery period when she was up and about again.

"It was brilliant not having 'accidents' during the day," she says. "But I felt a loss of identity. I wasn't planning to have more children but the hysterectomy meant it was impossible and that made me depressed. I'm feeling better now but it's forced me to reassess the image of myself as a mother and a woman."

De Villiers is quick to point out there are still many urban legends associated with a hysterectomy – a lowered libido after the op being one of the most common. But he regularly asks patients if having a hysterectomy has adversely affected their sex life. "And most tell me they wish they'd had the operation sooner," he says.

"I'm also surprised at the procedure's bad press as my experience with post-op patients supports the opposite," he continues. "In fact, patients who've had hysterectomies for valid reasons are mostly thankful for the improvement in their quality of life."

While some doctors might seem more scalpel-happy than others the role of the patient is critical. She needs to prepare herself and her family for the decision and the procedure itself. How? By considering the longterm effects, being informed about all the options and seeking a second – or even a third – opinion. The preparation process will put you as the patient in a good position to decide what's really best for you.

How a hysterectomy has changed their lives*

Is it really lifechanging?

"Absolutely. Before the op I used to spend most of the month on the couch with very heavy bleeding. I was anaemic and at high risk of osteoporosis. The fibroid I had was enormous and a hysterectomy seemed like the best option – even though I'd never had surgery before and I never imagined I would settle for a hysterectomy.

I'm so pleased I did. The recovery is pretty hard going but three months down the line I wish I'd had it done sooner."

Sue Samuels (38), Film editor, Cape Town

The impact on your sex life

"To be honest I don't think I was prepared for my wife's hysterectomy. Liz was only 35 when she had it done. It took me a bit by surprise. It wasn't about having more children. We have two fantastic sons and I've had the snip so we weren't planning to have more. But it just felt so final. I backed off completely, which has caused tension in our marriage. I'm working on understanding her and the situation better."

Andre Breitenbach (42), grape farmer, Paarl

The impact of counselling

"I don't think the doctor spent enough time explaining the operation to me. I feel as though I was rushed into the decision. I've had five children and my uterus had dropped. I'm happy with the results but it all seemed to happen very quickly and I'm uncomfortable with that."

Thandiswa Ndevu (48), Personal assistant to CEO , Randfontein

Not the only option

"I've suffered from debilitating periods for years. I have three children and don't plan to have more. I went to the doctor absolutely desperate for a solution. I thought she would suggest a hysterectomy. My mom had one when I was a teenager and I remember how wretched she felt. Instead my gynae recommended the Mirena. I was sceptical but haven't looked back. It's been brilliant. I feel like a teenager again."

Joanne Hendricks (44), stay-at-home mom, Pretoria

Uterine cancer: to cut or not

"My mom died of uterine cancer when I was 25 so when my Pap smear came back with abnormal cells I didn't hesitate. Neither did my gynae. I'm pleased I've had a hysterectomy . . . I'm very unhappy I can't have children but I'm grateful to have caught the cancer early and happy to be alive."

Sheila Walters (36), hair salon owner, Kempton Park

* Names (but not age, occupation or area) have been changed.

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