Modern Alternatives to Hysterectomy
Robert A. Dein, MD, FACOG
Obstetrics/Gynecology, Bryn Mawr Hospital

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Reasons for Hysterectomy
Hysterectomy, which means the surgical removal of the uterus, remains one of the most common operations performed in America today. Reasons for hysterectomy include excessive bleeding, pelvic pain, fibroid tumors, uterine prolapse, and cancer. While many of these indications remain entirely valid, modern advances now offer doctors and patients alternatives to this surgical procedure. This article discusses alternatives to hysterectomy for two major conditions, menorrhagia, or excessive vaginal bleeding, and uterine fibroids.

Options for Managing Menorrhagia
As with any medical problem, the most important part of choosing the appropriate therapy for excessive bleeding is for your doctor to begin with a careful history, physical examination, and testing. Reasons for bleeding can usually be divided into three catgories: mechanical (i.e. fibroids or polyps), hormonal (i.e. excessive estrogen or anovulation), or neoplastic (cancerous). A work up should include a sonohysterogram, which is a specialized ultrasound that images the interior of the uterine cavity. This can determine if there is a polyp or fibroid present within the cavity. If there is a polyp present, this can nearly always be removed with a simple D. &C. procedure, which may in turn eliminate the bleeding problem. If there is a fibroid within the cavity, this may be removed with a hysteroscopic resection, which again may be curative, and thereby avoid the need for hysterectomy. It is important that a simple office endometrial biopsy be performed to rule out precancerous or cancerous lesions. Precancerous cells may be treated with hormones in women who wish to retain their fertility, but they are usually treated with a hysterectomy. Cancer of the uterus still nearly always requires surgery. If the reason for bleeding is felt to be a hormonal imbalance, the traditional treatment has been the use of birth control pills or natural and synthetic progesterone. There is a new technique now available which eliminates many of the problems inherent with the use of systemic hormones, namely a progestin secreting IUD called Mirena.

Mirena IUD
The Mirena IUD has been used by over two million women over the last ten years. It is a small T-shaped plastic device that is approximately the size of a quarter. This IUD is inserted by your doctor through the cervix into the uterus. This is done in the office without the need for anesthesia. The Mirena releases a small constant dose of the progestin Levonorgestrol. The effect over time is to thin out the lining of the uterus, and counteract the stimulatory effect of estrogen. With a thinner, more stable uterine lining, the woman will bleed less, and may even stop bleeding altogether. The advantages of the Mirena are that it is not only a treatment for excessive bleeding, but a very effective form of birth control as well, is fully reversible in case pregnancy becomes desirable, and lasts for 5 years. Since there is no estrogen in this device, it is appropriate for women who are breast feeding, or following treatment for breast cancer.

Endometrial Ablation
One of the most exciting new innovations to decrease the need for hysterectomy is a minor surgical procedure call an endometrial ablation, usually performed in the physician’s office. Uterine bleeding comes from the endometrium — the fluffy glandular lining of the inside of the uterine cavity. Endometrial ablation surgically destroys (ablates) that lining. Endometrial ablation has been performed for many years, but it was a difficult, long and potentially dangerous procedure.

The new technologies of endometrial ablation have lowered the operative time to 50 - 90 seconds, and have virtually eliminated the risks. There are now three major technologies for modern endometrial ablation, utilizing either a heated fluid filled balloon, or the use of an electrically conductive mesh, or an intrauterine infusion of super heated water. The mesh is the newest technique, it is called the “NovaSure” system. It uses a small gold foil mesh which is inserted into the uterus after a brief dilation of the cervix. A light general anesthetic is given, although some physicians perform this in their office with a local cervical block. The mesh device is attached to a computer driven controller which applies a very precise amount of electrical energy to the endometrium. Safety measures will prevent the machine from operating if a small hole is present in the uterus. After 50 - 90 seconds, the feedback mechanism on the controller indicates that the endometrium is completely ablated, and the mesh is then removed. Results have been dramatic with this new technology. Approximately 60% of women will not bleed at all after this procedure, and 92% will have significant improvement of their bleeding. Women who continue to bleed heavily can be re-treated, or may be candidates for hysterectomy. Side effects are few, and patients go home after one to two hours. Return to work is usually within a few days.

Uterine Fibroids
There are two techniques available to treat fibroid tumors without hysterectomy “Myomectomy” is the surgical removal of fibroids, and can be accomplished hysteroscopically if the fibroids are within the uterine cavity, or either by laparoscopy or traditional laparotomy. These procedures have the advantage of fully removing the fibroids, while preserving the uterus. A second technique is the new procedure of “Uterine Artery Embolization.” UAE is performed by an invasive Radiologist, and is similar in technique to Cardiac Catheterization. A small incision is made in the groin, and a catheter is inserted through the femoral artery into the uterine artery. Small plastic particles are then injected into the artery, clogging it, and reducing the blood flow to the uterus. Fibroids then die and shrink in size over time. Fibroids shrink an average of 39% after 3 months, and 52% by 6 months. Occasional serious complications occur, but complication rates are low.

In sum, there are many available techniques that may reduce or eliminate your need for a hysterectomy. As always, your best resource is your health care provider. Individual attention to your condition, needs, and desires will help choose the course that is right for you.

This article is part of our Menopause and You library, a web-based program sponsored by Women’s Health Source. To view the entire library of articles, visit www.mainlinehealth. org/whs and click on the “Menopause and You” link. To speak with our nurse counselor, call 1-888- 876-8764 or email whs@mlhs.org.
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