Alternatives to Hysterectomy
Few women are happy with the prospect of undergoing a hysterectomy--surgery to remove the uterus and, sometimes, the ovaries. In a recent survey by researchers at the Rand Corp. and UCLA, a majority of the 600 women interviewed said they would opt for an alternative to hysterectomy if offered a choice.
Finally--at a very gradual pace--women are being presented with alternatives.
Most hysterectomies are performed because of painful and very heavy menstrual cycles. This condition, called abnormal uterine bleeding, is often caused by fibroids--non-cancerous tumors--but can also be triggered by hormonal disorders, infections and other problems.
Two new procedures are being offered to women for the treatment of fibroids. Both are less invasive and dramatically reduce the risks and recovery time associated with hysterectomy.
One procedure, called embolization, is strictly for the treatment of fibroids.
The other procedure, which has been in use longer, is called resection and ablation. This technique is used on fibroids as well as some other problems causing abnormal uterine bleeding.
The increasing use of these newer procedures could begin to reduce the estimated 600,000 hysterectomies performed annually in the United States. Fibroids alone affect about 10 million women and account for one-third of all hysterectomies.
“It’s pretty easy to see why women don’t want hysterectomies,” says Dr. Joe Gambone, a reproductive endocrinologist at UCLA and a co-author of the survey. “Women don’t want to lose an organ. Hysterectomy involves an incision and a long recovery time. But none of these new alternatives is going to be appropriate for everyone.”
A traditional, or abdominal, hysterectomy is usually recommended for women with cancer of the reproductive organs and is sometimes the preferred treatment for endometriosis, the abnormal growth of uterine tissue. A traditional hysterectomy may also be recommended if a woman has scarring from previous surgeries.
The alternative procedures might, however, be better suited for many women. Nevertheless, consumers should proceed with caution.
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Each of the new procedures has fans and foes among different physician specialty groups such as obstetrician-gynecologists, surgeons and interventional radiologists. And some procedures are heavily promoted by manufacturers of the instruments used to perform the techniques.
Also, some doctors still will not recommend any of the new procedures. They may be skeptical of the advantages of the new techniques or may know little about them.
“The public has to know there are procedures out there that look good but their doctor may not be trained to do it,” Gambone said.
Women seeking an alternative to a hysterectomy are most likely to hear about resection and ablation. During outpatient surgery, the physician dilates the cervix and expands the uterus with fluid. A miniature telescope and surgical device are inserted to remove and coagulate the endometrial lining. Polyps and fibroids can also be destroyed, but the uterus is not removed.
The procedure, which can be done under local anesthesia with sedation or under general anesthesia, takes about an hour. Most women return home the same day and can resume normal activities in two to five days.
Resection and ablation, which is usually covered by insurance, causes infertility. But a similar procedure can be done for women with fibroids to keep the endometrial lining intact and preserve fertility.
The procedure has been around for more than 10 years but is now becoming more widely used, with various studies showing about an 85% success rate in eliminating or reducing bleeding.
“We have a technique that has high success rates over time,” said Dr. George Savage, senior vice president for research and development at FemRx, a Sunnyvale company that makes a resection and ablation system called OPERA--Outpatient Endometrial Resection and Ablation. This system has been in use much longer than the embolization technique, he said.
“There is a huge amount of attention being given to embolization,” Savage said. “But why do that when there is a proven alternative?”
Because, say the proponents of embolization, it may involve the fewest risks and the briefest recovery time.
In embolization, a quarter-inch incision is made in the groin to allow a small catheter into the femoral artery. An interventional radiologist then guides the catheter to the uterus and injects tiny, harmless synthetic particles into the blood vessels that supply the fibroid with blood. The particles cut off the blood flow, causing the fibroid to shrink. This in turn causes the pain, bloating and bleeding to abate.
A study by Dr. Bruce McLucas of Century City Hospital and UCLA and Dr. Scott Goodwin, an interventional radiologist at UCLA, found that eight of 10 patients reported significant improvement with embolization. More cases have since been done showing similar success rates, he said.
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“This is not a high-risk procedure,” McLucas said. “Patients are sedated but awake. They only need to be in the hospital for about six hours. All of the other procedures for removal of fibroids carry risks--of infection, [the need for] transfusion, adhesion formation and injury to other structures. With embolization, the chance of infection is small and there are no adhesions.”
One drawback of embolization is that most patients experience severe pain and cramping afterward and require pain medication. About 25% of the women undergoing the procedure have stayed one night in the hospital because of this pain, McLucas said. Patients typically feel they are back to normal in a few days.
Susan deBois, 51, was told by five doctors that she needed a hysterectomy. She was ready to have the surgery for large fibroids when she heard about embolization. She was immediately receptive.
“Embolization made so much sense,” she said. “It was not invasive surgery. I wasn’t losing my organs. I wouldn’t be off my feet for six weeks recovering.”
DeBois, of Los Angeles, is pleased with the results, despite severe pain after the embolization.
McLucas has followed about 100 patients and said there is no evidence that the fibroids will grow back. But others say that embolization is too new and unproven to be widely recommended. And because embolization is a new procedure, not all insurers cover it.
“If the fibroids are large and are near a vessel that can be embolized, then this can be promising,” Gambone said. “But it hasn’t been sufficiently tested.”
It is also too soon to know if removal of fibroids with embolization preserves a woman’s fertility. A study is underway on that question.
There are other options to hysterectomy as well, such as drug therapy and other surgical variations.
“In the old days everyone thought that once the uterus had served its purpose you just took it out if it was a problem,” Savage said. “In light of the new technologies, more sensitive physicians and demanding patients, folks are applying the dictum of doing as little as possible. If a fibroid is the problem, just take out the fibroid, not the whole uterus.”
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Removing Fibroid Tumors
Two new procedures are providing alternatives for women with fibroids who wish to avoid a hysterectomy.
Resection and Ablation
In this procedure, the surgeon inserts a tiny camera and instruments through the dialated cervix. The camera is used for guidance as the uterine lining-the endometrium--is cut away and coagulated. Fibroids and polyps can also be removed this way.
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1. fibroid tumor
endometrium
Falloplan tubes
uterus
ovary
cervix
ovary
Camera and surgical instruments
2. fibroid tumor
Fallopian tubes
ovary
ovary
uterus
cervix
Camera and surgical instruments
Embolization
After a quarter-inch incision is made in the groin, a surgeon places a catheter into the femoral artery and guides it to the uterus while watching the progress of the procedurevia X-ray imaging. Tiny particles of synthetic material are then injected into the artery to cut off blood flow to the fibroid. With the blood supply cut off, the fibroid will shrink.
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1. fibroid tumor
Fallopian tubes
ovary
ovary
uterus
synthetic particles
2. fibroid tumor
Fallopian tubes
ovary
ovary
uterus
synthetic particles
femoral artery
Source: FemRx and Dr. Bruce McLucas
