Women Are Undergoing Hysterectomies as a Last Resort, Thanks to Advances in Technology That Have Made Uterus-Saving Therapies . . . : The Treatments of Choice

As she entered midlife, Connie Koller was losing almost a week of every month to her abnormally heavy menstrual periods. Employed full time in the accounting department of Baltimore’s Good Samaritan Hospital, trying to keep up with the schedules of three children, the 41-year-old Parkville, Md., woman often felt as if she were having to plan her life around her periods.

“I was afraid to go anywhere because of the excessive bleeding,” she says. “I knew I had to do something.”

Like many women in their 40s, Koller was experiencing pelvic pain and bleeding that affected the quality of her life. Tests revealed that her symptoms were caused by endometriosis and fibroids, noncancerous tumors growing in her uterus.

In the past, fibroids were usually treated by removing the uterus of women who had finished having children. In Koller’s family, other relatives had undergone early hysterectomies because of fibroids.

Koller, however, had a relatively new option: She chose endometrial ablation, outpatient surgery that removed the lining of her uterus as well as her fibroids. The procedure, which she underwent a year ago at Greater Baltimore Medical Center, stopped her menstrual bleeding altogether while preserving her uterus.

“I didn’t have one pain, one cramp,” she says. “The only effects I had afterward were from anesthesia. There isn’t any real change in your body as a female--except that I haven’t had my period since the procedure.”

Like a hysterectomy, endometrial ablation usually renders women infertile. It’s not meant for everyone who is suffering from abnormal bleeding, doctors caution, and is not always certain to correct the problem. But many women are now considering this treatment along with other procedures that are less invasive than hysterectomy for such benign conditions as endometriosis, chronic pelvic pain and uterine prolapse.

“Typically, patients who now undergo a hysterectomy for a condition like fibroids have failed other forms of uterine therapy,” says Sandra Brooks, director of gynecologic oncology in the department of obstetrics and gynecology at University of Maryland Medical Center.

Over the last decade, more gynecologists have learned how to perform new, uterus-saving procedures using technologically advanced tools. And as they have expanded the range of procedures they feel qualified to perform, they have offered more treatment options to their patients.

From 1975 to 1994, the number of American women 30 to 54--the category most apt to get a hysterectomy--increased by 16.5 million. During that time, however, the number of hysterectomies performed annually in hospitals decreased from 724,000 to 556,000, according to the National Center for Health Statistics. (Those numbers do not reflect hysterectomies performed in separate surgical centers.)

Although hysterectomy is the treatment of choice for gynecologic cancer, at least 80% of hysterectomies are still performed for other reasons. Recognizing that the surgery may prove the best ultimate solution for a persistent gynecologic problem, the American College of Obstetricians and Gynecologists emphasizes it should be considered a treatment of last resort.

Current research suggests that the uterus continues to create beta-endorphins, the body’s natural painkillers, and prostaglandins, which help prevent blood clotting, after menopause.

Prostaglandins, in particular, may help protect women against heart disease.

“The years when doctors were doing hysterectomies at the drop of a hat are over,” says Thomas Elkins, director of general gynecology and obstetrics at Johns Hopkins Medical Institutions. “It used to be that after we had done a certain number of D&Cs; [dilation and curettage to scrape and remove uterine lining], we’d go to hysterectomy because we didn’t know enough and couldn’t tell enough of what was going on. The newer technology has taken away that concern.”

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Koller had put up with abnormal bleeding for almost nine years before her surgery. Her previous gynecologist had attributed her discomfort to endometriosis, a condition in which the uterine lining grows outside the uterus, and had led her to believe that hysterectomy was her only option.

After Koller’s health insurance changed and she was free to find a new physician, she reread a newspaper article she had saved about gynecologist James Dorsey’s success with endometrial ablation at Greater Baltimore Medical Center. She sought his advice. Dorsey found that her bleeding was caused primarily by fibroids, a condition which could be treated by endometrial resection and ablation. In treating her, he used new instruments that he says makes the procedure quicker and safer than before.

Physicians emphasize it is important for women to be aware of all of their treatment options and to seek care from gynecologists who are skilled at performing many procedures.

“Patients should feel comfortable knowing that whatever they choose is the best procedure for them and not the only procedure their doctor knows how to perform,” says Dr. George Savage, co-founder of FemRx, a California company that developed new tools for the endometrial surgery Dorsey performed.

As the baby boom generation moves through midlife, many women will begin to experience various gynecological problems. About 10 million American women suffer from excessive uterine bleeding, according to a 1993 study in the International Journal of Gynecology and Obstetrics.

Women who experience unusually heavy or light menstrual bleeding--or bleeding between periods or after sexual intercourse--should consult their gynecologists. Such bleeding can have many different causes ranging from hormonal imbalances and infections to cancer.

What, exactly, qualifies as abnormal bleeding?

According to the American College of Obstetricians and Gynecologists, one definition is bleeding that is so heavy it requires using more than one pad or super-absorbency tampon every two to three hours.

It is normal for women to have irregular amounts of bleeding near the beginning of their menstrual years and again as they approach menopause. Periods may become heavier or lighter in midlife because perimenopausal women ovulate less often.

However, women who have menstrual cycles that are longer than every 35 days or shorter than every 21 days should see their physicians. (The menstrual cycle begins and ends with the first day of blood flow.)

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Because the length of a woman’s cycle can be highly individual, what is important is maintaining a consistent pattern, says the Greater Baltimore Medical Center’s Dorsey.

To diagnose the source of the problem, a gynecologist may take a sample of tissue from the uterine lining. Other diagnostic tools include ultrasound to scan the pelvic organs and a fiber-optic scope, which examines the uterus.

Hormonal imbalances can occur when the body does not make the right amount of a certain hormone. Sometimes fluctuations can be caused by weight loss or gain, stress, heavy exercise, illness or certain medications. Often ovaries will fail to release eggs, a common occurrence in the years preceding menopause.

When a woman does not ovulate, the lining of her uterus can grow too much, a condition that leads to heavier and sometimes unexpected bleeding.

To treat a hormonally based condition, a gynecologist may use drug therapy consisting of low-dose birth control pills, progesterone or thyroid medications.

Various types of surgery treat other conditions, such as fibroids and endometriosis. New instrumentation is making procedures easier and more safe, physicians say.

When such treatments don’t relieve the bleeding, pain and other symptoms of gynecologic disorders, it may make sense for women to have the uterus removed. However, having a hysterectomy no longer means the automatic removal of the ovaries, particularly for premenopausal women.

“Just because a patient is in her 40s doesn’t mean her ovaries have to be taken out,” Dorsey says. “That is an old-fashioned view.”

A recent study of 1,300 Maryland women who underwent hysterectomies for benign conditions revealed that as long as two years after their surgery, most women were very pleased with the outcome, according to researcher Kristen Kjerulff of the University of Maryland Medical School. She served as principal investigator of the federally funded study, which looked at hysterectomies at 20 hospitals throughout the state from 1991 to 1995.

Researchers interviewed volunteers extensively before their surgery and conducted five follow-up interviews over the next 24 months. The study showed that the average age for a Maryland patient choosing hysterectomy was 42--the same as it is nationally. Most patients sought surgery because of fibroids. And most had tried other treatments before choosing hysterectomy.

“The average length of time between first seeing a doctor about their problem and having a hysterectomy was two years,” Kjerulff says. “These women were not being rushed into surgery.”

Before their hysterectomies, most patients had at least four of eight major symptoms of gynecologic disorders: heavy bleeding, pelvic pain, back pain, activity limitation, sleep disturbance, fatigue, abdominal bloating and urinary incontinence.

After surgery, most of the women reported that they felt better physically and mentally. They said their sexual functioning and pleasure also improved, a contrast to earlier anecdotal reports.

Kjerulff admits she was a little surprised by the results of the study.

“I went into it having read a lot of anti-hysterectomy literature,” she says. “We found very little evidence of women having hysterectomies unnecessarily and very little evidence of women being rushed into hysterectomy. . . . Many of them said they wished they had done it sooner.”

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Even so, the operation presents a profound transition for many women. At 61, Janice McCarthy of Baltimore recently had a hysterectomy to treat her uterine prolapse. After bearing five children, her uterus had dropped into the vagina due to the weakening of its support structure and was making her life difficult.

After considering options, she decided hysterectomy was the right choice for her.

Although she was far past her child-bearing years, McCarthy felt sad at the notion of losing the organ that had helped her create life. Some of the young doctors who initially treated her couldn’t understand her reluctance to schedule surgery for a part of her body that was no longer functional, she says. So she captured some of her thoughts in a poem that expresses her emotions.

Physicians need to be mindful of the deep and complex relationships humans have with their bodies, Elkins says.

“Doctors need to be more understanding across the board of what the body means to people,” he says. “It’s not the procedure of a hysterectomy itself that is the problem; it’s that we’re often not sensitive enough to what the patient is going through when we ask her to give up a major body part that has been so much a part of her life. . . . We must learn to be more cognizant of what women go through and how we can best help them in the least harmful ways.”

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Fibroids, noncancerous growths of muscle and fibrous tissue, are the cause of a third of the hysterectomies performed in the United States, according to the American College of Obstetricians and Gynecologists.

Fibroids can be the size of a pea or so large that they make a woman appear several months pregnant. They can form on the inside of the uterus, on its outer surface or within the uterine wall, sometimes affecting fertility.

“Even very small fibroids sticking into the uterine cavity can produce very heavy bleeding,” says Dorsey.

If the tumors are causing no symptoms, women nearing menopause often choose to “wait them out”: Typically, fibroids shrink when they are deprived of the estrogen produced by the ovaries.

Sometimes drugs are used to shrink fibroids temporarily, particularly before surgery.

Myomectomy is surgery to remove fibroids but preserve the uterus and its lining. There are several methods: Hysteroscopy removes growths inside the uterus after locating them with a thin viewing instrument inserted through the cervix. Laparoscopy removes tumors growing outside the uterus by inserting a viewing instrument, followed by a laser or scalpel, through an abdominal incision. Abdominal surgery, which can involve a hospital stay of several days, is sometimes used in serious cases.

Myolysis is a procedure that cauterizes the tissue between the uterus and the fibroids, cutting off the tumors’ blood supply. It is performed with a laparascope and two electric needles.

Endometrial resection and ablation is surgery that can remove fibroids as well as the endometrial lining. Technological advances have developed a new operative hysteroscope that is inserted into the uterus and can selectively resect (cut) the endometrial lining and fibroids, and ablate (coagulate) the uterine cavity. An outpatient procedure that usually takes less than an hour, this surgery allows patients to resume normal activities as quickly as the next day, according to Dorsey.

“There is a small but definite failure rate with endometrial ablation,” the gynecologist says. “If the procedure works for two years and the patient begins to bleed again, there are times when hysterectomy is the only way to guarantee success.”

Although endometrial ablation, which removes the entire uterine lining, is not recommended for women who wish to preserve fertility, resection of fibroids in the uterine cavity often solves bleeding and infertility problems.