Is Hysterectomy Too Radical a Solution to Fibroids?

Three years ago, Allyn Mulligan, then 44, went for a routine physical. During her internal exam, the doctor told her she had a benign fibroid tumor the size of a grapefruit growing on the wall of her uterus.

Although her periods were heavy--which can be a symptom of large or benign fibroids--the bleeding didn’t bother her. And because fibroids, which are growths of muscle and connective tissue in the uterus, are noncancerous, there was no reason to do anything but monitor the benign tumor’s growth, Mulligan said.

But within two years, Mulligan said, the fibroid had grown to the size of a melon and was putting pressure on her bladder. Her general practitioner recommended an obstetrician-gynecologist.

“She told me I needed a hysterectomy and, while I was at it, I should have my ovaries out to protect against ovarian cancer. She said I would need to take Lupron [an anti-estrogen drug that shrinks fibroids but also brings on symptoms of menopause] for three months and that I would need a vertical cut down my stomach, because the fibroid was so big. She said I would have to donate blood in case I needed a transfusion,” Mulligan said. “I was in shock. . . . It seemed so drastic given the symptoms.”

Drastic, but apparently not at all unusual. Uterine fibroids, as a 1995 article in Harvard Women’s Health Watch newsletter put it, are more common than blue eyes. They affect one-fifth to one-fourth of all women under age 50 and half of black women in their 30s and 40s.

Even though the tumors are benign and often produce no symptoms, they are the leading reason for undergoing hysterectomies in the United States, accounting for three of every 10 hysterectomies.

Because of this, there has been growing concern that too many hysterectomies are being done unnecessarily, robbing women of their fertility and, some would say, their sense of womanhood. As a result, an alternative operation, a myomectomy, which removes the tumors but leaves the uterus, has become more common.

Removing the uterus removes a woman’s chance to have children; there is some data that a hysterectomy can also decrease a woman’s sexual pleasure, because the uterus is sometimes involved in orgasm. If the ovaries are also taken out, a woman is plunged into menopause, which can produce hot flashes and other symptoms, and puts her at higher risk for heart disease and osteoporosis.

Many fibroids--such as Mulligan’s--are only detected during an exam and cause the woman few problems, generally disappearing with menopause. The American College of Obstetricians and Gynecologists estimates that 60% to 90% of fibroids cause no troublesome symptoms.

“The bottom line is: Is the surgery necessary to begin with? That’s the primary question,” said Dr. Richard U. Levine, vice chairman of obstetrics and gynecology at Columbia-Presbyterian Medical Center in New York City.

A 1993 Rand Corp. study indicated that in some cases surgery is not necessary: Sixteen percent of hysterectomies performed among seven managed-care companies were performed for “inappropriate reasons,” and another 25% were done for “uncertain reasons,” according to the think tank’s study.

When surgery is necessary, there are several reasons that doctors appear to favor hysterectomies: 1) a hysterectomy is a quicker, easier operation with fewer chances of postoperative problems and no chance of recurring fibroids; 2) unless a woman wants to get pregnant, many doctors do not believe a woman needs her uterus.

There’s no question, doctors say, that in most cases a hysterectomy is a much easier operation. In an abdominal hysterectomy, which is the most common, the surgeon, using an abdominal incision, a “bikini cut,” detaches the uterus from the ligaments that hold it up and from the blood vessels that feed it, and then peels away the vagina from the cervix, the mouth of the uterus. The operation can be done in less than an hour.

By contrast, a myomectomy can be a much longer operation. Diana, a 38-year-old massage therapist, recently underwent a four-hour myomectomy to remove 35 benign tumors--one at a time--embedded in the uterine wall.

Usually done with an abdominal incision, myomectomies can also be done using a laparoscope, a long skinny tube inserted into the belly button, or a hysterscope, a long tube inserted in the vagina. But Dr. David Barad, director of the Montefiore Medical Center’s fertility and hormone center in Dobbs Ferry, N.Y., said if a woman has many fibroids, or large ones, cutting and withdrawing them by these methods can be complicated, less effective and time-consuming.

Regardless of the approach, controlling the bleeding inside the uterus is also more difficult than with a hysterectomy, because the doctor must control bleeding in all the vessels inside the uterus and in the fibroids--not just the blood supply to the uterus.

Indeed, Barad said that a woman thinking about getting a myomectomy should ask the doctor how many he or she has done in the last three years. “If he says ‘two,’ maybe you should talk to somebody with a little more experience,” he said.

Despite that, the American College of Obstetricians says the risks of bleeding and post-op complications are only “slightly higher” with a myomectomy than with a hysterectomy. And the myomectomy has lower rates of infection and injury to the ureters, the tubes that carry urine from the kidney, the college said.

Nevertheless, another reason for favoring a hysterectomy is that there’s no chance of recurring fibroids. The college estimates that about 10% of those who had a myomectomy needed “subsequent treatment” for recurring fibroids.

Money may also play a role in some doctors’ decisions to perform hysterectomies, as opposed to the more time-consuming myomectomies--although the fees for each procedure are roughly comparable.

Dr. Stanley West, chief of reproductive endocrinology and fertility at St. Vincent’s Hospital in New York, cites an anecdote in his book “The Hysterectomy Hoax” (Doubleday, 1994) about a seminar on medical economics he attended. “The topic was how to care for women in order to maximize our fee. The experts who led the discussion reminded us that gynecologists make the most money by doing surgery and that the highest fees we can generate come from hysterectomy,” he wrote.

A Health Services Research study came to similar conclusions. “Our findings suggest that physicians may perform hysterectomies to enrich themselves financially. Those physicians with a higher caseload of privately insured patients are significantly more likely to perform a hysterectomy than physicians treating publicly insured patients.”

Nevertheless, all the doctors interviewed said they would not hesitate to do a myomectomy on a younger woman who wants to have children. As Levine put it, “That’s a slam dunk.” Similarly, no doctor interviewed said he would take out the ovaries in a woman with no known risk of ovarian cancer.

But the decision to do a myomectomy becomes murkier, some said, when a woman is older or has completed her childbearing.

“I think the prevailing opinion is if you have finished your reproductive years, a hysterectomy is the preferable operation,” said Dr. Henry Prince, an obstetrician-gynecologist at North Shore University Medical Center in Manhasset, N.Y.

Mulligan, who lives in Huntington, N.Y., has no children and has no intention of having any, but she said she was determined not to lose her uterus if she didn’t have to. “I feel like that’s part of what made me a woman. I would be willing to give it up for cancer, but why would I give it up for something benign?” she said.

She went to three doctors before she found West, who was willing to do a myomectomy for her. “I think the issue is that for older women, they offer the myomectomy as a poor relative of the hysterectomy, instead of laying out the risks and benefits and letting the woman make up her own mind,” Mulligan said. She had the operation last January--West removed nine other tumors in addition to the melon-sized one. She was back at work within five weeks, didn’t have to take Lupron or have a vertical incision, and her ovaries were left intact.

Mulligan said her experience going from doctor to doctor left her believing that more women have to become aware of their options and find a doctor they trust. “A hysterectomy is irreversible. . . . These are not evil people . . . but women have to start saying ‘no’ to hysterectomies.”