Each year in the United States, over 500,000 women have hysterectomies. One-third of all women in the U.S. will have hysterectomies before age sixty, most while they are still in their forties.

Hysterectomy is a controversial subject, because many hysterectomies are probably unnecessary. Some health experts suggest that a third or more of all hysterectomies should not have been performed. Necessary or not, most women have strong feelings about this surgery. If your doctor has recommended a hysterectomy for you, it is important to understand exactly what this means.

What is a hysterectomy?

Hysterectomy is surgery that removes the uterus (womb). With the uterus removed, you will not have any more periods, and you cannot become pregnant.

Here are the four basic kinds of hysterectomy:

Total hysterectomy: The phrase “total hysterectomy” can be confusing, as many people think it includes removal of the ovaries, leading to “instant menopause”. This is not the the case. In a total hysterctomy, the uterus and cervix are removed. The fallopian tubes and ovaries are left intact. The ovaries will continue to produce hormones, possibly for as long as they would have without the hysterectomy.

Total hysterectomy with oophorectomy: (bilateral oophorectomy, bilateral salpingo-oophorectomy) Total hysterectomy plus removal of the ovaries (and usually the fallopian tubes). There are some variations on this which may include leaving one ovary or part of an ovary. For women over age 45, many doctors recommend removal of the ovaries as part of any hysterectomy, even when the ovaries are still healthy. The doctor may feel that since the woman is near menopause anyway, this is not a great loss, and it will protect her against ovarian cancer. (Note, however, that ovarian cancer is not common in women who do not have a family history of ovarian cancer.) Removal of the ovaries results in instant menopause. Hormone replacement therapy (HRT) may be recommended, and the doctor will usually start your HRT while you are still in the hospital, possibly even placing a hormone patch while you are still unconscious.

Supracervical (subtotal, partial) hysterectomy: The body of the uterus is removed, but the cervix is left in place. In the past, the cervix was always left in place, because surgeons did not have safe techniques for removing it. In the 1950s, new techniques (and the desire to prevent cervical cancer) led to removal of the cervix being the typical method. However, supracervical hysterectomies are still performed in some cases. Because you still have a cervix, you will need to continue regular getting Pap tests.

Radical hysterectomy: The uterus, ovaries, fallopian tubes, upper portion of the vagina, and the pelvic lymph nodes are all removed. This kind of hysterectomy normally is done only if there is a serious disease, such as cancer, that warrants it. If your doctor is recommending a radical hysterectomy, find out why! And get a second opinion.

Do I really need this?

Hysterectomy is usually “optional”, but may be the only effective treatment for a condition that is causing pain or other complications. Unfortunately, some doctors may not be aware of the effectiveness of alternative treatments, or they may simply prefer hysterectomy because it is simpler. On the other hand, sometimes hysterectomy is the only (or the best) way to solve the problem.

Most authorities now agree:

Hysterectomies are necessary for: Uterine, ovarian or invasive cervical cancers, or for the management of other cancers

Hysterectomy can be an appropriate treatment for: Large or rapidly-growing fibroids, severe endometriosis, serious damage to the uterus from infection or childbirth, severe bleeding that cannot be controlled through other methods, chronic pain from pelvic adhesions, prolapse

It is usually not appropriate for: Precancerous conditions of the cervix, benign ovarian cysts, small or painless fibroids

It is unnecessary for: Sterilization, abortion, menstrual irregularities

If your doctor has recommended hysterectomy, make sure you understand exactly why. Find out exactly what type of hysterectomy is being proposed. Find out whether or not there are alternative treatments, and how they may apply to your case.

It is always wise to get a second opinion before undergoing major surgery. Some insurance companies may require that you do so. Your doctor or your insurer can provide you with an appropriate referral. Don’t be afraid to ask questions!

What are the alternatives?

Available alternatives depend on the condition that is being treated and your overall health. Some possible alternatives:

Do nothing. If your condition is not life-threatening and does not pose a significant threat to your health, you may choose to take a “wait and see” approach. You will need to decide whether you can tolerate the current symptoms, and discuss with your doctor the best way to continue monitoring your condition. Some conditions are likely to get worse if untreated, but others will stay the same. Some conditions, such as fibroid tumors, may improve after menopause.

Treat the problem with hormones or other medications. Hormones or drugs may be helpful in controlling some conditions. However, not everyone can safely take hormones. Hormones and other medications can have unpleasant side effects, and some are not appropriate for long-term use.

Use some other kind of surgery. It may be possible to remove certain kinds of tumors, such as fibroids, and repair the uterus. Sometimes other organs or tissue can be removed without removing the uterus.

Other treatments. Treatments such as D&C, endometrial ablation, insertion of mechanical devices, laser treatments, radiation therapy, and others may be helpful for some conditions.

What will it be like?

How is the surgery done?
What are the risks?
How should I prepare for surgery?
What is the recovery like?
How will this change my life?

For information about before, during and after a hysterectomy, see the following post about “Having a Hysterectomy”.

What else should I know?

Hystersisters is a nonprofit organization providing positive support for women before, during and after hysterectomy.
See our page of helpful links.

© 2005 Rosemary K. West

In 1961 Jenny Joseph wrote a poem entitled “Warning” which begins,

“When I am an old woman…
I shall wear purple
With a red hat which doesn’t go, and doesn’t suit me…
But maybe I ought to practice a little now?…”

In 1996, a BBC poll found that “Warning” had become Britain’s favorite poem.

Inspired by the poem, and by her own enjoyment of a red hat, Sue Ellen Cooper of California, along with a few friends, started the Red Hat Society. Members meet for tea parties and other events, wearing bright purple outfits and red hats. (Junior members, who are under age 50, wear lavender outfits and pink hats.) As the society grew, the idea spread, and there are now over 55,000 members with over 2,000 chapters around the world.

Information about the original Red Hat Society can be found at www.redhatsociety.com. The rights to reproduce and sell copies of the poem “Warning” belong to Elizabeth Lucas, who has a website at www.elizabethlucasdesigns.com.

Wait and Watch

If your fibroids are not causing any symptoms, or if the symptoms are minor, your doctor may recommend that you simply leave them alone, with periodic examinations to see whether or not they are growing.

Medication

If your symptoms involve menstrual irregularities, the doctor may suggest that you try taking birth control pills to regulate your periods. Although estrogen can cause fibroids to grow, low-estrogen birth control pills are available. If the pills can regulate your cycle, this may provide the relief you need. Of course, if you want to become pregnant, taking birth control pills is not an appropriate long-term solution for you.

For severe bleeding symptoms, some doctors may prescribe a drug treatment known as a GnRH (gonadotropin-releasing hormone) agonist. Lupron is one brand name for this kind of drug. Lupron works by decreasing your body’s estrogen production. This treatment leads to shrinkage of the uterus and fibroids. Unforuntately, the side effects can be unpleasant, including hot flashes, reduced libido, and vaginal dryness. This treatment also prevents pregnancy. Because long-term use of GnRH agonists can lead to bone loss, they are usually prescribed for only a few months. After the drug is discontinued, the fibroids will probably start growing again. For that reason, GnRH agonists are used mainly as a pre-surgical treatment. Because the drug is expensive and has side effects, it may be considered unnecessary or undesirable prior to surgery, especially if the fibroids are not very big. There is some concern that if small fibroids shrink too much, the surgeon will not be able to find and remove them. However, if the woman has severe anemia, this drug in combination with iron supplements can be very helpful in reducing or eliminating the anemia prior to surgery. The use of these drugs is controversial, so if they are recommended for you, make sure you understand exactly why and what your doctor expects.

Myomectomy

Myomectomy is a “conservative” surgery that removes the fibroids, leaving the uterus intact. This procedure is preferred by women who wish to become pregnant or who simply prefer to keep the uterus. There is a chance that after a myomectomy, the fibroids will grow back, although it may take a long time for this to happen. It is difficult to know how likely regrowth is, as various sources estimate that anywhere from 10% to 80% of women will experience a recurrence of fibroids after myomectomy.

In some cases, myomectomy may be performed by entering the uterus through the vagina. However, if the fibroids are too large and numerous to use this option, an incision will be made in the abdomen. This is usually a horizontal cut above the pelvic bone, below the “bikini line”.

After administering general anesthetic, the doctor will insert a catheter to keep the bladder drained during the surgery. A second catheter is used to stain the interior of the uterus with blue dye. Once the abdomen has been opened, the surgeon will locate the uterus and the fibroids. Each fibroid is injected with a drug called Pitressin. This cuts off the fibroid’s blood supply for about twenty minutes, giving the surgeon enough time to cut the fibroid out of the uterine wall. After removing the fibroids, the surgeon repairs the incisions in the uterus.

Hysterectomy

Hysterectomy is a “nonconservative” surgery that removes the uterus. With the uterus removed, you will not have any more periods, and you cannot become pregnant. Your fibroids will not grow back.

In the past, hysterectomy was often the only choice available to women whose fibroids caused serious symptoms. Hysterectomies are one of the most commonly-performed surgeries in the United States, the country which leads the world in hysterectomies. Many women’s health experts believe that a large number — perhaps even most — of hysterectomies are unnecessary. Only about 10% of hysterectomies are performed for life-threatening conditions such as cancer.

Because of this, the use of hysterectomy to treat fibroids is controversial. Many doctors understandably do not want to perform this procedure on women who may want to have children or on any young women. Other doctors still believe hysterectomy is the best choice, especially for women over 40 and those not interested in childbearing. Younger doctors are less likely to recommend hysterectomy than older doctors.

A doctor’s attitude may be that if you cannot or do not intend to become pregnant, your uterus is merely excess baggage. Many women agree. Removing the uterus can have many advantages. It eliminates the inconvenience of menstruation, the need for contraception, and the risk of uterine or cervical cancer. Many women who have had hysterectomies feel liberated sexually, personally and medically.

On the other hand, even if pregnancy is not in your plan, you may wish to keep your uterus. Some women find that the loss of the uterus makes sex less enjoyable, since they no longer experience uterine contractions. The vagina may be shortened, leading to discomfort during intercourse. Some researchers believe that removal of the uterus can lead to earlier menopause, even when the ovaries are left intact. Some women simply object to the removal of any organ unless absolutely necessary.

With a vaginal hysterectomy, the surgeon approaches the uterus through the vagina, and pulls it out. With an abdominal hysterectomy, the surgeon makes an incision (similar to that used for myomectomy) in the abdomen.

There are four basic kinds of hysterectomy:

Total hysterectomy: The uterus and cervix are removed. The fallopian tubes and ovaries are left intact. The ovaries will continue to produce hormones, possibly for as long as they would have without the hysterectomy.

Total hysterectomy with bilateral salpingo-oophorectomy: Total hysterectomy plus removal of the fallopian tubes and uterus. There are some variations on this which may include leaving one ovary or part of an ovary. For women over age 45, many doctors will recommend removal of the ovaries as part of the hysterectomy, even though the ovaries are still healthy. The doctor may feel that since the woman is near menopause anyway, this is not a great loss, and it will protect her against ovarian cancer. (Note, however, that ovarian cancer is not common in women who do not have a family history of ovarian cancer.) Removal of the ovaries results in instant menopause. Hormone replacement therapy (HRT) may be recommended.

Subtotal (partial, supracervical) hysterectomy: The body of the uterus is removed, but the cervix is left in place, and the vagina is not shortened. Because you still have a cervix, you will need to continue regular getting Pap tests. There is a small chance that you could have a recurrence of fibroids in connection with the cervix.

Radical hysterectomy: The uterus, ovaries, fallopian tubes, upper portion of the vagina, and the pelvic lymph nodes are all removed. (In some cases one or both ovaries may be left intact if they are not involved in the disease.) This kind of hysterectomy normally is done only if there is a serious disease, such as cancer, that warrants it. If your doctor is recommending a radical hysterectomy, find out why! And get a second opinion.

Other Treatments

Laparoscopic myomectomy: In laparoscopy, the doctors make a small incision and use a camera mounted on a tube to look around inside the abdomen. Additional small incisions are made in order to perform surgery. Laparoscopic surgery is appealing because it is often done on an “out patient” basis, meaning the patient goes home the same day, and because the scars are usually smaller than with more conventional surgeries. However, laparoscopy does have its own risks and limitations, and may not be suitable for all situations.

Hysteroscopic myomectomy: If the tumors are inside the uterine cavity and not deeply embedded in the wall, it may be possible to remove them using a hysteroscope, a tubular instrument inserted through the cervix. As with laparoscopy, this surgery usually allows the patient to return home the same day.

Embolization: This is promoted as a “non-surgical” technique and is performed by radiologists. However, it is invasive, and small incisions or punctures are necessary. Catheters inserted into the arteries are used to introduce material that will plug the blood vessels leading to the fibroids. The fibroids then die and wither. The patient may experience severe cramping for several days, a week, or more. It may take several months before symptoms improve. Currently, this technique is still considered experimental.

Myolysis: The tumors are destroyed with electrical current or a laser. They then die and shrink. This is still an experimental technique, and there is little information available.

© 2005 Rosemary K. West

Perhaps the first time you ever heard of fibroids was the day you were diagnosed as having them. Or perhaps you suspect you have fibroids, but can’t seem to get a definite diagnosis. If your mother or sister has them, you may wonder if you will get them, too.

It can be difficult to find thorough, reliable information about fibroids. If fibroids are causing problems for you, you may find it hard to make decisions about the treatment that is best for you.

On these pages I’ve put together the results of my own research and experience. You’ll also find links to other sources of helpful information.

What are fibroids?

A fibroid is a benign tumor that grows in or on the uterus. Fibroids are the most common tumor of the female reproductive organs. They are often embedded in the wall of the uterus, but they may also be attached to the outside, or to the inner lining.

Fibroids can be any size. The largest recorded fibroid weighed 140 pounds! But normally fibroids are relatively small, ranging from the size of a pea (or smaller) to a grapefruit. If you have fibroids, your doctor may describe their combined size as it relates to the number of weeks in a pregnancy.

Other names for fibroids: myomas, fibromyomas, leiomyomas, leiomyomata uteri

If you want to know what large fibroids look like, this article on uterine fibroids includes a color photo. And here is a photo, very detailed, showing all three kinds of fibroids.

What causes fibroids?

No one really knows what causes fibroids. Anywhere from 20% to 50% of all women have them, and many women have them without ever knowing it. They appear more often in women over 35, and in women of African heritage. However, women of any age and ethnic background may have fibroids. Their growth is stimulated by estrogen, so women taking birth control pills or estrogen replacement therapy, women who are pregnant, or women who experience increased estrogen levels during perimenopause may experience symptoms caused by enlarged fibroids. At this time, there is no way to predict which women will get fibroids.

Can fibroids be prevented?

Since we don’t know what causes them, we really don’t know how to prevent them. Because their growth is linked to estrogen, fibroids usually shrink (and often disappear) after menopause. So perhaps one way to prevent fibroids is to reach menopause!

What are the symptoms?

Many women have fibroids, even large ones, and experience no symptoms. Others experience many unpleasant symptoms, even with small fibroids. Fibroids may cause any or all of these symptoms:

• Constantly feeling heavy or bloated in the abdomen, feeling as if you have a foreign object in your abdomen
• An enlarged or distorted uterus, uterus pushed out of its usual position
• Abdominal swelling that makes you look bloated or pregnant
• Irregular periods, extremely heavy bleeding during periods, large clots expelled with menstrual blood, unusually long periods, spotting and bleeding between periods, unusually severe menstrual cramps, cramps similar to labor contractions
• Anemia caused by the excess bleeding
• Pressure on the bladder, frequent urination, difficulty urinating
• Pressure on other abdominal organs, possible damage to organs
• Constipation
• Painful intercourse, bleeding after intercourse
• Infertility, miscarriage

Be aware that all of these symptoms may be caused by other conditions. Do not attempt to diagnose yourself and do not assume that you have fibroids based on symptoms alone. It is important to get a diagnosis from a qualified health professional.

How do I know whether I have them?

You need a medical diagnosis. A gynecologist will start by performing a manual pelvic exam. In many cases the doctor will be able to feel and recongize the fibroids at this time. The next step is to confirm the diagnosis with a sonogram (ultrasound). This is an easy, painless procedure. The radiologist will insert a special probe into the vagina to view your uterus, and will also run another probe over the outside of your abdomen to get a different point of view. The doctor should count the fibroids, note their locations, and take their measurements. Be aware that an exact count may not be possible.

Some doctors may use MRI to look for fibroids, but this is an expensive, time-consuming procedure and is not likely to do a better job of finding the fibroids than ultrasound. MRI may be used when other conditions are suspected.

Another diagnostic procedure is hysteroscopy. This involves inserting a tubular instrument through the vagina and cervix, into the uterus. A light shining through the tube allows the doctor to view the interior of the uterus. You may experience spotting and cramps for a couple of days following the procedure. The procedure is not used on pregnant women.

Depending on your symptoms, the doctor may perform an endometrial biopsy. Although this is a fairly simple procedure that can be performed in the doctors office without anesthetic, it is considered surgery. You will need to take a pregnancy test before this procedure, as it is not safe for pregnant women. The doctor will insert an instrument through the cervix and scrape some tissue from inside the uterus. The tissue will be sent to a laboratory for testing. You may experience some cramping, and there may be spotting or other light discharge for a few days.

Are fibroids dangerous?

It would be very rare for uterine fibroids to present a threat to your life. They are almost never malignant. Occasionally, a fibroid may become twisted, cutting off its own blood and oxygen supply, resulting in severe pain which requires immediate surgery. Fibroids are sometimes associated with miscarriages or other problems in pregnancy, so if you have fibroids and plan to have children it is important to discuss this issue with your obstetrician. In the long term, the symptoms caused by large fibroids may have a negative effect on some aspects of your health and well-being. If fibroids are causing discomfort for you, it is a good idea to investigate your options with a gynecologist.

What are the treatments?

See the next post, which will provide a discussion of the various methods of treating fibroids.

What are the risks?

Diagnosis: Of course, an incorrect diagnosis is possible. Some women report that they have suffered needlessly for months or years because their doctors failed to diagnose fibroids. In some cases, fibroids were diagnosed incorrectly when another condition was the real problem.

It is always wise to get a second opinion before undergoing surgery or other major treatments. Don’t be afraid that asking for a second opinion will insult your doctor! Your doctor will probably be glad to provide a referral for you and will likely welcome the additional information. In most cases, the second doctor will probably confirm the first doctor’s diagnosis. If they disagree, you may need to get a third opinion to help sort things out.

Second (and third) opinions are routine. In some unusual cases, women with very difficult-to-diagnose conditions may need to consult even more doctors. But don’t start opinion-shopping as a way to avoid facing the truth and making a decision!

Surgery: All surgery has risks! Generally, when routine surgery is performed by competent, experienced doctors on a typical patient, the risks are minimalized. Keep in mind that each patient’s situation is different. The type and severity of the risks you face are determined by a number of factors, including your medical history and current condition. You and your doctor should have a frank discussion about the risks your face and what can be done about them.

Medication: There are side effects and risks associated with almost every medication. Some are not very serious, while others can be dangerous. Some of the risks may depend on your own medical history and lifestyle, so it is important to provide complete, honest answers to the questions your doctor, nurse or pharmacist may ask. Sometimes the risks of a medication outweigh the benefits, and you will have to choose another option.

Waiting: The most obvious risk of a wait-and-see approach is that the condition will get worse. If you are simply waiting, it is important to get regular checkups to monitor your condition.

Cancer: Less than 1% of fibroids are cancerous. If you choose surgery to treat your fibroids, you will be asked to sign a release that allows the doctor to perform additional surgery in case cancer is found. This is a good idea. Although cancer is not likely, you should be prepared to have it handled quickly and efficiently, just in case.

In the meantime, you should be getting a regular Pap test to check for cervical cancer. If you are over 40, your doctor will probably recommend regular mammograms (to screen for breast cancer) as well. If you have a family history of uterine or ovarian cancer, your should tell your doctor, as there may be other tests you should get.

What is the best treatment?

Unfortunately, there is no easy answer to this question. The “best” treatment depends entirely on the individual. The type and severity of symptoms you are having, your age, your general health and medical history, your lifestyle and personal preferences, all must be taken into account. In addition to having frank discussions with your doctor, you may find it helpful to visit a support group or discuss your situation with friends who have undergone fibroid treatments. Information is your best tool in making a decision.

Remember, it’s your body! You have the right to complete, accurate information about your condition. You have the right to make the ultimate decision about your own treatment. Your doctor, your friends and relatives, people you meet at parties, experts who have books to sell and TV shows to promote — all of them will have opinions and preferences. They will try to influence you. They may be honest and caring people with good intentions, but they don’t necessarily know what will be best for you in the long run. Listen to them and take what they say into account. Then listen to yourself.

What else should I know?

Adenomyosis is often mistaken for fibroids.
See our page of helpful links.

© 2005 Rosemary K. West

Be aware that none of these sites can guarantee 100% accuracy, and the information may not always be up to date. If in doubt, call your state licensing agency or local medical board.

The Association of State Medical Board Executive Directors directs you to participating state licensing boards, where you can find out that status of your doctor’s license and other interesting information.

At the American Medical Association website, you can
learn about your doctor’s education and training.

Docinfo sells reports on physician disciplinary history.