Each year over 600,000 women in America have a hysterectomy, making it the second most common surgical procedure in the United States. In the case of cancer, hysterectomy may clearly be the preferred treatment option, but other conditions including fibroids, endometriosis and uterine prolapse offer alternative treatments that can be tried first. When considering hysterectomy women need to weigh the short-term benefits against the risks and costs.

Women with the following diagnosis typically require a hysterectomy: Uterine cancer

• Ovarian cancer
• Fallopian tube cancer
• Cervical cancer

• Abnormal vaginal bleeding
• Fibroids
• Adenomyosis
• Endometriosis
• Chronic pelvic pain
• Pelvis inflammatory disease
• Uterine prolapse
• Abnormal cell growth in the lining of the uterus or cervix

Reasons for Hysterectomy

Source: Miller BA, et al. (1999). Five reasons to consider a hysterectomy. Patient Care, 33(14): 34?50.

Hysterectomy for treatment of abnormal vaginal bleeding (dysfunctional uterine bleeding)

There are many possible causes for abnormal vaginal bleeding including pregnancy, hormone imbalance, thyroid problems, polyps or fibroids (small and large growths) in the uterus, cancer of the uterus and infection of the cervix.

Though vaginal bleeding is the most common cause for a hysterectomy, many experts believe a hysterectomy should be used for treating dysfunctional uterine bleeding only when other medical treatments have failed.1 The cause of the bleeding should be thoroughly evaluated with tests such as an endometrial biopsy before hysterectomy is considered.

Hysterectomy for treatment of fibroids

Fibroids are benign growths (not cancer) in the muscular wall of the uterus that can be very tiny or as large as a cantaloupe. Between 20% and 40% of women over 35 years have fibroids with African American women at higher risk. Women may be symptom free or experience abnormal menstrual bleeding, pain and/or pressure. Hysterectomy may be recommended to remove uterine fibroids to:

• Relieve chronic pelvic pain.
• Correct anemia from prolonged, heavy, and irregular vaginal bleeding.
• Prevent regrowth of fibroids. Approximately 15% to 30% of fibroids grow back within 10 years of their surgical removal (myomectomy).
• May correct leakage of urine (urinary incontinence).

Hysterectomy for treatment of uterine prolapse

Uterine prolapse is a progressive condition caused by weakness in the muscles and ligaments of the pelvic floor that results in the uterus descending into and sometimes outside the vagina. Uterine prolapse commonly occurs along with other types of pelvic organ prolapse.

Hysterectomy may relieve some but not all of the problems caused by uterine prolapse. Pelvic pain, low back pain, or pain with intercourse (dyspareunia) may persist after surgery. In some cases, symptoms may return following surgery. The success rate is lower if there has been prior pelvic surgery or radiation therapy to the pelvis.

Depending on severity of the condition, there are other surgical and non-surgical options. If hysterectomy is chosen, vaginal hysterectomy is generally the best approach for treating uterine prolapse.

Hysterectomy for treatment of endometriosis

Endometriosis is a condition that occurs when endometrial cells develop outside of their normal location inside the uterus. These cells respond to the menstrual cycle in the same way as those lining the uterus. The resulting internal bleeding can lead to chronic inflammation and the formation of adhesions and scar tissue. Symptoms of endometriosis stop when menopause occurs, however, if hormones are supplemented problems can continue.

Hysterectomy may be considered as surgical treatment for endometriosis when:

• Symptoms are decreasing the quality of life.
• The function of abdominal organs, such as the bladder or bowels, is impaired because of scar tissue.
• An ovarian cyst is present.
• Treatment with medication has failed to relieve pelvic pain or other symptoms.
• Childbearing is completed and the woman does not wish to try treatment with medications to control her symptoms.
• Endometriosis symptoms outweigh the risks and discomforts of surgery.

Hysterectomy for treatment of adenomyosis

Adenomyosis is a disease that occurs when the cells that normally line the uterus grow into the muscular tissue of the uterine wall. It occurs most frequently in women over age 30 who have had a full-term pregnancy and is rare in women who have not had a full-term pregnancy. Though most women do not experience symptoms related to this condition, a hysterectomy may be recommended if adenomysosis is discovered in a younger woman with severe symptoms including prolonged periods, painful menstruation, or increasingly intense cramping.

Hysterectomy for treatment of chronic pelvic pain

Chronic pelvic pain may be a steady pain or a pain that comes and goes, which may be associated with a woman's menstrual cycle and/or serious enough to interfere with normal daily activities. Pelvic pain that has lasted for at least 6 months is considered chronic. According to the American College of Obstetricians and Gynecologists, hysterectomy is indicated as a treatment of chronic pelvic pain only when a documented disease or surgically correctable condition of the pelvic organs is present. When hysterectomy is performed solely for relief of pelvic pain, the results may be disappointing.2

References

1. Speroff L, et al. (1999). Dysfunctional uterine bleeding. In Clinical Gynecologic Endocrinology and Infertility, 6th ed., pp. 574?594. Philadelphia: Lippincott Williams and Wilkins
2. American College of Obstetricians and Gynecologists (1996). Chronic pelvic pain. ACOG Technical Bulletin, no. 223, pp. 1?9. Washington, DC: American College of Obstetricians and Gynecologists.