Uterus removal: Alternative treatment modalities to save uterus
Removal of uterus brings with it drastic changes in the physical and emotional, as well as reproductive well being of a woman
India is witnessing an increase in the number of women, especially young women, undergoing a hysterectomy, which refers to the removal of the uterus. Experts have raised concerns regarding this rising number, wherein more than 22,000 Indian women between 15-49 years of age out of 700,000 surveyed had undergone hysterectomy (reports from 2018). The median age of undergoing the procedure has been estimated to be 34 years, which may be associated with early onset of menopause as well as concerns regarding conception/pregnancy. More concerning is the fact that this trend is being observed globally. Surprisingly, there have also been reports from the medical community that call this procedure avoidable or unnecessary when alternatives are available.
In this article, let us look into the need for hysterectomy for the commonly indicated conditions and the possible minimally-invasive or non-surgical alternative therapeutic modalities.
Hysterectomy may be indicated in cases such as excessive menstrual bleeding, chronic pelvic pain or Endometriosis, uterine tumors (fibroids), or cancers of the female reproductive system (uterine, ovarian, cervical, fallopian tubes). Hysterectomy may be combined with the removal of ovaries (oophorectomy), or cervix and fallopian tube (salpingectomy) or removal of all the above-mentioned structures (total hysterectomy with bilateral salpingo-oophorectomy). Such procedures need to be discussed clearly with the healthcare provider as the surgery has long-term effects on the overall health, genito-urinary and sexual health, longevity, and reproductive ability of the woman. Regardless of age, the procedure will result in early menopause, thereby impacting fertility and the ability to bear children. Secondary effects such as reduced bone density, behavioral/emotional changes may also occur due to hormonal imbalance following the procedure.
The above reasons do not mean that hysterectomies should be avoided. The absolute indications for the procedure are invasive cancer of the reproductive system including the uterus, cervix, ovaries, fallopian tubes, vagina; severe infection (e.g. pelvic inflammatory disease) that does not respond to treatment; severe and uncontrollable uterine bleeding due to adenomyosis; serious complications during childbirth such as a ruptured uterus, prolapse of the uterus etc.
Alternatives to the treatment of conditions where hysterectomy may be indicated
Uterine fibroids are the most common condition for which hysterectomy is advised. Fibroids are benign tumors that oftentimes do not present with symptoms. In fact, these tumors may grow from an early fertile age and persist until menopause, following which they undergo spontaneous regression, due to depletion of sexual hormones. Thus, surgical treatment may be avoided and a wait-and-watch approach may be adopted. Cases of symptomatic uterine fibroids may be treated alternatively in a minimally invasive manner by myomectomy, Hi -Frequency ultrasound ablation, uterine artery embolization, etc. Myomectomy refers to the removal of the fibroids alone. Uterine artery embolization involves the injection of small particles into the uterine arteries feeding the fibroids, cutting off their blood supply. The success rates for these procedures are comparable to that of hysterectomy and are associated with lower rates of complications. Hormonal therapy using gonadotropin-releasing hormone (GnRH) agonists, oral contraceptives, etc. may also be indicated.
This condition refers to the growth of the uterine lining (endometrium) in other organs, commonly the ovaries, fallopian tubes, bowels, outer walls of the uterus, and rarely in the kidney, bladder or lungs. The chief issue faced by women with this condition is difficulty in conceiving. Symptoms include pelvic or abdominal pain or pressure along with the heavy menstrual flow. Spotting or bleeding may also occur between periods. Over time this condition causes scar tissue to form in the affected organs, and when the reproductive system is involved, leads to infertility.
Alternative surgical interventions for the treatment of endometriosis include excision/ablation of the endometrium, resection of the obliteration caused by scar tissue. Laparotomy may be indicated in cases where the minimally-invasive ablative approach does not remove all the growth/scar tissue. Although this procedure is more invasive and requires a longer recovery period, it is less invasive than hysterectomy and aids in retaining fertility.
As with fibroids, hormonal therapy may be indicated in these cases as well. Non-steroidal anti-inflammatory medications may be indicated to manage pain. Alternative modalities of acupuncture, biofeedback have also been reported for the management of symptoms of endometriosis with variable results.
In this condition, the muscles and ligaments in the pelvis become weak due to which the uterus may slip down into or beyond the vagina. There is constant debate among gynecologists regarding the removal of a falling uterus. Some gynecologists suggest that repair of the weakened ligaments and muscles that hold the uterus is sufficient along with physiotherapy rehabilitation (pelvic floor strengthening). This may be accomplished by laparoscopy (called laparoscopic Sacro-hysteropexy), wherein the weakened tissues can be sutured to the stronger ligaments. A vaginal approach of the procedure, termed vaginal uterosacral hysteropexy, may also be performed as a uterus preserving procedure, which leaves no abdominal scars.
Non-surgical management may include use of vaginal pessary- a removable ring-shaped rubber device placed into the vagina to support areas of prolapsed tissue. Several kinds of pessaries are available, the best for your condition will be decided by your doctor. While pessaries do not cure the prolapse, symptoms can be relieved partially or completely. They may be helpful in pregnancy by holding the uterus in place before it enlarges and invades the vaginal canal.
Abnormal Uterine Bleeding
Dilation and Curettage (D & C), which refers to dilation of the cervix and removal of tissue from inside the uterus by scraping or scooping may be indicated in cases of heavy bleeding. Endometrial ablation may also be an alternative approach along with pharmacological agents such as prostaglandin inhibitors, oral contraceptives, GnRH agonists, anti-fibrinolytic agents, etc. LNG-IUS, or commonly called Mirena, can be placed in the uterus after the D&C. It is a hormonal delivery device which will prevent endometrial proliferation and thereby reduce the monthly bleeding. Excellent results in excessive bleeding.
Chronic Pelvic Pain
Long-term pain in the pelvis may occur due to any of the above-mentioned conditions or pelvic inflammatory disease, adhesive disease, inflammatory bowel disease, etc. Identification of the proper cause of the condition is mandatory in planning the appropriate treatment. Adhesiolysis, which means the removal of adhesions are removed in order to restore organ blockade and function may be considered. Similarly, nerve blocks, denervation procedures, uterosacral ablation may be indicated to relieve the symptoms of chronic pelvic pain. Trigger point injection of pain medications, acupuncture, physical therapy has also been tried to address the symptoms with varying results.
Removal of uterus brings with it drastic changes in the physical and emotional, as well as reproductive well being of a woman. It is therefore important to make an informed choice after a thorough discussion of the effectiveness of each therapeutic modality indicated for the condition.
Article Dr. Anu Vinod Vij, Obstetrics & Gynecology, Motherhood Hospital, Kharghar
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