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Hysterectomy - Is this the only option?

Dr. Ranjit Chakraborti

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Hysterectomy comes from the Greek word Hystera, meaning womb. It is the surgical removal of the uterus.

Right now, Hysterectomy is the second most common major surgery after caesarean section in India, 65% of these are due to heavy and irregular bleeding problems.

Reasons: " Heavy menstrual bleeding or dysfunctional uterine bleeding " Uterine fibroids " Uterine prolapse " Endometriosis and adenomyosis " Chronic pelvic pain " Cancer of the cervix, uterus or ovaries.

Alternative Options

Dysfunctional Uterine Bleeding (DUB) / Menorrhagia It is considered as menstrual loss of 80ml per month. Medical Management Done with Ethanyslate & Mefanemic Acid, which control bleeding. It can be used only during 3-5 days of the menstruation. First line of treatments are Tranexamic Acid and Non-steroidal anti inflammatory drugs. Hormonal Management Done with either Progesterone or combination of Pregesterone & Estrogen (Oral contraceptive pill). Intra Uterine Hormone Management These are levonorgestrel hormone releasing devices which lasts for 5 years, releases progesterone in localized manner on daily basis. It reduces bleeding in 75% of the cases. Surgical Management Hysteroscopic Endometrial Resection, meaning stripping of the line of the uterus. It is done using an electrosurgical wire loop. Thermal Ablation is used to destroy the lining of the uterus. It is done through hysteroscope using laser beam.

Fibroids Medical Management This is done by using GnRH analogues in case of women in child bearing ages and Danazole. Surgical Management The options are: Myomectomy-Abdominal open, Laprascopic, Hysteroscopic and Vaginal. The fibroids are cut into small pieces by morcellating devices. The uterus is preserved so that the woman can maintain her ability to bear children. Embolization-This is a minimally invasive procedure by which the arteries that supply blood to the fibroids are blocked. It involves minimal blood loss, no stitches or surgical incision, no abdominal scar and no prolonged hospitalization. Myolysis- This means shrinking the fibroids using electric current. Endometriosis Medical Management This includes GnRH analogues, Oral Contraceptive Pills and Progestins. Progestins such as medroxyprogesterone acetate, are more potent than OCPs and are recommended for women who do not obtain pain relief from or cannot take OCPs. Surgical Management Conservative surgery is accomplished by laparoscopy. Endometrial implants are excised or removed by laser.

If the above medical or surgical options fail, then the woman can decide to opt for Hysterectomy in consultation with the doctor.

Hysterectomy is also used to treat uterine cancer or very severe pre-cancers called Dysplasia, Carcinoma in situ or microinvasive carcinoma of the cervix.

Hysterectomy could be done in such cases: " Where there is failure of medical management " Disease had advanced and remaining uncontrolled with contraceptive management " Where there is a risk of malignancy " Disease process causing other complications as bowel, bladder, uretoric obstruction / pressure symptoms.

Types of Hysterectomy:

Vaginal Hysterectomy This is performed through a small incision in the vagina. The procedure helps in the removal of small fibroids specially when endometrial growths are not present. But this is not used when there is a probability of cancer in the uterus and ovaries.

Abdominal Hysterectomy The procedure is done through larger abdominal incision. The cervix may be removed with the uterus based on the complication. Abdominal hysterectomy is done when the size of the uterus is very large, uterine fibroids are larger than 8 inches across or located around blood vessels, cancer of the ovaries, uterus or cervix is possible and there is severe scarring or severe endometriosis in the pelvic area.

Total Laparoscopic Hysterectomy (TLH) / Laparoscopically Assisted Vaginal Hysterectomy (LAVH) LAVH is done through several small incisions in the abdominal wall through which slender metal tubes known as trocars are inserted to provide passage for the laparoscope and other microsurgical tools. During the course of LAVH, the uterus is detached from the ligaments that attach it to other structures in the pelvis using the laparoscopic tools. If the fallopian tubes and ovaries are required to be removed, they are also detached from their ligaments and blood supply. LAVH is done when the fibroids are small to moderate in size, uterus is slightly larger than normal, removal of endometriosis and scar tissue in the form of adhesions confined to fallopian tubes and ovaries and removal of ovaries. This is a relatively new surgery which requires specialized skills not only on part of the surgical team but need to be backed by upgraded equipment and infrastructural support system in the operating theatre.

Advantages " Miniature abdominal incisions " Decreased post operative pain " Shortened post operative recovery " Fewer post operative infections " Fewer adhesions " Relatively shortened hospitalization " Access to advanced pelvic reconstruction procedures As we have discussed above both hysterectomy and the alternative options, it is important to remember that help would be required at home post any procedure. The woman may not be able to do heavy work for the first few weeks. She can do gentle exercise based on doctors advice. There could be some vaginal discharge for 3-4 weeks. The colour may be red or brown and is due to the healing of the wound and dissolving of the stitches. One should note that after having hysterectomy, the sexual life could be affected both emotionally and physically. One of the most common emotion that is seen is fear. Thinking about initiating sex after hysterectomy leaves many women apprehensive. But it is only noirmal to worry about pain. Once the doctor has advised, the women need not worry about such issues. But sexual activity could not be initiated at least 4-6 weeks after the surgery. It is very important to remember that hysterectomy does not lead to permanent loss of sex drive. It is always advisable that post hysterectomy, wife must talk to the husband about her mental and physicl state. Sharing this information will help the husband understand her emotional and physical needs. The husband plays a pivotal role in determining the success of the surgery. It is unfortunate that even today, most men (inlcuding women as well) dont understand the nature of female anatomy or the functional results of hysterectomy and harbour misconceptions regarding sexuality after the operation. If the man equates removal of the uterus with loss of libido or diminisghed feminity, he may inadvertently avoid sexual interaction with her. A hystrerctomy can be seen as a unifying experience, one that the couple face together, talking and listenimg to each others needs, communicating their feelings as they change day by day. With the right support network in place, there is no reason why a womans sexual function cannot improve following recuperation from the operation. We as doctors always try to assuage fears and doubts regarding both hysterectomy and its alternative options and provide a reasonable amount of factual information to the couple.



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