Hysterectomy and Alternatives in 2010
Every year, over 400,000 American women have surgery to remove part or all of the uterus. We say that these are hysterectomy-related surgeries. Sometimes, a related procedure will be done at the same time, such as removing one or both ovaries, or some type of pelvic repair. Unfortunately, there is much confusion when discussing gyn surgery, so we like to be specific about what procedure is actually being discussed in any scenario. A hysterectomy in one woman may be completely different than a similar sounding procedure in another woman.
The least invasive and simplest hysterectomy-type procedure is the LASH or LSH. A laparoscope is used with other small instruments through tiny incisions to remove only the abnormal part of the uterus. Patients are 85% recovered in 10-14 days and can resume normal activities. It is not actually a hysterectomy because only a portion of the uterus is removed. The ovaries are left in place and although no more periods or pregnancies occur, this does not create menopause and most women describe less hormonal difficulties or PMS.
A TLH or total laparoscopic hysterectomy is when the whole uterus is removed with laparoscopic technique. Recovery takes 1-2 weeks longer because there is an incision in the vagina that has to heal. LAVH or laparoscopic-assisted vaginal hysterectomy is similar, but part of the surgery is done vaginally. A TLH or LAVH is usually preferred over LASH if there is disease in the cervix or pelvic pain as a major factor.
For the last 3 years, we have added a new option to many gyn surgeries. This new technology is robotic assistance, where we use laparoscopic techniques and also the daVinci robot. The high tech instruments and increased optics and magnification with daVinci are a benefit for many women having laparoscopic procedures and we have had excellent results with our patients.
Sometimes, these surgeries are done without laparoscopy, through an open incision (TAH) or vaginally (TVH). An abdominal approach is often chosen when cancer is present or very large masses. Recovery is longer and risks are higher. A vaginal approach is often used when the primary problem is prolapse or pelvic support problems.
Unless specifically added to the plan, the ovaries are left in place as with LASH for any hysterectomy. This is a very important point since the ovaries are separate organs and treated individually for every patient. The only reason to remove both ovaries during a hysterectomy, is if there is a specific problem with both ovaries, or advanced menopause or a special risk of ovarian cancer. In fact, there is an estimated 50% risk reduction in ovarian cancer with LASH or hysterectomy when the ovaries are left in place.
When excess bleeding is the main problem, there are other alternatives to hysterectomy-type procedures. There are hormonal treatments, a special IUD device and ablation or heat treatment to the uterine lining. When fibroids are the main problem, the treatment can be directed at only the fibroids, with embolization, ultrasound, or myomectomy (fibroid removal- usually with laparoscopy). When bladder leakage, prolapse or pelvic support is the main problem, then repair can be done with or without hysterectomy.
All women have to go through the process of menopause, which most commonly occurs when the ovaries either stop reproductive function (natural menopause) or are both removed (surgical menopause). With simple LASH or hysterectomy, periods stop but menopause occurs naturally, usually around age 45-55, which is best for most women. Of course women often have surgery after menopause has already occurred, but we know that the ovaries still produce low levels of hormones well into menopause. For this reason, it may be beneficial to preserve the ovaries unless menopause is advanced.
Obviously, when gyn problems are significantly affecting a women’s lifestyle, the treatment options are complex, and there are best alternatives for each individual.
Westcoast Woman
Article
3-30-10
