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Saving the Uterus

With advances in diagnosis and management of various gynaecological disorders, many options have been unlocked for women that can save their uterus. Sonal Shukla explores

An increasing number of women, as well as many physicians believe strongly that the uterus has many roles—not just that of an incubator for the baby. Yet, world over, hysterectomy (removal of the uterus) is the second most common surgery in women, only next to caesarian section delivery.

The most common reasons for doing hysterectomy in a woman are fibroids of uterus, heavy periods, prolapse of uterus, ovarian tumours and cancers of genital organs. In the US more than half million women undergo hysterectomy each year and it is estimated that by the age of 65 one third of women will have had their uterus surgically removed. In Australia, the incidence is 4.8 per 1,000 women. In UK one in five women after the age of 60 will have hysterectomy. In India, only extrapolated figures are available which is 23,10,263 out of 1,06,50,70,607, according to international database 2004. It is believed that in developed countries, with the availability of alternative treatments, the rate of hysterectomy is decreasing.

"In India, the incidence seems to remain same or is increasing because of misuse of the procedure," opines Dr Vimal Grover, Senior Consultant Obstetrics and Gynaecology, Fortis La Femme. Despite awareness and informed education, the pace with which hysterectomy is being conducted in Indian hospitals remains the same over the last two decades, believes Dr Duru Shah, Medical Director, GynaecWorld, Mumbai and Former President, FOGSI. However, with the advances in diagnosis and management of various gynaecological disorders, many options have been unlocked for women which can save their uterus.

Learning the Boundaries

There are several conditions for which hysterectomy is advisable or medically necessary. These include ovarian, uterine, or cervical cancer; uncontrollable bleeding; severe endometriosis or adenomyosis; and complex hyperplasia, to name a few. "Any surgical procedure should be performed only if there is a valid reason to it. In conditions like malignancies, hysterectomy is definitely recommended. In benign conditions, if the patient's condition demands it, it must be done. Surgical options should be considered only if absolutely essential or if medical therapy has failed," shares Dr Gayathri Karthik, Consultant in Department of OBG, Manipal Hospital, Bangaluru.

A large percentage of hysterectomies are performed to relieve fibroids, endometriosis or other conditions related to hormonal imbalance. According to Dr Kamini Rao, Medical Director, Bangaluru Assisted Conception Centre, hysterectomy in these cases may be avoidable, but women are often unaware that there are alternatives. "Many women in this second group find sufficient relief from their symptoms once their hormonal balance is restored through a programme of natural support. This approach is an especially good alternative for women with fibroids, as fibroids often subside after menopause anyway," shares Dr Rao.

Hysterectomy may be followed by negative consequences, which may significantly impact the quality of a woman's life. Dr Shah says, "It has been scientifically shown that women who undergo hysterectomy at a young age, reach menopause a few years earlier than those who have their uterus intact." This is because during hysterectomy, the blood supply to the ovaries does get marginally disturbed. And if the ovaries are removed along with the uterus in a younger woman, it causes an even greater harm. Her normal hormone levels change drastically when ovaries are removed causing premature menopause and its implications. "It's also important to weigh the long-term consequences of a hysterectomy. There are emotional aspects to hysterectomy that affect both your initial decision and your experience following surgery," opines Dr Anuradha Kapur, Max Healthcare, Delhi.

The loss of hormonal balance can create myriad symptoms, including premature ageing, weight gain, vaginal dryness, and so on. There are also other complications, including heightened incidence of urinary incontinence. "It has been shown that hysterectomy (even without oophorectomy) during a woman's reproductive years, increases the risk (triples the risk according to some studies) of heart attack during the remaining reproductive years. If the ovaries are removed as well, the risk of developing heart disease and osteoporosis is further increased," states Dr Shakti Bhan Khanna, Senior Consultant and Clinical Coordinator, Department of OBG and Gynae Onco-surgeon, Indraprastha Apollo Hospital, New Delhi. Many women who enter menopause as a result of hysterectomy face years of hormone replacement therapy (HRT) to restore their hormonal balance.

Informed Decision

Experts today suggest avoiding hysterectomy, unless absolutely necessary. "I would certainly recommend avoiding hysterectomy without proper indications. Alternatives to hysterectomy should always be explored before subjecting the patient to hysterectomy. In the absence of an organic cause for excessive uterine bleeding, it is preferable to use medical methods instead of surgical methods, especially if the woman desires to retain her uterus," says Dr Grover.

The decision to have a hysterectomy should not be taken lightly. There are medical conditions that require treatment for example cancer, prolonged heavy bleeding to the point of severe anaemia, or incapacitating pain. "As with most decisions, you should carefully consider the pros and cons of hysterectomy as they relate to your particular medical situation and emotional well-being," avers Dr Ashwini Bhalerao Gandhi, Consultant Gynecologist, PD Hinduja Hospital, Mumbai. In most cases, hysterectomy also includes oophorectomy or ovarian removal. By the age 60, at least 33 per cent of women have already undergone hysterectomy. Amazingly, 90 per cent of these surgeries are classified as 'elective' surgery or surgery performed by choice and not as a life-saving procedure. Dr Khanna points out that before choosing hysterectomy one should carefully explore hysterectomy alternatives which are available so that an informed decision about what is best for the patient can be taken. Many times, conditions for which hysterectomy is suggested may be successfully treated with alternatives to hysterectomy that include less invasive surgeries, pharmacological treatments, and observation.

At present, there are various surgical and non surgical techniques available which can be used as an alternative to avoid hysterectomy. "Today, when a woman bleeds heavily during her periods there are many other procedures and medications that help. It is possible to carry out a minimally invasive surgery, which is associated with less pain, quicker recovery and treatment of the problem without removing the uterus," shares Dr Shah.

Alternate Therapies

"Despite awareness, the pace with which hysterectomy is conducted remains same over last two decades" - Dr Duru Shah Medical Director GynaecWorld Mumbai

"In India, the incidence of hysterectomy seems to remain same or is increasing because of misuse of the procedure" - Dr Vimal Grover Senior Consultant Obstetrics & Gynaecology Fortis La Femme.

"One needs to consider the pros and cons of hysterectomy as they relate to ones medical situation and emotional well-being" - Dr Ashwini Bhalerao-Gandhi Consultant Gynecologist P D Hinduja Hospital Mumbai

Uterine Balloon Therapy: A new development and technique, called Uterine Balloon Therapy (UBT), is invented solely to prevent hysterectomies in women who suffer from unmanageable periods and who no longer desire fertility. "For a woman who presents with heavy, prolonged, and/or too frequent periods, possibly anaemic and for whom hormonal therapy has failed, we may be compelled of either offering her surgery or nothing at all. But UBT makes it possible to avoid a hysterectomy," says Dr Khanna.

This is a simple procedure by which the inner lining of the uterus is compressed and thinned out with a special balloon inserted inside the uterus for a period of eight minutes. The balloon is connected to special equipment which helps to raise the pressure and temperature of the water in the balloon. With this heat and pressure, the inner lining (endometrium) is partially destroyed which leads to reduced bleeding later. The advantage of this procedure is that there is no blood loss, no pain, it is over in 10-15 minutes, does not involve hospital stay, and helps to save the uterus of about 95 per cent women in whom the uterus is otherwise normal.

Myomectomy: Sometimes a fibroid, even though small, sits in the cavity of the uterus and causes extreme pain and bleeding, or multiple fibroids may sit within a uterus and cause the problem. The uterus can be saved by just removing the fibroid in the cavity through a telescope (hysteroscop) inserted in the uterus through the vagina, or the multiple fibroids in the muscle of the uterus could be removed through the telescope (laparoscope) inserted through the navel. These procedures are carried out only in those women who wish to save their uteri. "It is advisable for patients who wish to become pregnant in future. Hysterectomy rather than myomectomy should be done in elderly patients, as the incidence of recurrence of fibroids is very high," shares Dr Kansal.

Transcervical Resection of Endometrium (TCRE): Here, a resectoscope is introduced through the cervix into the uterus and under visualisation, the endometrial lining is shaved off in strips, 7 mm wide and 3-4 mm thick. Hospital stay is shorter, pain lesser and recovery faster than surgery. However, treatment may not be permanent as bleeding may occur again, though lighter than before. Patient selection and counselling to have realistic expectation is necessary. Dr Dinesh Kansal, Head of Department and Senior consultant, Department of Gynecology, Dr B L Kapur Memorial Hospital, says, "TCRE is a highly skilled hysteroscopic procedure, but involves a risk of fluid overload and results are again unpredictable." The advantage of TCRE is that, the endometrial tissue can be sent for pathological examination, while the disadvantages include chances of recurrence of bleeding as endometrium can regrow, they cannot be pregnant and menses will stop. This is also far more expensive than others."

Laparoscopic/hysteroscopic myomectomy: It is recommended in patients with fibroid polyps or submucous fibroids of less than 4 cms and especially in women who have completed their families. Here, the fibroids are removed through a laparoscope. The postoperative pain is lesser and recovery faster. It is ideal for patients with single or few fibroids, subserous and intramural fibroids.

Hysteroscopic Polypectomy: Hysteroscopy is a procedure where a thin tube with a camera (hysteroscope) is passed inside the uterus to look inside the cavity. A polyp is a growth in the uterus that might become malignant. Hence removal of polyp via hysteroscope is hysteroscopic polypectomy.

This is a short daycare procedure, quick and easy recovery is possible thereby avoiding hospitalisation, discomfort and expense of major surgery. The cons are hysteroscopy-associated complications, anaesthesia risk, perforation and infection.

Mirena (Hormone loaded Intrauterine device): A small plastic device is placed in the womb (uterus) to prevent pregnancy which contains hormones in a very low dose which causes decrease in the size of endometrium (lining of uterine cavity) and hence decreases the bleeding. "Mirena is a revolutionary device which has drastically reduced the incidence of hysterectomies done for heavy periods. Though there is slight irregularity of menstrual cycle in initial months, it is usually well tolerated by patients," says Dr Kansal. The pros for this procedure are amenorrhoea in 99 per cent of patients, contraception, decreases size of fibroid and treats anaemia as it decreases bleeding. However it needs to be changed as its lifetime is of five years only, is expensive and the woman can suffer initial irregular menses, leading to spotting.

Agonadotropin-releasing hormone agonist (GnRH agonist): These are medications that will temporarily shrink fibroids by about 30 per cent as they temporarily stop oestrogen production. Most fibroids are stimulated to grow by oestrogen, and without it, fibroids usually shrink. They act by causing a sort of medical menopause and hence decrease bleeding also. But once the effect of agonist is over, which may vary depending on the dose given, the fibroids grow back to their original size. Thus, this treatment is temporary and is used in women approaching menopause, or who are not fit for surgery.

The pros for this procedure are that it decreases size of fibroids, hence allowing laparoscopic/ hysteroscopic myomectomy and decreases bleeding, hence treating anaemia. The cons for this procedure are loss of bone density (osteoporosis), hot flashes and mood swings. Besides being expensive, the FDA has approved its use only for three months, recurrence is common and many patients require hysterectomy at a later date.

Uterine Artery Embolisation: UAE is a radiological procedure recently introduced as an alternative treatment for symptomatic uterine fibroids. The American College of Obstetrics and Gynaecology cautions about its potential for infection and other serious complications requiring emergency surgery. The radiologist introduces a catheter, usually through the right femoral artery, into each of the two uterine arteries, which supply blood to the uterus and, in turn, to the fibroids. A solution containing small particles is injected into the uterine arteries. The particles occlude the branches of the uterine arteries (blood outflow), and thereby, drastically reduce blood supply to the uterus and the fibroids. The procedure is usually done under conscious sedation and local anaesthesia, without general anaesthesia. According to Dr Bhalerao, six months after UAE the average fibroid is reduced in size by 40-60 per cent. Reportedly, UAE reduces uterine bleeding and symptoms related to uterine size such as urinary frequency and pelvic pain. Recent studies found that 22 per cent of patients undergoing UAE required hysterectomy or myomectomy. Additional patients required hysteroscopy. The reasons for the hysterectomy were continued heavy bleeding, pain and bulk related symptoms. Hysteroscopy was required because of vaginal discharge and many of those patients ended up needing hysterectomy.

MRI Guided Focussed Ultrasound: Relatively new, this is a non invasive technique useful for targeting single fibroids. Under MRI guidance, high intensity ultrasound waves are focused on the centre of the fibroid and the heat generated destroys the fibroid. The size of the fibroid has been shown to reduce modestly (about 13 per cent), but symptomatic relief was reported in close to 80 per cent of patients. The pain associated with treatment procedure will necessitate pain killers. "The procedure may cause skin burns at the treatment site and possibly some damage to adjacent tissues such as nerves. The procedure is still in its early stages of evaluation and long-term results and complications are unknown," shares Dr Bhalerao.

sonal.shukla@expressindia.com