/ 8 April 2011

Hysterectomies: More options than ever

Uterine fibroids or benign growths on the uterus, menorraghia or an abnormally heavy and prolonged menstrual period, pre-cancerous conditions of the cervix, endometriosis and certain types of reproductive system cancers — these are a few of the most common reasons why, after all other treatment options have been explored and excluded, a hysterectomy will be considered.

It’s one of the most common surgical procedures performed on women in the Western world. On average, one in three women in the United States will have the procedure before they reach the age of 60. In the United Kingdom, the figure is one in five women. But figures for South Africa are scant.

Being irreversible, it is not a procedure that is approached lightly. For psychological and physiological reasons, it can be a daunting prospect for any woman. A hysterectomy means the removal of the uterus or womb although it is common for other organs, such as the cervix, fallopian tubes and ovaries, also to be removed during the same procedure. Removing the ovaries also has long-term implications, including hormone replacement therapy (HRT), and requires pre-surgery discussion.

Several types of hysterectomies are performed regularly. A radical hysterectomy means the removal of the uterus, cervix, upper vagina and the parametrium. This is usually performed to treat cancers. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situation.

A total hysterectomy means the removal of the uterus and cervix, and a subtotal hysterectomy refers to the removal of the uterus, leaving the cervix in place. Along with the great strides achieved in medicine over the past 50 years, surgical techniques have also evolved and this has led to several options for gynaecologists and their patients to consider.

Abdominal hysterectomy
The most common form is an abdominal hysterectomy, during which the incision is made in the abdominal wall and the uterus is extracted through the incision. For a vaginal hysterectomy, the incision is made at the top of the vagina, and the uterus is removed through the vagina. Laparoscopic or keyhole surgery allows the surgical team to view the procedure through a video camera.

As you would expect, there are pros and cons to each technique. An abdominal hysterectomy is preferred by many gynaecologists as it gives them more options to explore the abdominal cavity. However, this requires four to six weeks’ recovery time for the patient.

Because a vaginal hysterectomy usually means fewer complications, a shorter hospital stay and much quicker recovery, it is preferred by many and this is backed by solid research. It is the first choice if performed by a trained vaginal surgeon.

Obviously, the least invasive procedures are the laparoscopic techniques, but there are not as many South African gynaecologists experienced in these newer methods as there are in other countries.

But the rate of hysterectomies being performed is on the decline in the Western world, especially in the UK, because of the introduction of new alternative procedures. For instance, endometrial ablation, a procedure performed through the vagina to remove the lining of the uterus, is less invasive than more commonly used techniques.

Also, other remedies are coming to the fore. A new procedure for menorrhagia can be done in a day with minimal disruption to the patient and recovery is fast. And new drugs have been developed for the treatment of endometriosis, which have proven effective enough to avoid surgery altogether.

Alternative surgical treatments, alternative remedies that avoid surgery — the best advice is to find a gynaecologist you trust and respect and discuss all the options with him or her. In particular, inquire about the doctor’s experience and expertise regarding new techniques. As the old cliché goes: forewarned is forearmed.

Hysterectomies will be the topic of Bonitas House Call on SABC2 on April 16 at 9am