Alternatives to Hysterectomy

A recent article appeared in the prestigious journal “Clinical Obstetrics and Gynecology” puts the spotlight onhysterectomy Hysterectomy (the removal of the uterus). This is a surgery that, although has seen a significant reduction in incidence, is still one of the most common gynecological interventions.

Surgery of the uterus can be performed via abdomen or vagina: we talk of Hysterectomy when Uterus is removed completely and subtotal Hysterectomy when Cervix is left with its connections to Vagina.

Removal of the uterus has been associated with important psychological, sexological and urinary disorders and with genital prolapse.

The most frequent Hysterectomy indications are:

  • Symptomatic uterine fibromatosis (uterine fibroids associated with pelvic pain and heavy menstrual bleeding);
  • Cervix or uterine cancers;
  • Ovary and Fallopian Tubes tumors;
  • Recurrent serious Endometriosis refractory to medical treatment;
  • Serious Anemia from uncontrollable uterine bleeding (medical therapy, endometrial ablation, embolization);
  • Sometimes, particular conditions of prolapse associated with longitudinal hypertrophy of cervix.

In fact, there are now a lot of alternatives to avoid Hysterectomy and this surgery is increasingly considered as a “last resort” when other approaches have failed or are impossible.

Even today, one of the most important signs is certainly Uterine Fibromatosis. Alternatives to consider before arriving at the operating theater are already more. For Fibromatosis, in addition to medical therapy that aims primarily to control symptoms such as irregular bleeding and pelvic pain, more frequent and widely validated are conservative interventions such as ultrasound focused systems and embolization. The same surgery, when necessary, is very often limited to Myomectomy, that is the removal of localized lesions of leyomioma.

Even for Endometriosis and pelvic pain medical treatment allowing wide margins of success and it is seen that an aggressive attitude toward small lesions is no longer justified, if asymptomatic. The introduction on the market of progestins particularly active on endometrial tissue and on pain has led to a very important turning point in therapeutic strategies and it is seen that Hysterectomy is not always conclusive.

Irregular bleeding, abundant menstruation (menorrhagia and metrorrhagia) that very often lead to anemia, already found good solutions in commercially available medications and use of Medicated Intrauterine Devices (IUDs with progesterone) was another important contribution, among very useful other when metabolic and cardiovascular conditions systemically prevent use of hormones. Also, evolution of some pills, and particularly the progestin component of some of them, has considerably reduce abundant menstrual flows.

Polypoid formations and submucosal endouterin leiomyomas are easily removed with minimally invasive interventions of operative hysteroscopy which allow even the complete ablation of the endometrium.

In conclusion I would like to point out that:

  • There is no age in which the uterus can be sacrificed, excised without a proper reason; reasons of pelvic statics, sexological, psychological, spraying in the ovaries do indeed suggest the usefulness of conservation at any age;
  • Recourse to Hysterectomy should always be carefully evaluated, especially when is not tied to oncological needs. The surgical conservative alternatives, new medications (administered vaginally and intrauterine) and the widely tested embolization techniques and focused ultrasound system, can be considered to more and more women of all ages.

 

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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