Should You Really Get a Hysterectomy? An Ob/Gyn Explains When to Consider Alternatives
Sometimes it's the best solution for fibroids, pain, or other gyno problems, but often there are other solutions that will work.
By Lauren Streicher, MD
HRAUN
After years of putting up with monthly flood-like periods, you've consulted with your doctor, who has advised you that the time has come to get rid of the source of the bleeding and proceed with a hysterectomy. Before you check your calendar to schedule surgery, you may want to consider whether removing your uterus is your only, and best, option.
Roughly half a million hysterectomies are performed every year. While approximately one-third of American women—most between the ages of 40 and 44—will eventually lose their uteruses, Black women are consistently the most likely to have a hysterectomy. One logical explanation is that Black women are at the highest risk for developing fibroid tumors, by far the most common reason for the surgery. (This racial disparity isn't seen after age 50, when fibroids are rarely an issue.)
That said, one factor in the disproportionate number of young Black women under­going hysterectomy is that many Black women live in areas where alternatives to the surgery are not offered, and they're less likely to be informed that they have other options. One study revealed that 38% of women (of all races) were never even offered an alternative, despite the availability of other safe, effective treatments that can be considered before proceeding with surgery.
Ultimately, what empowers women is the ability to make a good choice—whether it's surgery or not—based on accurate, balanced, and scientific information. As an ob/gyn who wrote a book called The Essential Guide to Hysterectomy, I'll help you understand the issue.
What are the most common reasons for a hysterectomy?
Five major categories send someone down the road to this surgery. After fibroid tumors, abnormal bleeding is the most common diagnosis. Pelvic pain, often from endometriosis, is next on the list, followed by pelvic organ prolapse such as a dropped uterus, bladder, or rectum. Last (and responsible for the smallest number of hysterectomies) is a gynecologic cancer.
Are there hysterectomy alternatives?
Other than cancer, virtually every one of these diagnoses has many alternative treatments, which in some but not all cases will eliminate the need for removal of the uterus. For example, many fibroids can be shrunk with fibroid embolization, or removed (myomectomy) while leaving the uterus in place. Heavy bleeding can often be reduced with medication, endometrial ablation, or placement of a progestin IUD. Endometriosis can be suppressed using a number of different medications, and the associated pain can be reduced with pelvic floor physical therapy (a treatment that can also sometimes be used for pelvic organ prolapse).
The Scoop on Sex After a Hysterectomy
Women who do go ahead with a hysterectomy are often not offered a minimally invasive procedure (vaginal, laparoscopic, or robotic) as opposed to removal of the uterus through a traditional abdominal incision. This is particularly true for Black women, who are half as likely as white women to undergo a minimally invasive hysterectomy, meaning they end up with not only a longer recovery time, but also increased risk of surgical complications.
When is hysterectomy the best option?
Still, it's important to emphasize that many hysterectomies are appropriate and beneficial. Defining "unnecessary hysterectomy" is actually somewhat subjective. Some would say that the only women who need a hysterectomy are those who risk death if they forgo the procedure. Using that criterion, only around 10% of women who end up with a hysterectomy needed it. However, if one considers "need" more broadly, quality of life should also be taken into account. That means that even if a hysterectomy is not lifesaving,
it may still be a woman's best option.
Every woman who faces this issue should be provided with unbiased, scientific information.
Some women are willing to put up with a lot to avoid losing their uteruses (fertility being one reason) and are willing to have frequent visits to the gynecologist, ultrasounds, endometrial biopsies, and alternative therapies. Other women are done—done with the bleeding, the pain (say, from endometriosis), the feeling that they're single-handedly supporting the tampon and pad industry and planning their lives around their periods. It is an injustice to women to insist that they undergo multiple less effective treatments rather than one definitive treatment that will provide a permanent cure if the latter is what they feel is in their own best interest.
I ran a national poll of women who'd had a hysterectomy and found that the overwhelming majority (86%) were pleased with the result; many commented that they wished they had done it sooner. The key is that they decided hysterectomy was the best option after weighing all alternatives. Women who regretted the decision tended to be younger and specifically stated that they hadn't been offered any other option.
Even after a woman decides hysterectomy is her best option, her decisions are just beginning. Laparoscopic? Robotic? Vaginal? Save the cervix? Remove the cervix? Keep the ovaries? Lose the ovaries?
Ideally, every woman who faces this issue should be provided with information in an unbiased, objective, scientific way so she can make appropriate decisions based on her needs and desires. That way, women looking for alternatives won't feel they are being sold a procedure they're trying to avoid, and those who desire a hysterectomy will know what to expect.
This article ran in the November 2020 issue of Prevention.
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