One-third of American women experience some type of pelvic health disorder by the time they're age 60. And about 600,000 women every year have a hysterectomy -- removing their uterus to relieve troubling symptoms. Overall, an estimated 20 million women have had a hysterectomy.
These tumors, usually benign, are generally found in the smooth muscles of the uterus, and can cause pelvic pain, infertility, and heavy menstrual bleeding. Uterine fibroids are a common reason why women have hysterectomies, accounting for between 177,000 and 366,000 of the annual total.
If your fibroids are causing no symptoms, it's entirely reasonable to adopt a strategy called "watchful waiting" -- monitoring their status with your doctor and not having any surgery unless problems develop. But if you are experiencing pain, discomfort, or pressure, there are several less-invasive options for treating fibroids:
- Myomectomy. This is the surgical removal of the fibroids alone. It can be done through an abdominal operation, laparoscopically (entering through the navel), or via hysteroscopy (inserting a thin, telescope-like instrument called a hysteroscope through the vagina). A laparoscopic or hysteroscopic approach is least invasive, and these are also less costly and require shorter recovery time. The da Vinci robotic myomectomy is another technique that offers precision and smaller incisions on open procedure. There is a small chance that what was thought to be a fibroid could instead be a cancer called uterine sarcoma. For this reason, the FDA recommends not cutting the fibroid into small sections before removing it, a process called laparoscopic morcellation.
- Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE). This is a fairly simple, noninvasive procedure in which small particles are injected into the uterine arteries feeding the fibroids, cutting off their blood supply. Unlike a hysterectomy, this procedure preserves the uterus and helps women potentially avoid surgery. It's been used for years to help stop hemorrhage after childbirth or surgery. Symptoms improve in 85% to 90% of patients, most of them significantly.
- Hysteroscopy. The insertion of a thin, telescope-like instrument through the vagina can be used if the fibroid is primarily within the cavity of the uterus. This is a minor surgical procedure with minimal recuperation time, but can only be offered to women who have fibroids within the lining of the uterine cavity.
- Medical management. Painful symptoms of uterine fibroids can be initially treated with nonsteroidal anti-inflammatory drugs (NSAIDs), like Motrin. If that isn't effective, another option is a class of drugs that blocks the ovaries' production of estrogen and other hormones. Their side effects can include symptoms of premature menopause and a decrease in bone density. This is done only prior to scheduled fibroid removal, not long term. The fibroids will grow again after therapy is stopped.
Menorrhagia means heavy vaginal bleeding. In many cases, the bleeding has a known cause, like uterine fibroids (see above), but in other cases the cause remains unknown. There's a medical threshold for menorrhagia -- losing more than 80 mL of blood in each menstrual cycle -- but most doctors now tend to define menorrhagia by how much it affects your daily life: causing pain, mood swings, and disruptions in your work, sexual activity, and other activities.
Some options for treating menorrhagia, short of hysterectomy:
- Medical management. Menorrhagia's first treatment of choice is medical, using either oral contraceptives or an intrauterine device (IUD) that releases a hormone called levonorgestrel. Both of these treatments reduce menstrual bleeding significantly, although women report being generally more satisfied with the IUD. If you're still planning to have children in the future, these are probably your best options.
- Endometrial ablation. There are a variety of techniques that can be used to remove the lining of the uterus. You should only consider these options, however, if you are done with childbearing. New, "second-generation" methods like thermal balloon ablation, cryoablation, and radiofrequency ablation have success rates up to 80%-90%. These are all outpatient procedures mostly done in the doctor's office, so they don't have the same complication rates and extended hospital stays involved in hysterectomy.
- Occasionally, an NSAID is prescribed during menses to help reduce blood flow from the uterine lining.
Uterine prolapse happens when your uterus drops from its normal position and pushes against your vaginal walls. It can be caused by a number of things, but one of the most common causes is vaginal childbirth. Advancing age, smoking, pregnancy, and obesity are also significant risk factors.
Obviously, a hysterectomy will solve this problem -- but there are less drastic approaches that you can also consider. One treatment option is a vaginal pessary -- a removable device placed into the vagina to support areas where prolapse is happening. There are several different kinds of pessaries, and your doctor can help you decide which is best for your situation. They don't cure the prolapse, but can relieve symptoms partially or completely. Often, they can be helpful in pregnancy, holding the uterus in place before it enlarges and invades the vaginal canal.
There are also multiple surgical methods for treating uterine prolapse, and surgeons may use more than one technique. Sometimes, they will have to be combined with a hysterectomy, but for some women it is possible to avoid this step.
The risks of placing mesh through the vagina to repair pelvic organ prolapse -- a procedure done roughly 75,000 times in 2010 -- may outweigh its benefits, according to the FDA. However, the use of mesh may be appropriate in some situations.
Other types of surgery include paravaginal defect repairs and repairs of enteroceles, rectoceles (hernias of the intestine or rectum into the vagina), and cystoceles prolapse of the bladder into the vagina.
About 5 million American women experience endometriosis, which occurs when tissue that behaves like the lining of the uterus -- the endometrium -- grows in other areas of the abdominal cavity, such as the ovaries, fallopian tubes, or outer surface of the uterus. Symptoms include pelvic pain, painful intercourse, spotting between periods, and infertility. The average woman with endometriosis has symptoms for two to five years before being diagnosed.
About 18% of hysterectomies in the U.S. are performed due to endometriosis -- and it doesn't necessarily cure the problem. As many as 13% of women see their endometriosis return within three years if their ovaries are left in place; the number climbs to 40% in five years. And since endometriosis often affects young women -- with an average age of about 27 -- a surgical option that removes all possibility of pregnancy isn't really an alternative.
Treatments for endometriosis depend on the severity of the symptoms and the woman's needs. For example, pain can be treated with over-the-counter or prescription pain relievers. To treat pain and abnormal menstrual bleeding, women may be prescribed hormonal treatments such as birth control pills or drugs that drastically reduce estrogen levels. These drugs, however, aren't for women who are trying to get pregnant, and they are not a permanent treatment: Going off the medication usually means the endometriosis symptoms come back.
A more long-term treatment for endometriosis that is more likely to help with fertility problems is laparoscopic surgery, a minimally invasive approach to either remove the endometrial growths and scar tissue, or burn them away with intense heat. If the growths can't all be safely destroyed this way, surgeons can take a more invasive approach, a laparotomy, which involves making a larger cut in the abdomen. This requires a much longer recovery period, but is still less invasive than hysterectomy and offers the prospect of retaining fertility.
Chronic Pelvic Pain
Chronic pelvic pain affects many women: Some studies indicate that as many as 39% of women have some kind of chronic pelvic pain. It's most common in younger women, especially those between 26 and 30 years old.
Pelvic pain can be caused by many things, including the above-mentioned uterine fibroids and endometriosis, pelvic inflammatory disease, and bowel and bladder issues like irritable bowel syndrome, interstitial cystitis (an inflamed bladder), and musculoskeletal issues. Women who have experienced sexual abuse are also more likely to experience chronic pelvic pain.
A hysterectomy should be considered a last resort for chronic pelvic pain, especially since many types of pelvic pain aren't cured by the surgery. It's important to work with your doctor to uncover the specific cause of your pain so that the treatment can be targeted to that cause, giving you the best chance of relief. For example, if you are diagnosed with uterine fibroids or endometriosis, one of the treatment options described above might have the best chance of putting an end to chronic pelvic pain.
Other treatment options, depending on the cause of your pain, may include:
- Stopping ovulation with hormonal methods like birth control pills
- The use of nonsteroidal anti-inflammatory medications
- Relaxation exercises, biofeedback, and physical therapy
- Abdominal trigger point injections; medication injected into painful areas in the lower wall of the abdomen can help relieve pain.
- Antibiotics (if an infection, such as pelvic inflammatory disease, is the source of the pain)
- Psychological counseling
It's still possible that, whatever your health condition might be, a hysterectomy may be the most effective and appropriate treatment. But with many alternatives available, it's important to discuss all your options with your doctor first.