Hysterectomy Indications & Medical mgmt treatment options: Endometriosis

Indications for Hysterectomy:

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Hysterectomy is the surgical removal of the uterus. By age 60, 25% of American women have had this procedure. More than 500,000 hysterectomies are performed each year in the US, which is the highest rate among any nations with published data on this procedure. It is twice the rate of hysterectomies in English women and four times the rate in French women. Studies report that between 11% and 19% of all hysterectomies are performed to treat extensive endometriosis. Having endometriosis plus severe symptoms is, in fact, a major risk factor for eventually requiring a hysterectomy. It should be noted that hysterectomy does not necessarily cure endometriosis. One study reported that endometriosis reappeared in 13% of women within three years of a hysterectomy and in 40% after five years. Most women are satisfied with the procedure. A major analysis of evidence on hysterectomies reported that symptoms related to menstrual problems decline significantly in most women, although none completely disappear for all women. The majority of women also experience improved quality of life and emotional functioning, although 8% of women who were not depressed and 12% of women who were not anxious before the procedure developed these emotional states afterward. Still, one study suggested that 70% of recommendations for hysterectomies did not meet the standard of care as determined by expert groups. In such cases, patients were not given alternative choices or adequate diagnostic evaluations. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids should certainly seek a second opinion. ***In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors. One study reported a greater sense of loss, more residual symptoms, and more pain in younger women (under 30) who have undergone hysterectomy than in older women. In one study, 37% of such younger women regretted their decision to have a hysterectomy. Once careful instruction is given for all the risks and benefits of the different surgical options, the physician must then respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause. Both the patient and the physician should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery. Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, or the number of times he or she has performed the procedure in question. The more, the better. Asking for complication rates may be helpful, but a patient should realize that an experienced surgeon may have a higher number of high-risk patients, and therefore, a higher complication rate than a less experienced surgeon with fewer serious cases. Several medical management options are available for the treatment of Endometriosis. The treatment for Endometriosis and Adenomyosis are virtually identical. However, it must be noted that many women diagnosed with Adenomyosis do not respond to traditional treatment. In the majority of cases, hysterectomy is the only cure for Adenomyosis. These include: NO TREATMENT, which can lead to more serious health problems. Limited use of ANALGESICS and nonsteroidal anti-inflammatory drugs (NSAIDs). ORAL CONTRACEPTIVES can be given cyclically (the patient has a monthly menses) or continuously (the patient has no menses during treatment). PROGESTINS (Provera 10 mgm every day) or Depo-Provera injections will incompletely suppress ovarian function, but can be associated with breakthrough bleeding; they may be useful in a few women who cannot tolerate oral contraceptives. GnRH AGONISTS are synthetic decapeptides. The GnRH agonists initially stimulate the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). Al a consequence, blood estrogen levels initially rise, then fall to menopausal levels within a few days. After 7 to 10 days, these drugs produce a menopausal state which is fully reversible. This produces amenorrhea (no menses), which permits regression of endometriosis and relief of symptoms. The GnRH agonists do not have any known direct effects on the ovary. Leuprolide acetate (LUPRON DEPOT) is usually given as a single monthly 3.75 mgm intramuscular injection. Nafarelin acetate (SYNAREL) 200 Fg nasal spray used twice a day, is a superactive, hydrophobic stimulatory analog of GnRH that is 200 times more potent than naturally occurring GnRH, and is delivered in a metered nasal spray pump. Note that GnRH Agonists may be used for the Treatment of Adenomyosis, but recent studies have found that the GnRH Agonists do not provide adequate long term relief for the pain and bleeding associated with Adenomyosis. SURGERY - In the infertile patient, laparoscopic therapy is almost always conservative, consisting of excision, laser vaporization, or electrosurgical desiccation of endometriosis.Every attempt should be made to conserve as much ovarian tissue as possible in these patients. Patients who have completed childbearing often undergo more radical laparoscopic therapy, including hysterectomy and/or bilateral salpingo-oophorectomy (removal of the ovaries). Simple removal of the uterus and\or ovaries is not necessarily the appropriate operation, however. If the surgeon removes the uterus and ovaries, but leaves implants of endometriosis behind, the patient may continue to have pain very similar to that she experienced prior to the operation. **Remember, symptoms may be as much a result of the implants of endometriosis as from the uterus or ovaries. Adequate laparoscopic treatment of endometriosis requires a surgeon who is familiar with the pathophysiology of endometriosis and its various appearances. They must possess the skills to treat implants on or near vital structures in the pelvis, and have access to the proper laparoscopic equipment necessary to perform these procedures. http://www.onasoils.com/EndoTopics.htm

If you need a hysterectomy, should you also have your ovaries removed?

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I have changed my view about this controversial subject since the first edition of this book was published._ At that time, I suggested that women who were having a hysterectomy performed for appropriate reasons also consider having their ovaries removed after the age of about forty-five._ My thinking at the time was that the ovaries would continue producing hormones for only a few years thereafter, and this advantage would be overshadowed by the benefit of removing the ovaries and eliminating the 1 percent chance of developing ovarian cancer in your lifetime._ However, a number of issues have come to my attention since then, and I now believe that the ovaries should almost never be removed at the time of hysterectomy._ First, the risk of ovarian cancer goes down if the ovaries remain after hysterectomy._ The reason for this is not clear, but it may be that the path for potential carcinogens from the vagina to the ovaries is interrupted when the uterus is removed._ Thus, the risk of a woman developing ovarian cancer after hysterectomy is probably closer to 1 in 300 rather than 1 in 80 for women who have not had a hysterectomy._ The benefit of removing ovaries for ovarian cancer prevention has been overstated in the medical literature and is, therefore, misunderstood by most physicians. Significantly, the ovaries produce hormones long after menopause._ Estrogen continues to be produced in small amounts, about 25 percent of normal pre-menopausal levels._ Blood levels of estrogen in some post-menopausal women are equivalent to the levels attained by low-dose estrogen patches used for estrogen replacement in menopause._ The circulating level of estrogen produced by the patch has been shown to be sufficient to prevent bone loss in clinical studies._ Studies also show less bone loss in women who have ovaries than in women who have had their ovaries removed._ Studies show that women who have had their ovaries removed (and have not taken replacement estrogen) have higher rates of heart disease than women the same age who still have their ovaries. Testosterone is usually thought of as solely a male hormone._ However, it and other androgen (male) hormones are produced by the ovaries from the time of the first menstrual period._ These androgens continue to be produced by the ovaries after menopause._ Testosterone has many direct and indirect benefits to your body._ Some of the testosterone is converted into estrogen by your body, and it circulates in the bloodstream to all of your tissues where it has a direct effect on many organs._ It helps to build bone and thus reduces osteoporosis._ Its steroid features prevent muscle loss that often occurs with aging._ Testosterone directly affects the brain and increases libido._ Sexual feelings, desire, and arousal are all related to androgen levels._ Testosterone also affects brain function and mood._ Women with hormones from their own ovaries have a lower rate of depression than women who have had them removed, even if estrogen replacement therapy (ERT) is taken. Some physicians have argued that women can replace estrogens and androgens with medications._ However, less than 30 percent of women who have a hysterectomy and removal of their ovaries will actually take hormones. _Therefore, 70 percent of women will not have the benefit of their own hormones._ Some women do not take ERT because they feel fine and do not understand the benefits of taking estrogen for their bones._ Some women are concerned about the still controversial issues surrounding estrogen and breast cancer, although it appears that the effect of estrogen on the risk of breast cancer may be small._ Some cannot afford the medication._ For whatever reason, most women would be better off with their own supply of estrogen and testosterone from their ovaries. Another problem with estrogen replacement therapy (ERT) is the dilemma that some doctors and women have as they try to find the right doses._ Some women note that despite trying multiple regimens of ERT, they still do not feel right._ Because hormone production and metabolism is a complex issue, it should not be a surprise that we are not able to mimic normal hormone levels in all women._ For all the above reasons, I have recently started recommending that most women choose to keep their ovaries at the time of hysterectomy for uterine problems, regardless of their age. However, there are a few situations where women may wish to have their ovaries removed at the time of hysterectomy._ If the ovaries are affected by endometriosis or a woman has severe endometriosis and pelvic pain, studies show that removing the ovaries is associated with better long-term relief of pain than if the ovaries are not removed._ Severe adhesions, or scar tissue, around the ovaries may also cause continued pelvic pain. Some women are at increased risk for developing ovarian cancer._ If you feel your family history suggests an increased risk for ovarian cancer, you should see a genetic counselor to help evaluate your risk._ The counselor may suggest you have BRCA (breast/ovarian cancer) gene testing to determine if you have inherited the gene that increases your risk._ If you have an increased risk, you should strongly consider having your ovaries removed._ In this case, the benefits of removing your ovaries and preventing ovarian cancer should far outweigh the benefits of keeping your own ovarian hormones. Some women are very uneasy about leaving their ovaries in because of the fear of ovarian cancer._ They may have seen a friend or relative die of this terrible disease._ As a result, some women may choose to have their ovaries removed at the time of hysterectomy._ But for each woman, the risks should be weighed carefully against the benefits of having her own hormones from her own ovaries after menopause._ Women tend to make very different decisions based on their particular circumstances, their feelings about estrogen replacement therapy, and their risk and fear of ovarian cancer._ However, it is always best to make these decisions based on accurate and current medical information._ This decision is yours to make and should be discussed in detail with your doctor._ As always, if there are unanswered questions or concern, get a second opinion. What Is Right For You?_ The decision to have a hysterectomy should not be taken lightly. There are medical conditions that require treatment - cancer, prolonged heavy bleeding to the point of severe anemia, or incapacitating pain. However, as outlined throughout this book, all medical conditions have more than one option for treatment. Medicine is an evolving art as well as a science. Recently, with more open attitudes towards women's opinions and feelings, and with the advent of new technology, doctors have been looking for new medical treatments for gynecologic symptoms in order to avoid hysterectomy. As outlined above, there are possible side effects of hysterectomy, none of which are entirely predictable for each individual. But, for some women, hysterectomy will be the right treatment._ 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. On one hand, you should weigh the degree of discomfort that your gynecologic problem presents to you, the ways in which it interferes with your health, both emotionally and physically. On the other hand, weigh the potential risks of the operation, including the possible physical as well as the emotional side-effects of having a hysterectomy. There are women who happily choose to live with fibroids the size of a 5 month pregnancy despite the fact that they have some daily discomfort and look pregnant. Other women choose surgery for small fibroids because they are distressed by symptoms, or by worry, and don't wish to live with the problems any longer. Ultimately, the final decision about the appropriateness of a hysterectomy, or any type of surgery or medical care, should be made by each woman herself. Questions to ask your Dr: Can Having a Hysterectomy Affect Your Sexuality?_ Can Hysterectomy Lead to Psychological Problems?_ Can Having a Hysterectomy Lead to Psychological Problems for Your Partner?_ Can Having a Hysterectomy Affect Your Bladder Function?_ Can Removal of the Uterus Increase the Risk of Heart Disease?_ Does Removal of the Ovaries Increase the Risk of Heart Disease?_ What is a Radical Hysterectomy?_ After You HAve a Hysterectomy, What Do You Look Like Inside?_ What Happens to a Woman's Monyhly Cycle After Hysterectomy?_ Can Removal of Your Ovaries Affect Your Sexuality?_ What Can Be Done if Hysterectomy Has Caused Sexual Problems?_ What Are the Possible Complications of Hysterectomy?_ Can Hysterectomy Relieve Gynecological Symptoms?_ Can Hysterectomy Improve the Way You Feel?_ Can Hysterectomy Improve Quality of Life?_ Can Medication Relieve Pain or Bleeding?_ What Questions Should You Ask Your Doctor If It Is Recommended That You Have a Hysterectomy?_ Should You Get a Second Opinion?_ http://www.gynsecondopinion.com/hysterectomy.htm