Caring For Our Bodies: When Surgery is Necessary

Hysterectomy can be an excellent treatment option – in some cases

I love my job and I love that most things we talk about in obstetrics and gynecology could make a grown person blush. Our line of work is very real and very human, and I certainly appreciate the patients who can bring a sense of humor to their visit. Not too long ago, I met another patient who reminded me how lucky I am. On the chart, the nurse wrote “patient here to order her hysterectomy.”

At most doctor visits, a nurse or medical assistant will sit down with you first and ask a bunch of questions. Usually the first one is, “What brought you in today?” or some version of this. You can imagine the variety of stories we encounter; there’s never a dull moment.

Many women come to the office because they feel it is time to have their uterus removed for one reason or another. On this particular day, I smiled because of how nonchalantly she told the nurse that she wanted a hysterectomy as if she were ordering a burger at a drive thru.

Some women cry if you bring up surgery! But, indeed, she was “done” with her uterus. It had served its purpose in her mind- brought her four children and many years of awful periods. Now, she was 45 and her periods were unpredictable and heavier than they had ever been. So, she figured it was time to just get the “bloody thing” removed. All of the women in her family had hysterectomies, and she said she knew the time had come.

“…I put on the brakes.”

Though she had planned to schedule her surgery on the spot, I put on the brakes. In my mind, she was suffering from anovulatory bleeding (the medical term for how bleeding becomes irregular, unpredictable and sometimes very heavy as women approach menopause, and when the ovaries do not always release an egg each month to keep the menstrual cycle in its normal pattern.)

It is my job as an OB/GYN to make sure that nothing else going on. There could be abnormal cells or cancer inside of the uterus making it bleed too much. She could have fibroids (noncancerous growths in or on the uterus that sometimes cause excess bleeding). She could have an endometrial polyp (an outpouching of the lining inside of the uterus). She could have a thyroid problem causing her menstrual cycle to be out of sync; or, it could be a handful of other things. We needed to perform an examination, do some further testing, and then tailor treatment to what we find. Even the surgery is chosen based on the particular patient.

In general, there are three ways to manage any medical problem.

• Expectant management (“watchful waiting”)
• Medicine
• Surgery.

Let’s assume she has anovulatory bleeding, and after a complete discussion, she still wants surgery. I would like to focus on the surgery options for her.

First off, there are non-hysterectomy options, known as endometrial ablation techniques that essential burn the lining inside of the uterus to get it to stop bleeding. The woman would keep her uterus, but should never get pregnant after this procedure and would usually be recommended to have a sterilization (to get her “tubes tied.”) There are pros and cons to these procedures, and all need to be discussed. But, our patient here is still set on having a hysterectomy.

There are three routes of performing hysterectomy

There are three routes of performing hysterectomy: abdominally (with large incision), vaginally (no abdominal incisions), and laparoscopically (small, “keyhole” incisions on abdomen.) In the years past, the only option for hysterectomy was through a large abdominal incision. This would require extensive recovery with several days in the hospital. It is ideal for extremely large uteri, other pelvic masses, extensive scar tissue that is unable to be addressed laparoscopically. Vaginal hysterectomy was perfected over time and is really the most minimally invasive route. A woman could go home the same day after a vaginal hysterectomy, but she is often kept overnight in the hospital. Anesthesia could be just a spinal or epidural for the vaginal hysterectomy which makes it safer for some women who cannot tolerate general anesthesia. But, there are limitations to the vaginal approach. Size and shape of the uterus and whether it can be pulled downward into the vagina are important. Whether or not the uterus can fit out through the vagina and whether the surgeon can manipulate around the uterus to remove it are important. Scar tissue from prior surgeries and a person’s body habitus can make the vaginal hysterectomy more difficult, as well.

The laparoscopic approach is the most recently developed, and has become the majority of the hysterectomies done at Beebe. The advantage of this approach is that the pelvis can be well visualized, scar tissue can be addressed safely and we have refined our surgical techniques and procedures within the operating room that make theses surgeries quick and easy. The vast majority of our patients go home a few hours after their surgeries (same day surgery) and can return to their normal activities (except intercourse, swimming, tub baths, heavy lifting) in as little as 2-4 weeks. Though it is not available at Beebe, the addition of the DaVinci robot for laparoscopic surgery is ideal for cancer surgeries, very overweight women, and complicated anatomy.

Once we have all the pieces of the puzzle, we will decide on a treatment. It is important to have a personalized discussion with your doctor to tailor the intervention to your particular needs and preferences.