Have you earned that hysterectomy?

Uterine problems range from fibroids, diseases impacting on the lining of the uterus (dysfunctional uterine bleeding) to the occurrence of heavy and abnormal menstrual bleeding (as a result of disease) and pre-invasive cervical lesions.

“Facing the prospect of a hysterectomy- whether you are in your 30's or are an older woman approaching menopause- can be a traumatic experience for many women who see it as an attack on the centre of their very being as women.”

“Yet many South African women accept the surgery without fully questioning the procedure and understanding all the alternatives available to them,” says gynaecologist Kiran Kalian, of Gauteng's Union Hospital.

“It must always be borne in mind that surgery should be earned – undertaken only when a correct diagnosis has been established and all other options have been explored and excluded. Women should consider several factors; look at their ages, whether they have completed their families and the implications of surgery. They should also ask their gynaecologists several questions,” said Dr Kalian. These should include:

Are there any alternative treatments for my problem?

Menorrhagia (heavy menstrual bleeding) a problem that is caused either by disease of the uterus such as fibroids, endometriosis, infection or by an abnormality in the lining of the uterus in the absence of other pelvic disease (dysfunctional uterine bleeding) is a case in point.

Menorrhagia as a result of disease often occurs in women who are in their reproductive years. It sometimes disrupts their lives enough for them to seek hysterectomies. However, in younger women and those in the perimenopause – the phase before menopause actually takes place when ovarian hormone production is declining and fluctuating - irregular periods can be problematic. This is usually dysfunctional uterine bleeding which typically responds to medical management.

“Menstruation patterns vary from woman to woman. Generally, bleeding becomes a problem when it continues for a week and blood clots are present. Commonly haemostatics and other hormones are recommended for controlling bleeding in younger patients. It can also assist women who are still of child bearing age,” Dr Kalian said.

“Success has also been achieved internationally with the use of IUD to reduce Menorrahgia”, he said.

The rates of hysterectomies are declining in industrialised countries such as the UK because of the introduction of new alternatives to the procedure. Endometrial ablation - a procedure performed through the vagina to remove the lining of the uterus is gaining world-wide popularity

“This alternative to hysterectomy in patients with Menorraghia with a normal size uterus and absent pelvic disease can be done as a day procedure as it is cost effective and causes minimal disruption to a women's lifestyle,” says Dr Kalian.

Endometriosis, another common reason for a hysterectomy, may also respond to drug therapy aimed at disrupting hormones that control the menstrual cycle and can be effective when tissue implants are small.

This chronic condition is caused by bits of tissue from the uterine lining becoming displaced and implanting themselves in the abdomen outside the uterus, causing inflammation, pelvic pain, severe menstrual cramps, pain during intercourse, infertility, and irregular bleeding.

“If the symptoms can't be controlled with laparoscopic surgery, drugs or conservative measures, or a related condition called adenomyosis – which is when the endometrial tissue is embedded at several locations within the uterine wall - a hysterectomy may be advised,” Dr Kalian said.

“A hysterectomy is not, however, necessarily a cure for endometriosis”, Dr Kalian added.

How will the surgery be performed? What are the procedures available?

Worldwide, abdominal hysterectomies dominate the field. Recovery is slow and scarring of the abdomen results. As a result, Dr Kalian says he strongly advises women to ask their gynaecologist about alternative forms of hysterectomy and their experience in performing them.

He says as an alternative to abdominal surgery, the vaginal hysterectomy- removing the uterus through the vagina- has a number of advantages. These include reduced pain, no scarring and shortened hospital stays.

“Vaginal hysterectomy today remains the first choice in the way a hysterectomy should be performed. This has been backed by solid research as if offers superior benefits for recovery and minimal complications if performed by a trained vaginal surgeon”, said Dr Kalian.

“Laparoscopic hysterectomy allows the uterus to be removed with minimal access surgical techniques .A laparoscope allows the surgeon to view the patient's pelvic organs. It is inserted into the abdomen through one of several small incisions, along with additional instruments that can also be used to remove the uterus (a total laparoscopic hysterectomy) and treat any additional pelvic abnormalities”, Dr Kalian said.

Dr Kalian warned however that in South Africa, very few gynaecologists have received adequate training to perform this technique.

What are the risks?

Patients are strongly advised to always enquire fully about the success rates of all procedures, the frequency with which they are undertaken by their gynaecologists and possible post-operative complications.

“The doctor's preferred method of surgery and his personal success rate should always be on the agenda”, added Dr Kalian.

Do my ovaries need to be removed? If so, will I take hormones?

“Hormone Replacement Therapy (HRT) is common when ovaries are removed. Side effects such as weight gain are common. Again, the full implications of HRT should be fully discussed with patients,” Dr Kalian said.

Hysterectomies are a vast and complex subject matter in the field of women's health to cover in just a single discussion. The central message to take home though is that women must always bear in mind that it is their right to question common practice and decide what is best for them.

“Being knowledgeable, conducting research and getting educated opinions is vital when it comes to making informed decisions,” said Dr Kalian in conclusion.

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Solly Mabotha
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