Hysterectomy to treat Fibroids? Why?

Day after day I have patients that come to my office with symptomatic fibroids who were wise enough to go for a second opinion after being told that the only option to treat their fibroids was a hysterectomy. It can be very upsetting to hear that the only option is to lose a part of the body that, even if pregnancy is no longer an option, may often have significant emotional value in helping define a woman’s self-image. With all of the different options available, a hysterectomy may actually be the best, and it certainly should be included in the options, but it should not be the only option. There are a few reasons that this occurs so often in gynecology offices.

Believed to be the best option

The first is that the gynecologists often truly believe that this is the best option for their patients. While there are many new alternative treatments, a hysterectomy is the only true definitive treatment which guarantees that the woman will not have any future symptoms from her fibroids or uterus.

Multiple Options

Some gynecologists believe that it can be confusing to patients to offer them too many options that can be difficult to understand. While it is definitely part of our jobs to simplify the options in a way that our patients can understand, it is too simplistic to exclude options simply because the gynecologist doesn’t believe them to be good options. Because the treatment of fibroids is not usually an emergency and simply being done to lessen symptoms, the decision to try alternative treatments that may not have as high a success rate as a hysterectomy but may be more emotionally and physically appealing, should be the patient’s decision, not the physicians. It is overly paternalistic to think otherwise.

Surgeon’s comfort with surgery and potential complications

A component of the limited counseling may be related to surgeon comfort. There are a variety of new options for treating fibroids but surgically we can either take the fibroids out (a myomectomy) or remove the uterus (a hysterectomy). While it may seem a little counter-intuitive, taking the uterus out is actually a simpler and safer procedure than just taking out the fibroids. A hysterectomy allows the surgeon to permanently cut off the blood supply to the uterus at the beginning of the procedure, so significant blood loss is rare. This is not true for a myomectomy where the uterus needs to live on after the procedure and therefore means that the risk of blood loss is higher in a myomectomy. The incision in a myomectomy often needs to be larger than it would be in a hysterectomy, so post-operative pain may be greater. Post-operative complications such as bleeding and adhesions leading to pain are also more common in myomectomies. Hysterectomies are also shorter, easier surgeries than myomectomies. All of this means that performing a myomectomy means more work and anxiety in managing post-operative issues hence the push towards a hysterectomy.

There are different types of Gynecologists and they all don’t deal with the same issues

Gynecology is a mix of medical practices that are related only in that they are practiced on women and on their reproductive organs. Within gynecology, there are doctors that only practice obstetrics and never operate unless they are performing a cesarean section. There are reproductive endocrinologists that spend their lives getting women pregnant and do not do any major procures or take care of pregnant patients past the first trimester. There are cancer specialists that only take care of women with gynecologic cancers. Most women, however have a general gynecologist that they go to for their annual exam. While these are often fantastic doctors with whom patients often have a strong bond, the average general gynecologist does less than one major operative procedure per month. This is compared to physicians who have chosen to specialize in non-cancerous gynecologic surgery, such as a urogynecologist or minimally invasive gynecologic surgeon, and typically perform between 200-500 major procedures every year. Like with everything in life, it you do not do something very often you lose your skills at doing it, it is not like riding a bike. Most gynecologists are aware that there is a procedure that they do well and those that they find more challenging. A general gynecologist may only perform 2 or 3 myomectomies a year, and knowing that they are more challenging and require more work, many generalists simply shy away from these procedures.

You are entitled to knowing all of your options and an experienced surgeon

Everyone has limitations and the greatest general gynecologist should not be expected to be responsible to know that there are options other than jumping to a hysterectomy, and they need to either provide these options to their patients or refer them to someone who can provide these options. Sadly, this does not always happen, and patients need to take their health care into their own hands. The internet now makes it much easier to find a gynecologist in your area that specializes in your problem. It is always right to seek out a second opinion. There are always options.

Charles Ascher-Walsh M.D.
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