What are alternatives to a hysterectomy?

Posted in hysterectomy; Posted 10 months ago by Andreas Obermair

During my training as a gynaecological oncologist, I was taught to keep in mind that there are always several ways to treat a medical condition. Since then, I offered my patients treatment options, rather than only one type of treatment. It often surprises me how personal circumstances can influence treatment decisions.

However, sometimes, I even discuss treatment options that I believe are suboptimal; and I flag them as an unwarranted option if I believe they are not serving my patient optimally.

In this article, I describe alternatives to a hysterectomy and how they depend on the specific medical condition that is prompting consideration of the surgery in the first place. Here are some alternatives for various gynaecological conditions:

Uterine Fibroids:

• Medications: Hormonal medications, such as the oral contraceptive pill, or systemic progestins may be prescribed to manage symptoms such as heavy bleeding and pelvic pain.
• Myomectomy: This surgical procedure involves the removal of individual fibroids while leaving the uterus intact. It may be performed through various approaches, including laparoscopic or hysteroscopic methods. A myomectomy is only indicated for women at childbearing age because of the risks involved.

Early-stage endometrial cancer:

• Medications: A hormone releasing intrauterine device (IUD) can be used to treat early stage endometrial cancer to avoid surgery. This is a relatively recent treatment that was assessed in the recent feMMe trial at the Queensland Centre of Gynaecological Cancer. You can read more about the trial findings here. Using a progestogen IUD to treat endometrial cancer is only for early stage disease and will not be possible if your endometrial cancer has invaded the wall of your uterus or your cervix or moved beyond your uterus.

Endometriosis:

Hysterectomy to treat endometriosis is only for women who completed their family. Treatment options to investigate before hysterectomy include:

• Medications: Hormonal medications or pain relievers may be prescribed to manage symptoms. There are drugs available that can also block the production of oestrogen and stop periods, thus alleviating symptoms and preventing further endometriotic lesions from growing.
• Laparoscopic surgery: Keyhole surgical approaches can be used to remove endometrial tissue growths while preserving the uterus and ovaries.

Adenomyosis:

Unfortunately, there are not many large studies on the treatment of adenomyosis. A hysterectomy is the definitive treatment for adenomyosis, ensuring no recurrence of bleeding or pain following the procedure. Other treatment options to manage symptoms include:

• Medications: Progestin IUD, systemic progestins, oral contraceptives or Danazole are medications which can provide initial symptom relief for some patients.
• Uterine artery embolization: Similar to uterine fibroid embolization, this procedure targets the blood vessels supplying the uterus to reduce symptoms.
• Magnetic resonance-guided focused ultrasound: This non-invasive procedure uses ultrasound waves to target and destroy adenomyotic tissue. Research is ongoing to assess its safety and effectiveness.

Uterine Prolapse:

The choice of treatment will depend on factors such as the severity of the prolapse. Treatment options to consider before hysterectomy include:

• Pelvic floor exercises (kegel exercises): Strengthening the pelvic floor muscles through exercises may help improve support for the uterus and reduce symptoms of mild uterine prolapse.
• Pessaries: A pessary is a device inserted into the vagina to support the uterus and other pelvic organs. Pessaries come in various shapes and sizes, and they can be an effective non-surgical option for managing uterine prolapse.
• Physical therapy and lifestyle modifications: Pelvic floor physical therapy involves working with a physical therapist who specializes in pelvic health. The therapist can provide exercises, biofeedback, and other techniques to strengthen pelvic muscles and improve support. Maintaining a healthy weight, avoiding heavy lifting, and practicing good bowel habits can contribute to overall pelvic health and reduce the risk of prolapse worsening.
• Hormonal therapies: For postmenopausal women, hormone replacement therapy (HRT) may help improve the strength and elasticity of pelvic tissues, potentially reducing symptoms of uterine prolapse.

Chronic Uterine or Pelvic Pain:

• Medications: Pain relievers or hormonal treatments may be prescribed.
• Laparoscopic surgery: If the pain is due to a specific condition like endometriosis, minimally invasive surgery may be an option.

Abnormal Uterine Bleeding:

• Hormonal therapies: Birth control pills, hormonal intrauterine devices (IUDs), or other hormonal treatments may regulate menstrual bleeding.
• Endometrial ablation: This procedure involves removing or destroying the lining of the uterus to reduce or eliminate menstrual bleeding.

Abnormal Cervical Cancer Screening test:

• A hysterectomy is the last resort and I normally advise against it in this context. The reason is that patients still need surveillance of the vagina post hysterectomy.
• However, in selected circumstances, a hysterectomy can be very useful in this context.

Disclaimer

While – as a gynaecological oncologist - I am aware of the alternative treatment options that I discussed above, I may not offer these alternative treatments through my practice. I am a highly skilled surgeon for certain complex pelvic surgical procedures, but not for all procedures.

It's important for individuals to discuss their specific condition, symptoms, and preferences with their healthcare provider to determine the most appropriate alternative to a hysterectomy. The choice of treatment will depend on factors such as the severity of the condition, the desire for future fertility, and overall health.

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