Carlos Sandoval-Herrera, MD FACOG FACS MSMIS, Director of Gynecology and Chief of the Division of Minimally Invasaive Gynecology at Mount Sinai Hospital and Medical Center
Enough is enough. You have been experiencing heavy menstrual periods for too long. You are sick of soaking 10 pads a day for 10 days every single month—plus uninvited and unexpected accidents. This is affecting your work attendance, this is affecting your relationship, this is making you take iron pills and you have a rash from using a pad every day—just in case of an unexpected accident. You now decide to be brave and go to the gynecologist office. There is no obvious abnormality on your pelvic exam and you got an ultrasound referral. The fact that your symptoms didn’t correlate with the doctor’s exam is confusing. You do the ultrasound and schedule your return visit with your Gynecologist.
You walk into your Gynecologist office for results after an ultrasound for heavy menstrual periods and you are told that you might need a hysterectomy. You come out of the office with a bunch of papers that tell you about your different options. In your mind, there is only the “H” word. You are scared; you are confused, you are puzzled. What should you do?
In the United States, there are approximately 600,000 hysterectomies performed per year. Surprisingly more than 50% are still performed through open surgery, yes OPEN surgery. While there are alternatives for minimally invasive hysterectomy, it seems that maximally invasive hysterectomy is still the norm. While your surgeon might have the expertise of Minimally Invasive training or experience, chances are that you might be offered an open hysterectomy at your local gynecologist office. The option for minimally invasive hysterectomy might not even be mentioned to you.
"Most of the well selected patients who undergo an endometrial ablation can tell you that they “skipped” the hysterectomy"
The reasons for which you might need a hysterectomy are: uterine fibroids, uterine prolapse, abnormal uterine bleeding, chronic pelvic pain, endometriosis and gynecologic cancer among others. All can be treated with a hysterectomy. The American Association of Gynecologic Laparoscopists suggests for patient’s and doctors to not perform open surgery for non-malignant disease of the uterus, to not routinely remove the ovaries during a hysterectomy in woman at low risk for ovarian cancer, to remove polyps of the inner lining of the uterus with hysteroscopy and to not misuse narcotics. Actually, in the modern management of pain for hysterectomy, you should be enrolled in an Enhanced Recovery After surgery protocol (ERAS), which does not include narcotics—most of the time.
So, after your counseling, and at the time of decision making, you inquire about the choices that are not a hysterectomy. The least scary option is medicine. You go home with the prescription for the medicine and you take it for a few months. Unfortunately, it didn’t work. Here you are again, at the doctor’s office. You still want to know at least another option that is NOT hysterectomy. This might be your case and I want you to know about it.
The option that might spare you from a hysterectomy—or at least buy you some time—is called endometrial ablation. An endometrial ablation is a simple procedure that eliminates the inner lining of the uterus. It can be done through radiofrequency, electro-surgery among others. It is an outpatient surgery procedure. It can be even done in the office. Menstrual bleeding does not stop all the time, but is reduced to normal or lighter levels. If ablation does not control heavy bleeding, further treatment or surgery may be needed. You might be a better candidate for this procedure if you are over 40 years old. You should not have an endometrial ablation if you have one of the following: endometrial hyperplasia, cancer of the uterus, recent pregnancy, current or recent infection of the uterus. An endometrial ablation has certain risks. There is a small risk of infection and bleeding. The device used may pass through the uterine wall or bowel. There is a risk of burns to the vagina, vulva, and bowel. Rarely, the fluid used to expand your uterus during electro-surgery may be absorbed into your bloodstream.If a woman still wants to become pregnant, she should not have this procedure. Pregnancy is not likely after ablation, but it can happen. An office-based endometrial biopsy needs to be performed before the procedure and it needs to be negative for endometrial cancer. You might not be an ideal candidate for endometrial ablation if you have multiple problems together. One example could be heavy menstrual periods plus uterine fibroids plus pelvic pain. Another example could be a large uterus.
Most of the well-selected patients who undergo an endometrial ablation can tell you that they “skipped” the hysterectomy, that it didn’t really hurt, that they went home the same day and that they are happy with the absent or minimal periods.
If you “fit” the picture above, ask your gynecologist if you can be an ideal candidate for endometrial ablation. If you need a hysterectomy, don’t settle with one recommendation for open hysterectomy, get a minimally invasive hysterectomy, ask for a second opinion, get your procedure with a high volume gynecologic surgeon—surgeon that performs 10 major cases a year. You have options. It’s your body.