Hysterectomy Decision Making is Hard

When an unfortunate day comes that a women decides that she must have a hysterectomy for one reason or another there are a series of decisions that must be made. Unfortunately, sometimes the doctor makes the decisions for her. Sometimes the doctor offers these as options, with an explanation of why of one thing or another might be done. These decisions are usually difficult. These decisions are based on lifestyle and odds of future problems. Women can be overwhelmed.

First decsion: What kind of hysterectomy? TAH? (explained in prior post). LAH?. Vaginal hysterectomy? Robot? Many times women are not given a choice. Sometimes women are given a fake choice, like "the robot is best, that is what needs to be done". There is a whole bunch of analytical thinking that needs to be done to choose the route.

Second decision: Take out the cervix? (explained in prior post). This decision is affected by the first decision. For instance it is difficult and traumatic to take out the fundus (see prior post) and leave the cervix in if the uterus is to come out via the vagina. Sure, you can cut a hole in the posterior vaginal wall, but that might lead to some significant surgical risks, even involving the colon and rectum. That's usually not worth it.

Third decision: Take out the ovaries? I will discuss that after the cervix.

Why would a women want to remove the cervix? The answer is first of all, cervical cancer will be impossible. Because of this, she may not need as many pap smears in the future. This can (optionally) save money on paps, which keep getting more and more expensive through the years. Please note, though, that I have saved women from vaginal cancer by doing pap smears in women who don't have a cervix. Doing the pap should always be a choice for women, should they choose to want to do it. Bean counters should not restrict it.

It is important, though, that even if a women chooses to skip pap smears, she will still need to get annual Gyne exams. This is to check a bunch of things that really matter. In no particular order, this will include: Bladder position, support, tumors (easily palpated via the vagina), rectal position and support, vaginal mucosa or skin, vaginal infections, the vaginal cuff support, position, or tumors. The skin of the Labia for tumors, melanomas (more common there than elsewhere per square inch, and I have found them there), infections, whether the cuff is getting weak and letting intestines fall into the vagina, the levator muscle position, strength, conditioning, and again, tumors, The quality of the ligaments and muscles that support all of these things. The breast exam for lumps, thickening, swollen lymph nodes, suspicious skin and or nipple changes, a general state of health, illness, or deconditioning. Sexuality issues are also important. Much help can be provided there if necessary. Also, to maintain a relationship with a trusted physician who can be a lifesaving resource when needed.

That last paragraph was an aside about general Gyn checkups. But back to the cervix. Another reason women might want to keep it is because there is some data that it might have a sexual purpose. The cervix definitely moves during sex and orgasm. The cervix is also very close to the G-spot. The science on the matter, though, shows no difference in measures of sexual function whether the cervix is in or not. Sexuality has been measured in studies, and there appears to be no difference. In my practice, I would talk about it with women prior to removing it, and discuss their options. The bottom line, taking it out removes what may be a normal organ in an effort to prevent cancer and save on pap smears, at some small undefined risk to sexual function. Keeping it preserves what may be a normal organ, and may preserve sexuality,  but raises the risk of cervical cancer back up to baseline. This decision should be evaluated in light of the woman's pap smear history. Any abnormal pap's or HPV in the past would argue for removal. If a woman does not get regular pap smears in the past, it would argue for removal, as she is likely to skip paps in the future, and risk becoming an unfortunate statistic. Keeping the cervix also preserves the normal arrangement of the supporting ligaments of the pelvic structures. This is only a benefit if the supporting ligaments are in good shape. Preserving stretched out poorly supporting ligaments is not a benefit but a recipe for a fallen bladder, rectum, and cervix. Finally, in an effort to preserve the cervix, there may have to be a change in the method of removal of the fundus. Like I said before, it is difficult to remove the fundus and keep the cervix if the plan is to remove the uterus via the vagina. Maximum preservation of the cervix (and G-spot) requires some kind of abdominal approach to the hysterectomy.

Should a women take out her ovaries for a hysterectomy that doesn't involve any ovarian pathology? This decision is even more complicated than the cervical one, and has day to day consequences for a woman. Removing the ovaries prevents nearly all cases of ovarian cancer. Keeping them preserves their important hormonal function. Ovarian cancer strikes about one in 60 women. But all women have important hormones, so losing the hormones affects everyone.

The official position of the American College of Ob/Gyn is to recommend removal of the ovaries after 50 years of age, leave them before 40 years of age, and make individualized recommendations in between. The in between years are very common.

Note that in some women, the ovarian cancer risk is so high that they should be removed as soon as she is done having her children. This would be women who carry the BRCA gene. I have now started testing for this gene in my office, and I have found women who carry the gene. I use Myriad genetics as my genetic testing provider.

If we remove the ovaries in a women under 57 years of age or so, there will be hormonal consequences. She will likely lose almost all of her estrogen and her testosterone. A woman would be lucky indeed if she didn't feel the loss of those hormones. There will usually be hot flashes and night sweats. Commonly there will be a loss of libido and orgasm. Almost always there will be a dry vagina. There may be a tremendous weaking of the skin of the vagina called Urogenital Atrophy. This makes for more urinary infections, leakages, pains, and small bladder syndrome. That is as icky as it sounds. It will likely make sex very dry and uncomfortable, oddly even when using lubrication. The pelvic ligaments may get weak. Moodyness is very common, although some people attribute that to the loss of sleep from the night sweats and flashes. Decreased memory is a common complaint. Long term, there is bone loss, usually at about 3 percent per year, becoming dangerously osteoporotic at about 20 years out. Altogether, I have seen lists that include about 150 symptoms of menopause. All of these are worse when the ovaries are removed. The cost of preventing ovarian cancer is quite high on a woman's life.

The good news is that these ovarian hormones that are lost are replaceable with their natural equivalents. These hormones can be taken orally or topically. Theoretically at least, they shouldn't increase her risk more than the natural hormones that they are replacing. Replacing these hormones is called Hormone Replacement Therapy, or HRT. HRT has it's own set of risks, but it certainly should not be restricted from a woman who is suffering as described in the prior paragraph. It really does normalize the life of women who are suffering.

There was a giant study done a few years ago called the Women's Health Initiative (WHI), which detailed the risks of HRT. When the study came out, many many women quit their HRT. The WHI found that HRT increased the risk of breast cancer by about 7 cases in 10,000 women. Concurrently, the cases of colon cancer dropped some similar amount. The WHI also proved that their class of women had no cardiac benefit from taking HRT. This was not the common wisdom of the day, and changed a lot of thinking. Since then ACOG has decided that women who don't need HRT should stop taking it. It is extremely important to note that the WHI excluded women who had menopausal symptoms. And mainly the women were an older group than perimenopausal women. Because of this, the WHI has no implications for perimenopausal women with symptoms, including surgically induced menopause. For perimenopausal women, we need to use older studies of symptomatic menopause. Many of these studies showed an unequivocal benefit to taking HRT.

It is really easy to see that these decisions are nontrivial. All four of these decisions above are about as important as decisions get. The  four decisions are

-How to take out the uterus
-Whether to take out the cervix.
-Whether to take out the ovaries
-Whether to take HRT afterwords

For the route of the hysterectomy, straight vaginal is easiest and least painful. It can be done in 20 minutes or less sometimes. Vaginal also gives access to vaginal repairs that might be neccessary. Laparoscopic is less painful than open but gives access to intraabdominal conditions. Laparoscopic also leaves unsightly scars on the abdomen. These scars are abhorred by fit women, they are life altering for models, movie stars, and young women. Laparoscopic takes a bit longer and has more surgical risks. Robotic takes longer yet, and leaves sometimes even bigger scars, and also has more surgical risks. Open leaves one scar just above the pubic bone, hidden by hair or bikinis. Open has more pain, but this passes in a few days. Open sometimes gives better access to pelvic problems. All of the abdominal approaches preserves the G-spot, optionally preserves the cervix, and allow better access to the ovaries and intra-abdominal problems.

I am open for comments.

Thanks for reading.

Next post on what I call the Therapeutic Alliance.

John Marcus
Obstetrics and Gynecology
Ridgewood New Jersey
201-447-0077