When Is a Hysterectomy Necessary?

Second only to cesarean birth,hysterectomy is a surprisingly common procedure among reproductive-aged women. Each year, about 600,000 American women have a hysterectomy to have their uteruses removed, but 90 percent of these procedures aren’t medically necessary — they’re being performed for non-life-threatening conditions, such as uterine fibroids, endometriosis, uterine prolapse, and abnormal uterine bleeding.

If your doctor has suggested that you consider having a hysterectomy, you may be wondering if this procedure is really necessary for you.

When a Hysterectomy Is Necessary

A hysterectomy is a woman’s only treatment option in cases of cervical, uterine, or ovarian cancer, says Linda Bradley, MD, vice chair of obstetrics and gynecology at the Cleveland Clinic in Ohio. An emergency hysterectomy may also be necessary if there’s an uncontrolled uterine hemorrhage or infection.

However, in the vast majority of other cases, alternatives to having a hysterectomy should be offered to women but often aren’t, Dr. Bradley says. “For many doctors, their only answer is to treat the problem with a hysterectomy, which is often unnecessary.”

Hysterectomy Alternatives for Noncancerous Conditions

The vast majority of hysterectomies are being performed for noncancerous conditions that may be successfully treated with other options, which preserve fertility. For example, these top five noncancerous uterine problems have multiple treatment alternatives that may work:

1. Uterine fibroids. These noncancerous growths account for about 30 percent of hysterectomies performed in the United States. While many women have no symptoms with uterine fibroids, others live with pain, bladder or bowel pressure, and heavy bleeding. The cause of uterine fibroids is unknown, but female hormones play a role. That’s why the condition usually gets better after menopause, when hormone levels decrease.

More than half of women with troublesome uterine fibroids want a treatment that will preserve their uterus, according to a survey of more than 960 women published in the American Journal of Obstetrics and Gynecology in October 2013. This shows that the number of hysterectomies for uterine fibroids is on the decline. Alternative treatment options for uterine fibroids include:

• Medication: Certain drugs can help soothe mild pain and control bleeding, Bradley says. Your doctor may also recommend injections that can shrink uterine fibroids, although this treatment can have menopause-like side effects, including hot flashes. A prescription morning-after pill was shown to help control bleeding in two studies published in the New England Journal of Medicine in February 2012. In one study, this medication performed significantly better than a placebo. In the other study, this medication was just as effective as the drug leuprolide acetate, but with fewer hot flashes.
• Myomectomy: This surgery removes uterine fibroids but leaves the uterus intact.
• Uterine artery embolization: This procedure cuts off the blood supply to uterine fibroids and shrinks them. “Some women have been able to become pregnant after this procedure, but usually it’s not recommended if a woman wants to preserve fertility,” says Ingrid A. Rodi, MD, a clinical professor in the department of obstetrics and gynecology at the David Geffen School of Medicine at UCLA.

2. Endometriosis. In endometriosis, cells from the uterine lining (endometrium) grow excessively outside the uterus, causing pain, bleeding, and sometimes infertility. “Endometriosis is common but doesn’t have to be treated with a hysterectomy,” Bradley says. Treatment alternatives for endometriosis include:

• Combined hormonal contraception: This may include birth control pills or other methods of contraception and is often a first-line treatment for endometriosis. “Stopping periods for four to six months and letting the body heal on its own can help,” Bradley says.
• Endoscopic surgery: Another alternative treatment option is surgical removal of scar tissue by endoscopic surgery, followed by medication that suppresses redevelopment of endometriosis.

3. Uterine prolapse. Uterine prolapse occurs when the pelvic floor muscles and supportive tissues weaken and the bladder or rectum sags with the weight of the uterus. This condition can cause pelvic discomfort, bladder or bowel function problems, and protrusion of an organ outside the vagina. “Uterine prolapse is uncomfortable, and it causes a pulling sensation,” Dr. Rodi says. If a woman desires to have more children, the uterus can be surgically suspended, or she can temporarily use a pessary — a device that holds the uterus in place. Pelvic floor exercises (Kegels) can also help restore muscle tone, and lifestyle changes such as weight loss and avoiding heavy lifting can help uterine prolapse.

4. Abnormal or excessive vaginal bleeding. When a woman experiences abnormal or heavy menstrual bleeding, the first thing that needs to be established is why it’s happening, Rodi says. The underlying cause should guide the treatment. The condition may be able to be managed by:

• Birth control pills or an interuterine device (IUD), which is a small, safe contraceptive device that’s inserted into the uterus.
• Medications taken during the menstrual period.
• Exercise and weight loss (if needed).
• A procedure such as endometrial ablation, which destroys the endometrial lining. Such a procedure may need to be repeated, but it carries less risk than hysterectomy surgery, concluded researchers who reviewed studies on the topic. Their analysis was published in the Journal of Minimally Invasive Gynecology in 2012.

5. Adenomyosis: With adenomyosis, the endometrium grows inside the muscular walls of the uterus. Pain and bleeding can be severe, and sometimes doctors will suggest a hysterectomy as treatment. Pain medication can help, and birth control pills or a progesterone IUD can control bleeding. Symptoms usually disappear after menopause.

Rodi says that adenomyosis is difficult to treat, and women with the condition often opt for a hysterectomy if they aren’t concerned about their fertility. But conservative treatments can be tried first. Uterine artery embolization and a procedure called magnetic resonance imaging-guided focused ultrasound shows promise in treating adenomyosis, according to a review published in the German journal Geburtshilfe und Frauenheilkunde (Obstetrics and Women’s Health) in September 2013.

Hysterectomy Alternatives: Get a Second Opinion

Bradley urges women who are considering a hysterectomy to ask a lot of questions, especially if they want children or aren’t sure yet. “A hysterectomy is permanent — you can never have a child after the procedure,” she says. Treatment for noncancerous uterine problems should be tailored to your specific circumstance. Ask your doctor, “Is a hysterectomy necessary, and what are my other options?” If you aren’t satisfied with the answer, get a second opinion.