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If you've been informed that you need a hysterectomy, this book is for you. Step by step, test by test, decision by decision, you'll know what to expect andwhat your choices are. Why are you having problems? Do you really need a hysterrectomy? What are the alternatives? Is it best to just "wait and see"? And if you do decide to go ahead, what type of hysterectomy procedure is right for you? From diagnosis to recovery, So You're Having a Hysterectomy is the ultimate guide for women facing this controversial surgery. Balanced, accurate information, real-life patient stories, and detailed illustrations give you the inside story on each medical procedure, while extensive self-help sections give you the power to find your own personal road to wellness—whatever you decide.
"Been there, done that, does not an expert make. Event though I have had a hysterectomy and am a sex educator/counselor, I still learned a great deal about hysterectomy from this book. Highly recommended reading."
—Sue Hohanson, RN CM, sex educator/counselor and host of the Sunday Night Sex Show
What Happens in this Chapter
How to make your decision
A brief overview of the different types of hysterectomy
Pros and cons of the alternatives
The upsides and downsides of hysterectomy
Unless you have invasive cancer or very severe bleeding, hysterectomy should no longer be seen as the answer to every gynecological problem. Heavy periods, fibroids, polyps, mild prolapse, endometriosis, and many other gynecological conditions can be helped by other procedures and drugs. Deciding between them all can be difficult, especially if your physician is convinced that hysterectomy is the best route and you're not. This chapter aims to help you sort through the confusion and reach a decision that is right for you.
The Hysterectomy Decision
Hysterectomy is the second most common procedure performed on women in North America-second only to cesarean sections-and around 1 in 4 women will reach the age of 60 without her uterus. Many people have questioned whether all these hysterectomies are really necessary. Studies in the 1990s showed that up to 2 in 3 women underwent the procedure without good medical reasons. Clearly, hysterectomy means big business-and big controversy.
If you are told you need a hysterectomy, it's important to keep a clear head. Ask lots of questions (somesuggestions are on page 73). Explore your options. Talk to other women, go on the Internet, get a second opinion-or a third, or fourth. Do not agree to a hysterectomy until you fully understand why you are having it, why the alternatives may not work for you, and what you can expect from the procedure.
Once your ultrasound and other tests have confirmed that you might need a hysterectomy, your physician will make a recommendation based on her or his experience with patients whose medical condition is similar to yours, the number of factors in your life that may affect your condition, his or her familiarity with a certain technique, and his or her knowledge of the most recent scientific studies.
Hysterectomy may be a medical necessity, for example if you have endometrial cancer or life-threatening bleeding. If not, the decision is less clear-cut and your physician should discuss alternate treatments with you before the decision is made to proceed with the hysterectomy. If you do decide on hysterectomy, again, there are several alternative ways to perform it. If there is no particular medical reason to choose one treatment over another, the decision may depend on practical considerations, such as locally available hospital resources, the comfort of your surgeon with a certain surgical procedure, and how quickly you need to return to work.
Chapter 6 covers the different types of hysterectomy and Chapter 7 summarizes the advantages and disadvantages of the alternatives-drug treatment, endometrial ablation, uterine fibroid embolization, and myomectomy. This chapter tries to pull it all together to help you make an informed decision about your treatment.
What Can You Do?
Most conditions have several possible treatments and your options will depend on your own personal circumstances. Start here with your condition. Once you know what treatments are available to you, check out page 48 for a summary of the pros and cons of each.
Your Options-Pros and Cons
This table summarizes the advantages and disadvantages of each treatment. The pros and cons of the alternatives to hysterectomy are discussed more fully in Chapter 7.
What Is a Hysterectomy?
Hysterectomy involves surgically removing the uterus and there are several different types of hysterectomy procedures (see also Figure 6-1 on page 85).
Subtotal or Partial Hysterectomy
This procedure leaves the cervix in place.
A subtotal hysterectomy is an option if you have fibroids or heavy uterine bleeding. It is not suitable for women with cancer of the cervix or uterus, for obvious reasons. It's also not an option for uterine prolapse.
The advantage of subtotal hysterectomy compared to total hysterectomy is that it does not disturb the anatomy of the pelvic floor. In theory, this might prevent sagging of the vagina (prolapse) or the bladder in the future. There is also less risk of injury to the urinary tract and reduced chance of infection after the procedure, as bacteria from the vagina are less likely to contaminate the area of the surgery. Some women prefer to have their cervix left in the belief that sexual function is less likely to be affected. Evidence shows, however, that most women have improved sexual function after hysterectomy, whether or not their cervix is removed (see pages 146-150).
The disadvantage of subtotal hysterectomy compared to total hysterectomy is the theoretical risk of cervical cancer in the future, although with regular Pap screening this has now fallen to one-third its old rate-to only 3 in 1,000. In addition, some women may require additional surgery due to prolapse of the cervix or bleeding.
This involves removal of the entire uterus, including the cervix. If the ovaries are left in place, you will continue to ovulate, but, of course, you will not experience a menstrual period. If your ovaries are removed as well, this is called a total hysterectomy with salpingo-oophorectomy.
A total hysterectomy is needed for a uterine prolapse and for cervical or uterine cancer.
The advantages and disadvantages of a total hysterectomy compared to the alternative therapies are covered on pages 55-60.
Should You Keep Your Ovaries?
In women with uterine fibroids or abnormal uterine bleeding, routine removal of normal ovaries is no longer recommended -unless you are approaching 50 years old. Women with ovarian cancer or endometriosis will almost certainly have their ovaries removed. You may have heard that in up to 1 in 2 women the ovaries stop working after hysterectomy anyway, so you may as well have them removed. In fact, recent studies dispute these findings, so the decision really hinges on your risk of ovarian cancer.
The downside of removing your ovaries before your own natural menopause is that you suddenly enter surgical menopause and menopausal hot flushes and night sweats will start. Your risk of heart disease and osteoporosis also starts to climb. Because the average age of menopause is around 50, women who have their ovaries removed at the age of 40 may lose 10 years of normal ovarian function. After menopause, however, the ovaries do not produce substantial amounts of hormone and removal of the ovaries may be reasonable.
The advantage of having your ovaries removed is that you no longer run the risk of ovarian cancer, so if you have a strong family history of ovarian cancer or a personal history of breast, colon, or rectal cancer, removal of the ovaries is worth considering. However, the risk of developing ovarian cancer if you choose to keep your ovaries is fairly small-about 1 in 140.
A radical hysterectomy involves removing all surrounding tissues including the top of the vagina, as well as the uterus, and is generally reserved for cancer of the cervix. The tubes and ovaries may be spared in younger women.
As is described in more detail in Chapter 6, there are three possible routes for your hysterectomy: through your abdomen in the usual way, through your vagina, or via laparoscopy (keyhole surgery).
The abdominal route is needed for cancer or if the fibroids are very large.
Vaginal hysterectomy involves removing the uterus through the vagina (see Figure 6-4 on page 90) and is the obvious choice for women with prolapse of the uterus. However, it is also an option for other conditions in certain kinds of patients. If you don't have cancer, and your uterus is easily accessible and "mobile" (not too firmly attached to other organs), vaginal hysterectomy may be worth considering. The advantage is that you will avoid any incisions in your abdomen. However, bear in mind that vaginal hysterectomy is not an option if you want to keep your cervix.
Laparoscopy may be a good route if:
you have a non-cancerous uterus of less than 16-weeks size
you have persistant pelvic pain
you have endometriosis
your surgeon is comfortable with laparoscopic hysterectomy
Making Your Decision on Surgical Routes
Compared to abdominal hysterectomy, vaginal hysterectomy and hysterectomy by laparoscopy are associated with shorter hospital stays and faster recoveries. However, not all women are candidates for these minimally invasive approaches. Whether they are right for you depends on the reason for hysterectomy and also on the expertise of the surgeon with the procedure.
Your doctor will weigh the risks and benefits of each surgical approach and discuss it with you.
Are the Alternatives Right for Me?
The alternative procedures to hysterectomy are shown on pages 48-49. Uterine fibroid embolization involves shrinking the fibroids by blocking their blood supply with tiny beads. Endometrial ablation is a procedure that destroys the lining of the uterus. Myomectomy is a surgery that destroys fibroids while leaving the uterus intact. (For a detailed discussion of these procedures, see Chapter 7.)
Uterine fibroid embolization may be a better option for you than hysterectomy, myomectomy, or endometrial ablation, if you have uterine fibroids that are bothering you, you do not wish to undergo hysterectomy, and have no desire for more children. It is not recommended for cancer.
Endometrial ablation may be the better choice if you simply have heavy bleeding with no obvious cause (such as fibroids) and do not want a hysterectomy or children. You will need to understand that the results might be temporary.
Myomectomy is the treatment of choice if you have large or numerous fibroids and still want to have children. If you have more than three fibroids larger than 5 cm (2 inches) buried in the wall of the uterus, you will need an abdominal myomectomy. If you have no more than three, you may be able to have laparoscopic myomectomy. Hysteroscopic myomectomy (via the vagina) may be done for relatively small fibroids in the uterine cavity.
The Advantages of Hysterectomy
If you suffer from cancer of the uterus, cervix, or ovaries, hysterectomy is necessary. By removing the cancer, hysterectomy may completely cure you, depending on how advanced your disease is.
Hysterectomy also saves lives in cases of severe, uncontrolled bleeding, for instance, as a result of childbirth or a blood-clotting disorder, or if the uterus is severely infected.
Hysterectomy immediately stops uterine bleeding and the results are permanent. By contrast, following endometrial ablation, about 1 woman in 4 eventually goes on to need a hysterectomy.
Best Option for Uterine Prolapse
Severe uterine prolapse is best treated with hysterectomy via the vagina although reconstructive surgery may also be possible to preserve the uterus. Other alternatives are not as effective, although they may work as an interim measure. The best of these is a vaginal pessary, a doughnut-shaped device that is inserted into the vagina to support the sagging uterus. However, it is often impractical and inconvenient. It has to be removed every night, washed, and reinserted the next morning. The vagina can get sore and infected and occasionally the pessary gets stuck (or forgotten). Vaginal hysterectomy, along with surgical repair of the sagging organs, corrects the problem.
Quality of Life Improvements
Hysterectomy can improve quality of life by eliminating pain and bleeding. A recent study at the University of Maryland involving almost 1,300 women tracked the women's experiences of hysterectomy beforehand and 3, 6, 12, 18, and 24 months after their surgery. The results were published in the American Journal of Obstetrics and Gynecology in 2000. The study found that after 2 years, 94 percent of the women said the results were better than or as expected, and 82 percent said their health had improved since their hysterectomy.
The Downsides of Hysterectomy
Like other surgical procedures, hysterectomy is an invasive procedure, which means it requires an incision, is fairly hard on your body, and recovery takes several weeks. Hysterectomy varies from the minimally invasive vaginal and laparoscopy techniques to a more invasive abdominal hysterectomy. The results, however, are permanent. By contrast, you might undergo a myomectomy procedure, which has a similar recovery time, only to have your fibroids grow back.
Uterine fibroid embolization requires only sedation, and endometrial ablation can be done under general, regional or local anesthesia. By contrast, laparoscopic, abdominal hysterectomy and abdominal myomectomy almost always require general anesthesia. Vaginal hysterectomy may be performed under general or regional anesthesia.
More Chance of a Blood Transfusion
A blood transfusion is rarely needed for hysterectomy (about 1 to 2 percent of non-cancer procedures), but it is more common than in alternative techniques, with the exception of abdominal myomectomy. Myomectomy can involve quite high blood loss, so if you're considering it, also consider one or more blood conservation options that can be planned in advance such as blood banking (see page 70).
Longer Hospital Stay
The hospital stay depends on the type of hysterectomy procedure, but it will be longer than for an alternative approach-again, with the exception of myomectomy. For example, you will usually be in hospital no longer than 2 days following a laparoscopic hysterectomy, or a vaginal hysterectomy, and 3 to 5 days following an abdominal hysterectomy or abdominal myomectomy. Alternative procedures such as endometrial ablation do not require hospitalization. Although women often go home the same day after uterine artery embolization, if severe pain is experienced they will be kept overnight to ensure that pain is under control.
You may take longer recovering from hysterectomy than from one of the alternatives, especially if you had an abdominal hysterectomy, in which case the recovery time is several weeks.
Excerpted from So You're Having a Hysterectomy by Togas Tulandi Barbara Levy Excerpted by permission.
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|Chapter 1||You and Your Uterus||1|
|The facts on your reproductive organs|
|Their roles in both reproduction and sex|
|How it all works together|
|What can go wrong|
|Chapter 2||Tests and Investigations||30|
|The basic pelvic exam|
|Pap smears, ultrasound, colposcopy, D&C, biopsy, hysteroscopy, and laparoscopy|
|What they tell us|
|Chapter 3||Is Hysterectomy Right for You?||44|
|How to make your decision|
|Types of hysterectomy|
|Pros and cons of hysterectomy and the alternatives|
|Chapter 4||Getting Ready for Your Hysterectomy||63|
|Pre-admission tests and procedures|
|Planning for a blood transfusion|
|Questions you could ask|
|Chapter 5||The Day of Your Hysterectomy||75|
|Your hospital checklist|
|Arrival at the hospital|
|Preparations for surgery|
|Chapter 6||The Hysterectomy Procedure||83|
|Step-by-step guide to the procedure|
|Abdominal, vaginal and laparoscopic routes|
|Tests and other investigations|
|Closing the incision|
|Chapter 7||Alternatives to Hysterectomy||100|
|The facts on D&Cs, uterine fibroid embolization, endometrial ablation, myomectomy, and myolysis|
|Chapter 8||When it's All Over||123|
|What to expect when you wake up|
|Your recovery in the hospital|
|Eating, drinking, going to the bathroom|
|Leaving the hospital|
|Chapter 9||Recovering at Home||137|
|Caring for your incisions|
|Going to the bathroom|
|Work, exercise, driving, flying|
|Chapter 10||How You Can Help Yourself||152|
|A healthier future|
|Diet, vitamins, and herbs|
|Chapter 11||Has my Hysterectomy Worked?||173|
|What to expect right away|
|The long-term picture|
|Results for pelvic pain and endometriosis|
|Chapter 12||Hormone Replacement Therapy||178|
|Skin patches, gels, rings, creams|
|Who should avoid it|
|Chapter 13||Future Directions in Hysterectomy||188|
|Fertility- and nerve-sparing techniques|
|Chapter 14||Who's Who of Hospital Staff||193|