On Women: Hysterectomy Usually Isn't the Only Choice

Some gynecologists are reluctant to offer minimally invasive procedures, so it's up to women to ask

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In the age of "patient empowerment," it seems almost a cliché to tell women to take charge of their health and demand more from their doctors. But when it comes to certain gynecological procedures, they need to do just that. One in four American women gets a hysterectomy, a rate that hasn't declined much in 25 years even though newer procedures can relieve uterine bleeding and painful periods—the most common reasons for the surgery—while sparing the uterus. What's worse, more than 85 percent of hysterectomies are still performed through a large abdominal incision, despite the fact that a less invasive method, in which the uterus is removed vaginally with the aid of a laparoscope inserted through tiny abdominal incisions, has been possible for over a decade.

This is pretty shocking, considering that 80 percent of gallbladder surgeries are done using a laparoscope and that recovery time can be reduced from at least six weeks down to two. "We need to educate women about these techniques," lamented gynecologist Charles Miller at last week's meeting of the Global Congress of Minimally Invasive Gynecology in Washington. He and other experts complained about the lack of media coverage of these kinder, gentler procedures; indeed, I was the only consumer reporter on site covering their comments.

Gynecologists are clearly shying away from these minimally invasive procedures. Laparoscopy is more difficult to perform, raising the risk of complications like perforation of the colon for those who aren't properly trained, says Elizabeth Battaglino Cahill, executive vice president of the National Women's Health Resource Center. And it usually leads to lower reimbursements than traditional surgery because of shorter hospital stays and less time in the operating room. Lower reimbursements may also explain why very few doctors have embraced a new sterilization technique that can be done in the office. Hysteroscopic sterilization, a procedure in which tiny coils are inserted up through the cervix into the fallopian tubes, is just as effective as tubal ligation without the surgical recovery time or risks from anesthesia. Its only disadvantage: Women need a follow-up imaging test after three months to ensure that the tubes have permanently closed; in 5 percent of cases, coils have to be inserted a second time. "It's a 10-minute procedure, where women can get off the table and go back to work. But many aren't aware it's available," says Keith Isaacson, an associate professor of obstetrics and gynecology at Harvard Medical School.

When it comes to having a hysterectomy, women tend to be kept in the dark about their various options. Besides favoring laparoscopy, up-to-date surgeons take the "less is more" approach, leaving the ovaries and cervix whenever possible. "Research now shows that the ovaries continue to produce some hormones up until age 80 and that women live longer with them than without them," says gynecologist William Parker, a clinical professor at the UCLA School of Medicine. Preserving the cervix may help avoid bladder problems and the reduction in sexual sensation often associated with hysterectomies.

Sometimes, the uterus doesn't need to be removed at all. In certain cases, like uterine cancer, hysterectomies are clearly warranted. But far more often, experts say, they're performed unnecessarily. Excessive bleeding and menstrual problems can be treated with endometrial ablation, in which a laser or electrical loop is inserted into the uterus through the cervix to destroy a thin layer of the lining and permanently stop periods. Troublesome fibroids can be excised through a surgery called myomectomy or treated with uterine artery embolization, which cuts off their blood supply, causing the benign growths to shrink. These procedures add up to less pain, shorter recuperation times, and a savings in terms of medical fees and lost work time.

Be aware that you may need to quiz your doctor about all the options and seek a second opinion if you're steered toward invasive surgery. Since there's a learning curve with every new technique, you'll want to find out how often a doctor performs it and ask about complication rates. In general, Parker says, gynecologists should have at least 30 cases under their belt before considering themselves proficient, and complication rates should be less than 1 percent.