Know All the Facts Before Hysterectomy

By Brad Silverman, M.D., Scripps Health

One of the complaints gynecologists hear most often from their patients concerns abnormal bleeding, such as very heavy bleeding during menstruation or bleeding between menstrual periods.  While this can occasionally be a symptom of uterine cancer, the most common cause is a uterine fibroid, which is a non-cancerous tumor that grows from the muscular wall of the uterus. Many women have symptomless fibroids that don’t require treatment, but if a fibroid causes bleeding or other problems, it should be removed.

The conventional treatment for symptomatic fibroids is hysterectomy, or removal of the uterus.  Hysterectomy used to require an open surgery with a large abdominal incision, but in many cases, it can now be performed laparoscopically. This is a minimally invasive process which requires a few smaller incisions rather than one large incision; when performed by a skilled laparoscopic surgeon, it can offer benefits including less pain and bleeding, fewer risks of complications, a shorter hospital stay, and faster return to activities.

One consideration in determining whether a woman is a good candidate for laparoscopic hysterectomy is the size of her uterus and how it can be removed from the body following surgery. Because the incisions are small, a large uterus might not fit through them.  Vaginal removal may be one option; another may be to place the uterus into a bag and reduce it to smaller pieces that can be taken out through the incision. However, not all surgeons are skilled in these techniques.

 Another option is to use a device called a power morcellator, which is a metal tube that is sharpened on the end and has a grasper. It is inserted through the incision, where it cuts into the uterus and pulls out whatever is being extracted. As this happens, microscopic fragments of the tissue may break off and be spread throughout the abdomen. If the fibroid is benign, as most are, this is not a serious problem. However, if what is thought to be just a benign fibroid is actually a cancerous uterine tumor (sarcoma) that has not been diagnosed, morcellation can potentially spread the cancer throughout the abdomen.  Although uterine sarcomas are very rare, they are highly malignant and, despite appearing to be confined to just the uterus, metastasize very quickly and may have already begun to spread in some patients. Morcellation could speed up this process and spread cancerous cells faster.

Why not test for malignant uterine tumors before using the morcellator? Unfortunately, there is no reliable test available. They are most commonly diagnosed when a woman has surgery for a preoperative diagnosis of fibroids.

Due to the possibility of spreading cancerous cells, the FDA recently issued a warning about the use of morcellators in hysterectomies, and is debating whether they should be banned. It is important to consider, though, that morcellation makes minimally invasive surgery possible for a significant group of women with large uteri who otherwise would undergo open surgery and its associated risks and drawbacks.  In contrast, there is a very small group of women in whom morcellation is a disastrous outcome. What is the right answer?

In this case, the right answer seems to be to ensure that every woman is able to see a surgeon who can explain all of the options to her, so that she understands the benefits and risks and can make a personal choice. It seems unacceptable to tell patients that they can’t have the opportunity to decide for themselves. We need to guarantee that patients understand the risks they are assuming in order to make an informed decision.

Michael “Brad” Silverman, M.D., is an ob-gyn  with Scripps Health. For more information or for a physician referral, please visit www.scripps.org or call 1-800-SCRIPPS (1-800-727-4777).