Alternatives to hysterectomies

THERE are a number of less invasive alternatives to a hysterectomy that have been made possible by developments in modern medicine, according to York District Hospital consultant gynaecologist Adrian Evans. They include everything from new forms of medication to using a hysteroscope to strangle or vaporise the fibroids which can cause heavy bleeding.

Many of the treatments are quick, safe and effective, says Mr Evans. And while they are not all appropriate in every case - a gynaecologist will assess each woman's history and condition before deciding which approach to adopt - it may be partly the attitudes of patients themselves that explains why some are not more widely used.

Nationally, he says, the number of hysterectomies being performed is going down: but not as quickly as it could be. Many women suffering the misery of heavy periods and heavy bleeding believe a hysterectomy may be the answer to all their problems.

"It may be that their mother had one, and she says 'I was never better than after my hysterectomy,'" he explains.

"People used to have a hysterectomy at the drop of a hat, but there are other things now that are so much better and less invasive."

There is no doubting that heavy periods can be a major inconvenience and discomfort, Mr Evans says - one that is not given the attention it deserves. Five per cent of all GP consultations are about heavy periods, he points out.

"It is a quality of life issue," he adds. "It is rare that people are endangered: but they do tend to feel tired all the time if they have very heavy bleeding. Most women are home makers and are working women as well, and it can mean that they do need to take time off.

"Often, the reason women consult us is because they have got to the point where they are regularly having one to two days off because it is so socially inconvenient."

But while a hysterectomy may solve the immediate problem, it is a major operation, with all the risks that that entails. Up to one in 1,000 patients undergoing a hysterectomy may die, and there is also some risk of an earlier menopause.

Because it is major surgery, it may require several days in hospital and then a long period off work - and there can be long-term problems, such as a prolapse or problems with controlling the bladder.

Ultimately, Mr Evans says, it is a woman's choice.

"I see myself as giving advice of what the different options are and try to help them see that a hysterectomy is a last resort.

"If a woman requests a hysterectomy, I will perform it. But I prefer to try other things first." So what are the alternatives?

Generally, says Mr Evans, a gynaecologist will want to try using medicine first, before turning to minimally invasive surgery which does not involve removal of the uterus, and considering hysterectomy as a last resort.

Here are some of the options:

Medical treatments

Tranexamic acid - a drug that can help to reduce bleeding by up to half. Initially used to reduce bleeding after tooth extraction, but now widely used for heavy periods as well.

Mirena - a tiny frame similar to a coil which sits in the uterus and gradually releases small quantities of a hormone that can again reduce bleeding by up to a half by 'fooling' the lining of the womb so it does not prepare to receive an egg. It can also used as a contraceptive.

Minimally-invasive surgery

Hysteroscope - a long thin tube with a tiny camera on the end that can be inserted into the uterus for diagnosing fibroids or polyps. Polyps can be nipped off in a very simple procedure using tiny forceps.

Bipolar diathermy - the hysteroscope is used to insert a tiny electrode inside the uterus. An electric current is then applied to 'vaporise' the fibroid. The technique can be carried out while the patient is awake.

Thermal ablation - a tiny probe is inserted into the uterus and a small balloon on the end is filled with water. This is heated to 87 degrees C, 'burning' and so killing off the lining of the uterus. Effective in eight out of ten cases. Can be carried out under local or general anaesthetic.

Endometrial resection - again performed under local anaesthetic using a hysteroscope. The membrane lining the uterus is cut away using a 'hot wire'.

Uterine artery embolisation - Generally used with larger fibroids, which can be up to the size of a 20 week old baby.

Updated: 09:02 Monday, September 30, 2002