Women's Problems
For generations, women whispered in low tones about going into the hospital for "women's problems." It was the inevitable and dreaded hysterectomy, which became as common as a tonsillectomy--it seemed easier to remove the source rather than treat the problem. Approximately 600,000 hysterectomies are performed each year in the U.S., according to The Journal of the American Medical Association, but in recent years, women have experienced an increased awareness of their bodies, and medical practitioners and technology have kept pace. Alternatives now enable women to keep their reproductive organs, and still treat the symptoms of discomfort and disease--without major surgery, long hospital stays and recovery time.

Causes for Hysterectomy
The most common reasons for hysterectomy, or removal of the uterus, are pain, abnormal, heavy bleeding and fibroids, with cancer or other life-threatening disease as a more rare occurrence. "We recognize that hysterectomy has its role--it does improve the quality of life for some women--but appropriate medical management could help women deal with conditions that would otherwise lead to hysterectomy," states Dr. Andrew M. Kaunitz, Professor and Assistant Chairman of the Department of Obstetrics and Gynecology and the University of Florida Health Science Center.

Fibroids, or smooth tissue tumors, also known as leiomyomata, are the most common cause--20-40% of women age 35 and older have uterine fibroids of a significant size, while endometriosis, an irregular growth of the uterine lining, and adhesions, normally separate tissues that grow together, are also problematic.

What's New?
Surprisingly, some of the alternative therapies come not from obstetrics and gynecology, but from radiation and cardiology. The angioplasty, or balloon therapy, commonly used to clear clogged arteries, introduced similar treatments for women. A group of specialized doctors, called Interventional Radiologists (IRs), provide "non-invasive" options that can eliminate the need for major surgery. Says Malay K. Mody, M.D., of the Summa Health System in Akron, Ohio, "The hallmark of what we do, is use imagery techniques, seeing within the body, not just to diagnose, but to do therapeutic procedures as well." IRs use methods like MRI, (magnetic resonance imaging), ultrasound, and X-ray, to monitor the maneuvering of tiny tubes called catheters, through blood vessels. Dr. Jacques Ravina in Paris, led the way six years ago, while Dr. Scott Goodwin introduced IR to the U.S. at the UCLA Medical Center in Los Angeles.

Selective Uterine Embolization
Both Dr. Ravina and Dr. Goodwin conducted studies that showed fibroid tumors, which account for nearly one-third of all hysterectomies in the U.S., could be treated non-invasively by selective or uterine artery embolization, with a high success rate.

Uterine artery embolization cuts off the blood supply to the tumor, which usually shrinks it by 40-50%, lessening or eliminating the pain and bleeding. While the patient is conscious, but sedated, a small nick is made in the groin area, to access the femoral artery, where a catheter is inserted and steered through the artery to the uterus. Tiny plastic particles are inserted into the blood vessels on both sides of the uterus, effectively blocking the blood supply. The patient requires six to eight hours of bed rest, so a one-night hospital stay is possible. Pain killing medication and antibiotics are often prescribed to fight cramping, fever and infection, and most patients recover in one to two weeks. Though some women have become pregnant after the procedure, fertility and menstruation issues have not been adequately studied.

While the procedure has been used for over 20 years, to stop bleeding after childbirth, approximately 1,500 to 2,000 fibroid embolization procedures have more recently been performed world-wide, reports the Society of Cardiovascular & Interventional Radiology (SCVIR). A geographic IR search service is available on the organization's web site www.SCVIR.org.

"Many doctors are not aware of [interventional radiology]," states Peter Swischuk, M.D. of Shands Jacksonville, "Some have heard about it and don't believe it…some know, but it comes down to a patient decision--the patient should know all the alternatives." Like most interventional radiologists, Dr. Swischuk prefers referrals from a gynecologist, or will refer a patient back to a supportive OB/GYN. "Turf is a big issue with physicians as in any profession," comments Dr. Kaunitz, "But our patients' welfare needs to transcend turf."

Endometrial Ablation
Another option to hysterectomy, endometrial ablation, or removal of the uterine lining through laser or heat, can also be done laparoscopically, through a catheter, as an alternative to open abdominal surgery. This procedure has widely replaced D&C's (dilation and curretage), the scraping away the uterine lining, which provides only temporary relief. Endometrial ablation, has a reported 70% success rate, but it is not recommended when fertility is an issue.

For endometriosis, lesions or nodules can also be removed by laser, cautery, vaporization or cutting with small surgical instruments that fit through laparoscopy tubes. Laparotomy is a more invasive method, where the abdomen is cut, requiring a hospital stay of two to four days and a recovery time of four to six weeks. A recurrence rate of 15-20% has been reported after these surgeries.

Prescriptions for Pain and Bleeding
Since most fibroids decrease with the onset of menopausal drops in estrogen levels, many doctors use hormonal treatment to alleviate the symptoms of pre-menopausal women.

"Hormonal treatment including oral contraceptives, can prove invaluable in restoring regular cycles, reducing heavy menstrual flow or cramps, shrinking fibroids, and for a variety of other gynecological situations," states Dr. Kaunitz. The lower estrogen level in the birth control pill sends a message to the ovaries to stop producing estrogen.

Similarly, GnRH (gonadatropinreleasing hormone agonists), synthetic hormones, act on the brain, to stop hormone production. One shot per month for 3-6 months has been shown to deliver results for fibroids and endometriosis. However, such hormones create menopause-like side effects and symptoms and fibroids recur soon after the treatment stops.

Non-steroidal antinflammatory (NSAID) drugs like Motrin can also help alleviate painful mentrual cramps, and while some naturopaths have also recommended herbal therapies like Prim Rose Oil and Cramp Bark for pain, there is no medical evidence to substantiate their effectiveness.

To Cut or Not to Cut...
If less invasive methods fail, surgery remains an option, but not necessarily a proven cure. Abdominal myomectomy, cutting fibroids and removing them through an abdominal incision, does not prevent more fibroids from forming and may involve a more difficult and longer recovery time. However, it does save the uterus and cervix, making it an alternative for younger women who wish to maintain their fertility.

Myomectomy may still be done less invasively with a hysteroscope through the vagina and cervix, or through a small incision that accommodates a laparoscope camera and medical instruments. Both methods generally require anesthesia and myomectomy patients may still require a hysterectomy for on-going or recurring problems with fibroids.

When both patient and doctor opt for a hysterectomy, there are still options. Whether or not to remove the ovaries is a major consideration. According to the National Center for Health Statistics, 45% of hysterectomies remove both ovaries, while in some cases only one is removed. Loss of the ovaries induces "surgical menopause," often with sudden and severe symptoms like hot flashes, vaginal dryness and night sweats. Partial hysterectomies leave the ovaries in tact.

Often, a supracervical hysterectomy can be performed, removing only the uterus and not the cervix. If done abdominally, a two to three day hospital stay and a six week recovery can be expected. When done laparoscopically, patients can go home the next day and expect a two to four week recovery.

Burt Webb, OB/GYN from the Burt Webb Center for Women's Care in Scottsdale, Arizona, prefers not to remove the cervix to preserve the libido. "I believe about 30% more patients enjoy intercourse more when we leave the cervix," he notes, "I believe that is a valid concern--more so than the low risk of cervical cancer," Webb adds.

Some believe that women experience psychological trauma after hysterectomy, not to mention the difficulty of a three to five day hospital stay and four to six week recovery. Many women do not have the option to put families and jobs "on hold" for that long.

Insurance is also an issue, for while most policies cover hysterectomies, they may not cover the alternative therapies. The most important factor, is to seek medical treatment when pain or bleeding is severe. If a doctor is unaware of alternatives or will not discuss them, seek a second or third opinion. There are choices, reminds Dr. Swischuk, "This is going to be the future treatment option for 20-30% of patients--we just get really good results."

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