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Moderator: Welcome to Viewpoint! Today we're speaking with Dr. Amy Porter from the Virginia Hospital Center on hysterectomy choices. Send us your questions and comments any time during the discussion. In the meantime, let's get started!

Amy E. Porter, MD: Thanks so much. I'm happy to be here and looking forward to the discussion.

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Savage, MD: What is the criteria for having a procedure done vaginally? I've already had an unsuccessful uterine emobolization and now have been told that a tradional hysterectomy is my only remaining option.

Amy E. Porter, MD: Ultimately, the ability to clamp the blood vessels determines the feasibility of the vaginal approach. Consideration of several factors is required:
Patient's body ability to access the uterus from the vagina
Any history of childbearing? Vaginal vs. C-Section
Any previous pelvic/abdominal surgery
Any benign vs. malignant family history

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Fairfax, Va.: I understand that hysterectomies are used to treat a number of medical issues. Everything from cancer to fibroids to chronic pelvic pain. How do you know if a laparoscopic alternative would be suitable given your medical condition?

Amy E. Porter, MD: Once again, accessibility/ability to clamp blood vessels determines the feasibility of the laparoscopic approach. Uterine size and especially location of fibroids relative to the blood vessels is the key factor of laparoscopy. Laparoscopic options are a good alternative to vaginal or abdominal options if a patient is a candidate for minimally invasive surgery but a vaginal hysterectomy alone will be technically impossible. Lapaproscopy can especially address mild pelvic adhesions.

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Falls Church, VA: I have been diagnosed with a fibroid tumor. My doctor is recommending a hysterectomy. I am 43 years old. I really don't want a hysterectomy. What are my options?

Marie

Amy E. Porter, MD: Management of fibroids is dependent on what your treatment goals are. For example, if we're treating excessive bleeding your doctor may discuss many different medication types, endometrial ablation, myomectomy, uterine artery embolization, and hysterectomy. If your symptoms are related to the size of the uterus, then a myomectomy or hysterectomy would be your lead choices.

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Fairfax, Va.: What are the other options other than hysterecomies?

If you have uterine fibroids, I understand that there may be other surgical alternatives or embolization. If so, what actually is involved in uterine embolization?

Amy E. Porter, MD: Once again, options depend on what your treatment goals are; control of bleed, pain, bulk symptoms like bladder or rectal pressure or sexual pain. Once a treatment goal is selected, proper treatment options can be discussed.

Uterine artery embolization involves threading a catheter through the femoral artery and into the small blood vessel feeding the uterine fibroid. The vessel is then blocked, which deprives the fibroid of nutrients and causes it to shrink.

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Silver Spring, Md.: My aunt had a hysterectomy and she was bed-ridden for weeks. What is the recovery time of a vaginal hysterectomy?

Amy E. Porter, MD: A typical hospital stay is one to two days overnight for a vaginal hysterectomy. Patients will be home for two weeks and then will mostly get back to their normal lifestyle. However, it is necessary to take it easy for six weeks because that is the healing time for sutures and the pelvic floor, and you don't want to disrupt the surgical bed.

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Takoma Park, Md.: Are there any steps I can take now to prevent having to have a hysterectomy in the future? Nobody in my family has had one. I am 37.

Amy E. Porter, MD: There is no prevention specifically for hysterectomy. Most of the problems that result in a hysterectomy are in a person's family history, like fibroids. It is a good thing that no one in your family has needed one.

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Fairfax, Va.: There are a number of risks associated with hysterectomies, how does that change with the laparoscopic alternative?

Amy E. Porter, MD: Actually, the risk for ureteral damage is slightly increased with a laparoscopic hysterectomy, but this risk is small. The main benefits of this approach come in decreased hospital stay, shorter patient recovery time and higher patient satisfaction.

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Huntingtown, Md.: After having a myomectomy my uterus is still enlarged. Should I consider other options in place of the traditional hysterectomy?

Amy E. Porter, MD: The treatment of your enlarged uterus will depend on two things: 1) what symptoms are we managing, and 2) is fertility still an issue for you. Merely having an enlarged uterus is not necessarily a need for surgery.

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Washington, D.C.: Can you discuss the preconditions for a uterine embolization (sp?) procedure? I've heard that this is a safer, less invasive way to avoid having surgery and also allows for the continued hormonal benefits. Thanks.

Amy E. Porter, MD: Uterine artery embolization is performed for large fibroid uteri. The fibroids should not be pedunculated (on a stalk) or submucosal (within the uterine lining) in location. Recent literature suggests a 75% success rate over five years for women who underwent UAE for excessive bleeding. It does not appear to be as good for bulk symptom control.

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Alexandria, Va.: Which procedure has the shortest recovery time?

Amy E. Porter, MD: Both the laparoscopic and vaginal approaches have a comparable recovery time. If the procedures go without difficulty, the biggest side effects are pain for a few days and fatigue up to two weeks. We still recommend no heavy exercise for the first six weeks after.

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New York, N.Y.: What do you recommend as a good online resource for this kind of information?

Amy E. Porter, MD: Some reputable web sites include mayoclinic.com and acog.org (American College of Obstetrics & Gynecology).

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Baltimore, Md.: All all GYNs up to speed on these procedures?

Amy E. Porter, MD: Surgical training for gynecologists is an ongoing process throughout their career. A good surgeon will always be mentoring with colleagues and attending specialized training sessions to maintain their skills. All GYNs are comfortable with the abdominal approach. Most GYNs are quite skilled with the vaginal approach, especially if their training programs emphasized this. Laparoscopy has long been a skill used in gynecology, and the additional education required to use the tools for a laparoscopic hysterectomy is available to practicing physicians. Definitely discuss with your doctor their comfort level with procedures-- you never want to talk your doctor into doing something he/she is not fluent with. Sometimes, the safest procedure for you is the one your doctor is going to do right.

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Centreville, Va.: Are both ovaries always removed when a hysterectomy is performed? If not, what determines how many are removed?

Amy E. Porter, MD: To remove or not to remove, that is the question. Historically, over the age for 45 a woman undergoing hysterectomy would have both ovaries removed to prevent ovarian cancer. Statistically, that results in the removal of hundreds of thousands of ovaries that would never have been involved in pathology. So now the question is, should they be removed routinely? This is a complex question that requires a discussion with your doctor about your individual risk factors and desires related to hormone replacement therapy.

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Centreville, Va.: What is the difference between a complete hysterectomy versus a radical hysterectomy? Thanks.

Amy E. Porter, MD: A hysteretomy is the removal of the uterus.
A subtotal hysterectomy (also known as a supracervical) is the removal of the uterus, but leaves the cervix behind.
In the lay public, a "complete hysterectomy" usually refers to removal of uterus and the ovaries. Medically, we do not use this term.
A radical hysterectomy is a special, extensive hysterectomy done for cancerous reasons.

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Downtown: Why do you think so many doctors don't fully inform their patients of all of their options. I've been in situations with my parents where I feel like you have to pry information from the doctor on the reasons why they prescribe a procedure or even options. It's scary to think that you have to know the right questions to ask when doctors tend not to be so forthcoming.

Amy E. Porter, MD: A patient should always feel that they can have as in-depth an interaction with their doctor as they desire. Some patients do not involve themselves in complex medical decisions. I cannot speak to the personal nature of your question; however, sometimes doctors are going through a complete thought process regarding all of your options, and are selecting out what they feel are to be the most viable options.

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Baltimore, Md.: If I have a hysterectomy will I still go through menapouse?

Amy E. Porter, MD: Yes. If your ovaries are removed, you will be in surgical menopause, which will occur immediately. If your ovaries remain behind, menopause tends to occur a year or two before its normal timeline in a hysterectomized woman. The actual definition of menopause = no period x 1 year. I take your question to mean the other signs and symptoms of menopause, which can include PMS, moodiness, sleeplessness, acne, hair changes, hot flashes, etc. Management of these symptoms is still possible.

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Fairfax, Va.: My sister recently went through surgery to have fibroids removed, the laparoscopic sounds like it would have saved her from a lot of discomfort. Why don't all surgeons offer this?

Amy E. Porter, MD: Laparoscopic removal of fibroids is generally done on well-selected patients with fibroids that are easily accessible, like pedunculated ones. If a person is trying to maintain their fertility, often an open myomectomy is the procedure of choice.

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Boston, Mass.: If you had all options open to you, which procedure would you have?

Amy E. Porter, MD: Although I hope not to have a hysterectomy, I would prefer the vaginal approach.

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Oklahoma City, Okla.: Is hysterectomy the treatment of choice for cervical cancer?

Amy E. Porter, MD: Cervical cancer, not an easy question. Super-early stage cancer in a woman who wants to be pregnant can be managed by a specialist with a cone procedure. Early stage cancer is treated with a hysterectomy plus radiation or chemo. Anything beyond early stage cancer is actually non-operable at this time.

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New York, NY: What are the three types of hysterectomy, and how are they performed?

Amy E. Porter, MD: Generally, the three types are:
Abdominal- incision in abdomen, hands-on access to uterus, blood vessels clamped, uterus removed.
Transvaginal- cervix is grasped in the vagina, incision in vagina, hands-on access to uterus, blood vessels clamped, uterus removed.
Laparoscopic- one cm incision in bellybutton, abdomen inflated with carbon dioxide, other small incisions made in lower abdomen and access ports are placed, instruments inserted through these sites, blood vessels clamped, uterus cut off at base, uterine tissue is sequentially chopped up and evacuated.

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Washington, D.C.: How does hysterectomy impact sexual function?

Amy E. Porter, MD: The biggest study to date on sexual function following hysterectomy was actually a survey of women regarding their own sexual health. The best predictor of good sexual function postoperatively (regardless of hysterectomy mode) was good sexual function preoperatively. In fact, women with good sexual function pre-op often had better sexual function post-op because they were no longer suffering from heavy periods, pain, and pressure.

There is a lot of debate in our literature regarding the cervix, i.e., should it be left in at the time of hysterectomy. There is no definitive role for the cervix in sexual function identified at this time.

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Washington, D.C.: Dr. Porter, can you tell me about the risks associated with having a hysterectomy?

Amy E. Porter, MD: Risks with all surgical types are: bleeding, infection, damage to bowel and bladder. Bleeding and infection risk tend to be higher with an abdominal approach. As I mentioned earlier, laparoscopy has a slightly higher risk of ureteral and bladder injury. Vaginal surgery holds the same risks but they are statistically lower probability. All surgery also poses anesthesia risks. Abdominal and vaginal surgeries can be done with regional anesthesia; laparoscopic surgery requires general anesthesia (intubation).

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Bethesda, Md.: What are the most common conditions that require a hysterectomy?

Amy E. Porter, MD: There are many conditions that may result in a hysterectomy. Some of them are:
Excessive bleeding
Endometriosis
Chronic pelvic pain
Adenomyosis
Fibroids
Cancer

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Moderator: Unfortunately, our hour is up. We've received lots of great questions. Thanks to Dr. Porter for fielding our inquiries.

Amy E. Porter, MD: You're welcome-- it's been my pleasure to be here today. For more information, you may want to visit virginiahospitalcenter.com or vhchysterectomy.com (an excellent explanation of all three hysterectomy options). For those interested in consulting me, I am always taking new patients and appointments may be made by calling 703.528.6300 (Arlington) or 703.437.8080 (Herndon).

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