Category: Hysterectomy

by Marcelle Pick, OB/GYN NP

Making the decision can be a difficult – and sometimes scary decision for some women. Many times, hysterectomy is recommended as a solution for a series of symptoms, other times its recommended due to disease.

Reports show than more than half of all women who undergo hysterectomy but retain their ovaries will experience symptoms of hormone shifting and imbalance – even though their ovaries are left in place and continue to function. What many women aren’t told is that the uterus and ovaries share their blood supply and once the uterus is removed, ovarian function can be negatively affected.

Women who enter menopause seemingly overnight have an oophorectomy – this is when the ovaries and uterus are removed. Many women are immediately put on synthetic HRT but still report menopausal symptoms – many times in the moderate to severe range.

If you have had or are considering a partial or total hysterectomy, or a total hysterectomy with bilateral oophorectomy, there are things you can do to help your body restore its hormonal balance.

You may want to consider hormone replacement therapy (HRT). Talk with a qualified healthcare practitioner to help you make this decision. Personal beliefs, family history and other risk factors – along with the way you feel should all be taken into consideration.

I recommend my patients consider phytotherapy. There are herbs like black cohosh, ashwagandha, red clover and chasteberry which are known to provide support for the sex hormones (estrogen, progesterone and testosterone) which fluctuate after a hysterectomy.

Many women will report having persistent hot flashes. I recommend using soy isoflavones – about 80 mgs a day. I suggest that you chose soy which is derived from the whole bean (not the germ) in either powder or pill form. I also recommend a high quality multivitamin/mineral complex dietary supplement. It’s a great way to support your body and insure that you are getting the nutrients you need during a time of hormonal transition.

by Marcelle Pick, OB-GYN, NP

Generally, many women who undergo a hysterectomy (but retain their ovaries) will experience changes in their hormones, even though they still have ovarian function. Some won’t note any differences following their hysterectomy, whereas others will immediately notice significant symptomatology of menopause, even though their ovaries are intact.

We have several recommendations for women who are having a hysterectomy.  First, they may want to consider the use of natural progesterone prior to the hysterectomy. They may then want to have their hormones evaluated by a local practitioner and introduce natural progesterone, 21 days on and one week off, or two weeks on and one week off.

In addition, we recommend they begin using soy isoflavones, 80 mg a day, to prevent the symptoms of hot flashes. We also recommend the use of black cohosh, one tablet twice a day, in-between meals, a quality multivitamin that contains calcium and magnesium, and omega-3 essential fatty acids. This will prove to be extremely beneficial, along with dietary changes consistent with decreasing carbohydrate intake, to alleviate many of the symptoms that some women experience after having a hysterectomy.

by Marcelle Pick, OB/GYN NP

Second only to cesarean section, hysterectomies are one of the most commonly performed surgeries on women — more than a half a million each year. This operation is done to remove all or part of the uterus, sometimes the cervix, and the ovaries. In certain cases, a hysterectomy is warranted – to save lives, to alleviate serious problems, to correct things impairing normal functioning and of course to improve the quality of life.

But I don’t recommend this course of action unless absolutely medically necessary and for several reasons. First of all, a woman’s reproductive system is central to the core of her, representing her femininity from puberty, through childbearing years, and even beyond menopause. Losing this aspect of womanhood, even symbolically, can leave emotional scars. While healing is possible on every level – both physically and emotionally – it can be traumatizing to lose fundamental organs.

Removing the uterus and other reproductive organs also poses physical risks and has consequential side effects, including and not limited to: bleeding and infection, damage to nearby tissue, hormone changes, symptoms of menopause, bladder and intestinal changes. Like with any other major surgery, a hysterectomy can have repercussions.

Surgical treatment may relieve much of the discomfort associated with uterine problems – bleeding, pain, bloating, and malaise — but I always try to first suggest the most minimally invasive procedures, utilizing medical management and natural treatments when possible, and often can obtain quite positive results.

Let’s examine the issues that contribute to surgical intervention, and some less invasive alternatives.

Menorrhagia (or heavy bleeding)

Menorrhagia is a common complaint for women, frequently prompting physicians to quickly consider a hysterectomy. But what constitutes heavy menstrual bleeding for one woman may not mean the same thing to another. In traditional medical practice the common phrase, “dysfunctional uterine bleeding,” is used to describe unusually heavy menstrual flow, as well as abnormal incidents of bleeding or spotting (such as between periods), after intercourse, after menopause, longer than a period, or heavier than a normal period. When a woman experiences atypical or excessive amounts of bleeding, we evaluate what may be causing it – physiologically, systemically, and even emotionally. Here are some common causes of menorrhagia and other uterine conditions:

• Uterine fibroids – noncancerous tumors in the uterus.
• Polyps – small, noncancerous growths on the lining of the uterine wall.
• Hormonal imbalance – causing excessive build up of the lining of the uterus.
• Ovarian dysfunction – leading to hormonal imbalance.
• Complications from pregnancy – miscarriage or ectopic pregnancy, when an egg implants in the fallopian tube instead of the uterus.
• Intrauterine device (IUD) – this form of birth control may cause heavy bleeding.
• Perimenopause – the transitional hormonal state leading up to menopause.
• Endometriosis – growth of the tissue normally inside the uterus which grows outside of the uterus.
• Adenomyosis – when endometrial glands from the endometrium embed in the uterine muscle. Endometriosis that is in the muscle of the uterus.
• Cancer – it is rare that uterine, cervical or ovarian cancer cause heavy bleeding.
• Medications – some medications can contribute to prolonged menstrual bleeding.
• Certain medical conditions – some diseases such as endometriosis, pelvic inflammatory disease, thyroid problems, lupus, and others can contribute to menorrhagia.

When abnormal pathology is ruled out, then we take a look at lifestyle and environmental factors that may be contributing to hormonal imbalance and menorrhagia. The state of hormones throughout a women’s cycle is like a delicate dance, and sometimes messages between hormones and body parts can be jumbled. These “mixed messages,” can influence their functioning, causing abnormal bleeding. Before jumping right to surgery, we try to restore hormonal balance naturally, sometimes through use of bioidentical progesterone, natural supplements, and lifestyle changes including decreasing stress and enhancing nutrition. By taking things a step at a time, with patience and respect for our body’s natural requirements and rhythms, we may be able to avoid surgical intervention.

Endometrial ablation

An endometrial ablation is one option for the treatment of abnormal uterine bleeding when hormonal therapies have failed. This is a procedure to remove the lining of the uterus, or endometrium. It is less invasive than a hysterectomy, and allows a woman to keep her uterus. Ablation means “to remove by erosion, melting, evaporation, or vaporization.” Endometrial ablation is done with a hysteroscope, along with a device that heats, freezes, or lasers the endometrial lining. This destroys a layer of the lining, and will usually completely stop monthly periods. Ablation may also be useful for examining select areas of the endometrial lining when other techniques, such as biopsy, may not be adequate.

This procedure is performed by a trained gynecologist (GYN) on an outpatient basis, or even in the office. It is fairly straightforward, with a manageable recovery. In certain circumstances, such as re-growth of the lining, a second ablation needs to be done. However, recent advances in the technology and devices used to perform ablations have decreased the incidence of repeat procedures.

Although endometrial ablation does work well for many women, it also eliminates the ability to carry a successful pregnancy. In fact, post-ablation pregnancies can be risky, so birth control is an important consideration. There is also a risk that endometrial ablation might mask endometrial cancer later in life, because it removes any spotting that would signal something abnormal going on in the uterus.

Other procedures

When uterine conditions require treatment beyond non-invasive methods such as hormone therapy, nutritional supplements or lifestyle remedies, certain other procedures can be performed prior to having a hysterectomy.

• Hysteroscopy: a thin, lighted tube is inserted through the vagina into the uterus, allowing a view of the cervix and uterus. Hysteroscopy can be diagnostic or operative. During an operative procedure, small instruments are inserted through the hysteroscope to treat certain conditions such as fibroid tumors.

• Myomectomy: an instrument is inserted through the vagina or abdomen to remove fibroid tumors. Depending on the size, location, and number of fibroids, myomectomy can be performed via hysteroscopy (vaginally), laparoscopically (through a small scope inserted into the abdominal cavity), or abdominally (a considerable medical procedure).

• Uterine artery embolization (UAE): a catheter is thread into the uterine artery to inject tiny particles which cut off blood supply to fibroid tumors. It is performed by an interventional radiologist, who specializes in treating internal conditions without making a surgical incision.

Choosing the best option

The decision to have a hysterectomy is complex, personal, and may seem intimidating. Although we have come a long way, there are still limitations with these types of procedures. With time we can look forward to medical technology bringing us more advanced treatment alternatives to hysterectomy. But until then, these techniques do offer women and their healthcare practitioners some useful options. In addition, exploring alternative treatments with fewer side effects can make a difference in the long-term outcome of your health.

Discussing all of the options with your healthcare provider and asking plenty of questions can help you better understand what is going on with your body. When I sit down with a woman considering these options, I encourage her to look inside herself, try help her have peace of mind, and make the right decision for her own well-being.

For more information, please see our articles on menorrhagia, menstruation, and hysterectomy.

by Marcelle Pick, OB/GYN NP

MRI–guided ultrasound ablation for fibroids

MRI-guided high-intensity ultrasound (MRgFUS), otherwise known as high–intensity focused ultrasound (HIFU),  has become a wonderful new addition developed as a noninvasive treatment modality for uterine fibroids. MRgFUS/HIFU actually uses high-intensity focused ultrasound beams to heat and obliterate the fibroid tissue. This leaves the nearby tissues undamaged with a minimal number of reported side effects, as well as very little down time for recovery.

So far, MRI-guided thermal ablation by focused ultrasound is documented to show limited success in long-term resolution of fibroids. It remains in the investigational stages and is only available in a few locations and most often this is a self-pay procedure. Insurance companies don’t cover this procedure as it is still considered experimental. The FDA has approved one type of technology for this (ExAblate) as a premarket application that is only for women who have finished childbearing.

However, a number of women have reported excellent success with this specific technique as a noninvasive alternative to a hysterectomy, as to date we don’t have very many noninvasive alternatives. The hope is that as time goes by, MRI-guided ultrasound technology will become perfected and its accessibility will become more widespread.

For the meantime, if you’re interested, you might want to visit the Uterine-Fibroids.org website for more information. Of great importance here is that you be sure that you seek medical treatment only at a center where the providers are skilled in this technique.

by Marcelle Pick, OB/GYN NP

There are times that medical terms can be a little intimidating to people who aren’t familiar with what they mean. Some of you might know what something means in a general way, but it’s always best to know, for your own well-being and peace of mind, specifically what something means. This will better help you know what’s going on with your body and also help you make the best decision about what’s right for you.

The procedure called endometrial ablation might be a great option for you to consider rather than having a hysterectomy, after you have tried other less invasive measures. For example, if you are seeking an option that would allow you to keep your uterus, especially if you have tried hormonal management and it did not work, then ablation may well be a good choice.

Here is more information about this procedure. Ablation means “to remove by erosion, melting, evaporation, or vaporization.” Endometrial ablation is done with a hysteroscope, along with a device that heats, freezes, or lasers your endometrial lining. This destroys a layer of your endometrial lining, and usually your monthly menstrual period will stop completely—at least for a while—and usually you will not be able to become pregnant following uterine ablation. However, it’s a good idea to remember that there are women who do get pregnant after this procedure, so it’s very important that birth control or sterilization be reviewed, as post-ablation pregnancies can be risky. Some insurance companies require that a woman be sterilized before they’ll pay for the ablation procedure.

Some types of this procedure can be performed by a trained gynecologist (GYN) in the office. It can be done fairly quickly and easily. This can be useful to treat selected areas of the endometrial lining. In other circumstances, it needs to be done under anesthesia after a hysteroscopically–guided dilatation and curettage (D&C) sampling. This may be an ideal way to exclude pathology, rather than assuming that an endometrial biopsy is adequate.

At Women to Women we don’t recommend this course of action as a first line intervention for several reasons. For one, we always try to suggest the most minimally invasive procedures and recommend medical management when possible. In addition, we generally obtain a good outcome with medical management of our patients who have heavy bleeding. Although endometrial ablation does work well for some women, the long-term results for treating heavy bleeding with endometrial ablation are not always predictable, and there is a relatively high rate of recurrence. Our nurses have heard from women who have had an ablation that it had failed and that their heavy periods returned after a year or two. Another issue is that there is a risk that endometrial ablation might mask endometrial cancer later in life, because it removes any endometrial spotting that would signal to you that something abnormal is happening in your body.

Now that you know more about this process, you can do what you think and feel is best for your healthy lifestyle. To sum it up, endometrial ablation has its limits. With time we can look forward to medical technology that will bring us more advanced treatment alternatives to hysterectomy. But until then, ablation techniques do offer women and their healthcare practitioners some options that can be useful in certain circumstances.

by Marcelle Pick, OB/GYN NP

Myomectomy for problematic fibroids

Myomectomy involves uterine resection which is the removal of a fibroid and a small portion of the uterus where the fibroid is attached. Myomectomy requires a highly skilled GYN surgeon, to obtain success.

Damage to the uterine tissue as well as the surrounding organs can happen with other techniques so the main goal of myomectomy is to minimize these complications. Myomectomy can be performed via open incision, or via laparoscope or hysteroscope. Each process has its advantages and limitations, but laparoscopic myomectomy and hysteroscopy myomectomy are less invasive than open surgery and require far less recovery time.

Not all fibroid cases make good candidates for this method. Many women do have good success with myomectomy, but women with larger or multiple fibroids, we have seen the fibroids return over time, depending on the size and position of the original fibroids, as well as the expertise of the surgeon.

Talk to your surgeon before you decide, ask questions, and you can also obtain more information here at Women to Women with our articles concerning the causes and the natural treatments for fibroids.

Many women have great success with this method of removal and were thrilled to not have such an invasive procedure such as a complete hysterectomy.

For more information about myomectomy for removal of uterine fibroids, visit www.ob/gyn.net.

by Marcelle Pick, OB/GYN NP

In the event that you may have the choice to forego a hysterectomy, you ought to know that together with hormonal support plus changes in lifestyle, there are many alternate options to explore that will take care of heavy bleeding, endometriosis, fibroids, and even polyps.

Current treatment options include:

•  Medical/hormonal management
•  D&C and hysteroscopy
•  Endometrial ablation
•  MRI–guided focused ultrasound (MRgFUS)
•  Laparoscopy and endometriosis excision
•  Myomectomy
•  Uterine artery embolization (UAE)

The actual success rates of these techniques differ greatly according to the patient and the support that is given pre and post-surgery, so it’s important to support whatever method you personally pursue with the healthiest lifestyle choices you can. A lot of women respond wonderfully to the nutritional measures , and several report how it has helped them make a speedy recovery from a variety of procedures — including hysterectomy!

Looking Ahead

Although heavy bleeding or even a diagnosis of fibroids may be disconcerting, it is seldom necessary for a woman to jump into surgery quickly. Considering additional options and techniques may guide you in a different direction with different results.

Since hysterectomy and fibroids are so common, studies looking into other options are constantly underway, and new techniques are being developed and studied in many parts of the world. Although the results of these innovations may be mixed, the good news is that these less invasive techniques do work for a number of women.

Unfortunately, the reasons being unclear at this time, no truly scientific, randomized double blind studies have yet been done to fully evaluate the various hysterectomy alternatives, their side effects, risks and benefits. Nor are any such studies currently being planned, though some observational studies on UAE (the surgery Dr. Condoleeza Rice had in 2004) have been done, comparing outcome satisfaction, failure rates, and cost compared to traditional hysterectomy methods. Visit the UAE Fibroid Registry at the SIR website for more information.

What Can You Consider Now?

We understand that numerous women have a choice when it comes to a hysterectomy; it may not necessarily be their destiny. Women to Women explore natural and less-invasive options and alternatives before stating that surgery is the only course of action. However, we also know when surgery is necessary. Did you know that certain women feel amazing after they have had a hysterectomy? Not only that, but those women suffer no side effects.

In case you do decide on surgery, we suggest preparing yourself for surgery in advance to increase your chances of a positive experience. Whether you opt for a nonsurgical alternative or you’re awaiting your date, investigate the measures you can take immediately to boost your nutrition, reduce your recovery time, and balance your hormones. The bottom line is – do what is necessary to feel well, whether that includes surgery or not, but know that by using pharmaceutical nutrient support, lifestyle changes and phytotherapy, these can all make the experience that much better.

by Marcelle Pick, OB/GYN NP

A large number of women of my mother’s era had no clue what was involved in getting a hysterectomy. Today, we are lucky because we now have a variety of degrees of a hysterectomy, as well as different techniques that are commonly used to perform the surgery. For any woman who is thinking about getting a hysterectomy, it is recommended that you take the time to learn the different types of hysterectomies performed today, and discuss each technique with your doctor. Women to Women truly believes that women should keep their bodies as whole as possible, as long as doing so does not interfere with their health, comfort and safety. We encourage women to opt for the least invasive technique that is available to them.

Total hysterectomy

In a total hysterectomy, the entire uterus and cervix are removed (ovary status is officially referred to separately). Total hysterectomy can be done abdominally (abbreviated TAH), with an incision most often these days made along the bikini line. In more emergent situations, a vertical type of incision is made through the abdominal wall from the belly button to the pubis. This type of surgery required more downtime and healing time as well. TAH can also be performed through the vagina, with no large incision through the belly. If this procedure is an option, it may be one to consider as the healing time will be less.

The newer and more sophisticated procedures use laparoscopy to assist the hysterectomy procedure. In laparoscopic hysterectomy, the organs are visualized and manipulated through a laparoscope, and the uterus is removed either through the vagina (laparoscopically assisted vaginal hysterectomy, or LAVH) or through a small incision in the stomach.

Whether they use the vagina or the small incision in the abdomen depends on the size of the uterus and issues that are requiring the surgery to begin with. The incisions are tiny (~½”, beneath the belly button and on the lower pelvis/abdomen, beneath the bikini line). You may have several small incisions that tend to heal very quickly.

This type of surgery leads itself to a much quicker recovery, with far less disruption of the bowel and pelvic floor architecture. It is best performed by a laparoscopic specialist, someone that does this type of surgery often, as not all surgeons are skilled at this. The choice here depends on the reasons for doing the surgery, the patient’s anatomy, and the surgeon’s preference. If you have a preference, undoubtedly communicate this to your surgeon.

While doing a hysterectomy, a surgeon may also remove the ovaries and fallopian tubes. Sometimes this is not decided until the time of the surgery. This is called a bilateral salpingo-oophorectomy, or BSO. (Together with a total abdominal hysterectomy this is referred to as a TAH/BSO). There are numerous considerations to make before you consent to this surgery, mainly because of the artificial onset of menopause due to loss of your natural sex hormones. Again, the decision depends on the individual problems that are at issue here. If this is the only choice available to you, be certain that it’s possible to regain your hormonal balance with the help of excellent support measures and a healthy lifestyle.

Young women who must undergo a BSO should seriously consider suitable estrogen replacement for several health benefits. The younger you are the more important it will be to consider replacement. We try to suggest bio-identical transdermal estradiol options when needed — complemented with bioidentical progesterone and nutritional supplements. When supplemented properly many young women can feel excellent post-surgery.

Partial hysterectomy

In a partial or subtotal (supracervical = above the cervix) hysterectomy, the ovaries and/or cervix are left whole. These procedures, too, can be performed abdominally, vaginally, or laparoscopically. Regrettably, a lot of women either are not made aware or don’t know these options exist. Several doctors take out the cervix automatically as a precaution against cervical cancer.

At our practice, we’ve seen that the benefits of retaining your cervix (more sexual enjoyment and sounder inner pelvic architecture) outweigh the relative risks. If you do choose to keep your cervix, you will need to continue normal annual screenings and Pap tests.

At Women to Women, we typically refer women for a laproscopically-assisted supracervical (partial) hysterectomy (LASH, or LSH). We suggest women try to keep their ovaries (no BSO); if at all possible, however this is case and personal dependent as well. Again, not all doctors are skilled in these newer techniques. Those who are skilled often specialize in endometriosis treatment, as well. You may have to look for them in your local area or be willing to travel somewhere else to have your procedure.

We also recommend considering your options on preparing yourself for surgery. To start you may want to read our articles about hysterectomy, sign up for a few sessions of acupuncture, and use Peggy Huddleston’s book and audiocassette, Prepare for Surgery, Heal Faster, to enhance your healing and decrease your recovery time.

by Marcelle Pick, OB/GYN NP

Hysterectomy is the second-most common significant operation performed on females inside the United States. (The most common is cesarean section delivery). Every year, more than 600,000 women undergo a hysterectomy. Despite the fact that some progressive doctors claim that up to 90% of hysterectomies are unnecessary, more conservative estimates put that number between 20–30%. Either way, that is a lot of women that may be having unnecessary hysterectomies.

There are quite a few reasons why women are recommended to consider an elective hysterectomy. The most common are intense bleeding, when many things have been tried and failed, large fibroids, endometrial polyps, endometriosis, causing debilitating pain and discomfort and other endometrial concerns. Some women are fed up with the discomfort or the bloating that accompanies a large fibroid uterus, or have a uterine prolapse, (a condition in which the uterus drops). More serious indications include cancers of the uterus or ovaries — conditions that truly merit immediate surgery. However, if we take a closer look, the latter are relatively uncommon and leave women with few choices, so this conversation and topic is geared toward women who are considering surgery for less clear-cut reasons.

Heavy bleeding

Throughout traditional medical practices heavy blood loss is termed “dysfunctional uterine bleeding” when it is not the normal amount of bleeding but no demonstrable organic pathology is found. Diagnosis is made by exclusion since organic pathology always has to be ruled out. What may be more useful for us to identify as “dysfunctional,” or imbalanced, are the environmental and lifestyle influences affecting our hormones and sending the uterus mixed messages. Every now and then these influences lead to a state of estrogen dominance, and in other cases the menses may be out of sync, because of general hormonal imbalance. In whichever case, tuning in and paying attention to what the body and mind require can restore balance naturally. Furthermore, what is dysfunctional for one woman may not be for another, and the term is somewhat subjective by nature, so it should be discussed with a knowledgeable and experienced provider.

Having reached a state of hormonal imbalance, a woman’s body can get stuck, and even her greatest efforts to restore balance can take quite a few months. The annoyance of having to change pads hourly, double up on tampons, wash extra linen, never wear white at that time of the month and timing activities around heavy flow leads several women to the end of their gynecological rope. When women in this situation ask for a hysterectomy, nearly all doctors in America will respond by scheduling surgery as soon as possible and who can blame them. But in our book, surgery should never be the first, or even the second, recourse in the face of heavy bleeding. That is because we have seen firsthand how much things can change when the right steps are taken. The good news is, no matter what, an old dictum from surgery generally applies: bleeding eventually stops when a woman goes through menopause.

Heavy bleeding often occurs, even if it has never happened before, around perimenopause and in several cases can be successfully addressed with many natural measures before pursuing surgery. In nearly all cases, a woman with dysfunctional uterine bleeding can be offered a trial of non-surgical intervention such as “medical management” (using a progesterone effect on the uterus) of dysfunctional bleeding prior to referral for “surgical management.” This approach is normally safe, as long as the lining of her uterus has been appropriately evaluated with an endometrial biopsy or D&C if necessary, and as long as her red blood count remains sufficient.

At our clinic, we’ve had excellent results treating heavy bleeding with high-dose bioidentical progesterone, in the form of creams or oral tablets, along with other supportive supplements. Lifestyle and dietary changes that decrease stress and increase core nutrition are also extremely effective in this arena.

Several bleeding issues reflect irregularities of the endometrium, so the symptoms are strongly influenced by the monthly ebb and flow of estrogen as well as progesterone. Simply because of this, these difficulties normally react extremely well into a natural rebalancing of hormones by way of diet plan and life style changes. Furthermore, a natural approach should be given a trial before advancing to surgical intervention. Surgery is no small matter, and the removal of organs can lead to additional problems that are just as troublesome or more so, only different. And, just as heavy bleeding dissipates with menopause, so too do conditions of the endometrium.

Postmenopausal bleeding

Be aware that post-menopausal bleeding is a completely different matter, in addition to any sort of bleeding that happens after menopause, and needs to be immediately assessed by your healthcare provider. Women with postmenopausal bleeding are often referred for vaginal ultrasound so the endometrium of the uterus can be evaluated and measured. If the endometrial thickness is above a certain width, an endometrial biopsy is recommended. Certain drugs such as Tamoxifen for breast cancer can cause the thickening, and women on tamoxifen who have thickened stripes should be seen by GYN specialists for this side effect.

Adenomyosis

Constant heavy bleeding that does not stem from a discretely recognizable source such as fibroids, and which doesn’t respond to medical management, is often a result of adenomyosis of the uterus. Adenomysis is generally referred to as endometriosis interna. In this condition, which is sometimes mistaken for uterine fibroids, the glandular endometrial lining of the uterus invades the bulk of the uterine muscle wall. This is also known as endometriosis of the muscle.

Although most women who have adenomyosis never have symptoms, it can cause the uterus to grow 2–3 times its normal size and be accompanied by severe menstrual cramping. During the pelvic exam, the uterus can feel large and bulky. It occasionally is recognized by ultrasound, or more definitively by MRI, and confirmed by pathology after a hysterectomy; however it is technically seem as a benign condition.

Adenomyosis frequently fails to respond to the influence of progesterone under medical management. If you have exhausted all natural measures and still suffer with persistent heavy bleeding, you might want to enquire further about this potential diagnosis. Endometrial ablation is one alternative that has shown for some to be very helpful and is an alternative to hysterectomy, along with the Mirena IUD; either may be considered in certain cases.

Fibroids

No less than 40% percent of hysterectomies performed are for fibroids. (Fibroids technically are not part of the endometrium). Nobody understands just what exactly will cause them, but they are certainly a hassle. They are extremely real and women’s worries about them must not be dismissed as merely worrying. We suspect their growth is most likely fueled by estrogen but are unsure yet regarding the details.

Fibroids are fairly common: at least one in five women over age 35 has them. So many women think mistakenly that if they have fibroids they will sooner or later need a hysterectomy. This just isn’t true. Often doctors recommend a hysterectomy for patients with fibroids even when they are symptom free! This is like cutting off your nose to spite your face.

At Women to Women, we have countless patients who deal with their fibroids successfully through dietary changes, lifestyle changes, including looking at their stress levels and working to change them, and supplements — as well as acupuncture, if they are having symptoms. We suggest the book Women’s Bodies, Women’s Wisdom, written by my friend and colleague, Christiane Northrup, MD, which includes a fabulous section on treating and living with fibroids without surgical interventions. See our articles for more information on the causes as well as natural treatment for fibroids.

Fibroids may cause bleeding and pain or discomfort, an ever present sense of fullness and can grow in some, but certainly not all cases. A fibroid’s size is described as though someone was pregnant, comparing it to the gestational age of the fetus — for example, a 5-month size fibroid — or it can be described as a fruit, the size of a grapefruit or orange, etc. Women can have several fibroids of various sizes and shapes. Some fibroids grow very little over time, and many women are oblivious that they have them. Your healthcare provider can often feel an enlargement of the uterus while doing a pelvic exam and may order an ultrasound if they feel it is warranted.

An ultrasound will measure the fibroid and better evaluate any other abnormalities that are there as well. You could be sent for repeat ultrasounds to make certain your fibroids are not growing too big or too quickly over time. Your doctor may in addition order a CT scan or an MRI if additional information is needed. Fibroids are very seldom cancerous and are not needed to be biopsied. But remember that any kind of dysfunctional uterine bleeding should probably be evaluated with an endometrial biopsy to rule out any other causes for the bleeding.

Polyps

Uterine polyps or endometrial polyps are irregularities of the inner uterine lining (something like fleshy skin tags, only on the inside). Polyps are often the source of irregular bleeding and can be a large nuisance, BUT they are not commonly cancerous. Polyps of the uterine lining are often difficult to see on regular ultrasounds, but a “sono-hyst” (sonohysterography) or saline-infused ultrasound is much better at diagnosing this more accurately. It is not unusual to obtain fragments of a polyp when getting the results back on a sampling that was taken when an endometrial biopsy was done.

Nearly all endocervical polyps can be removed through the vagina, as they are present at the opening of the cervix, but uterine/endometrial polyps are usually removed via the D&C with hysteroscopy method, which is slightly more invasive but definitely less traumatic than a hysterectomy.

Endometriosis

Endometriosis is a condition that is normally more painful than dangerous. A lot of women who have endometriosis are unaware of its presence until they attempt to become pregnant. Endometriosis can cause severe fertility problems and always needs to be ruled out if someone has cramping with their menses and can’t get pregnant. It can also cause irregular spotting, bleeding, and pain, including pain with intercourse. For women with severe endometriosis, the pain can be unbearable, especially around their period, and or around ovulation.

Acupuncture can be very helpful for pain management. If fertility is an issue, PT techniques such as integrative manual therapy (IMT) and Clear Passages could be investigated. Both these techniques have been quite successful in increasing fertility when every else failed. Laparoscopy is often used in more severe cases for conclusive diagnosis and treatment. For more precise information on alternative treatments for endometriosis, see our articles on this topic.

In case your decision to get a hysterectomy is an optional one, consider yourself fortunate. You may want to spend some time researching your options and then figuring out what will be the best choice, or option for you before you decide to have surgery. The good news is that more and more options are becoming available.

by Marcelle Pick, OB /GYN NP

One of the latest most up-to-date procedures may completely change the way we handle uterine fibroids. This procedure is called uterine fibroid embolization (UFE) or uterine artery embolization (UAE). Uterine fibroid embolization is a technique which is regularly performed by an interventional radiologist. The majority of gynecologists have not been trained in advanced radiology, so this is the reason why it is usually done by radiologists working with the referring gynecologist.

UAE was first developed in France, and has been performed in the US since 1995. Prior to that the embolization procedure had been used to stop hemorrhaging after childbirth and bleeding in other areas of the body.

Many healthcare practitioner may not know of it yet, so many women are not aware there is an option to treat their uterine fibroids.

A referring GYN is not required for a woman to pursue this option The process will first begin with a consultation by the consulting radiologist followed by an initial MRI evaluation and or an Ultra Sound of the uterus. This will help to establish whether the woman is a good candidate for the procedure. If the findings state she is the procedure will be scheduled for a future date. The UAE is generally performed in the radiology department and generally you will receive a mild intravenous sedation. A small catheter is then inserted into an artery in the groin, it is carefully threaded into the uterine artery under radiological guidance, then dye is instilled to create a visual picture of the pelvis and uterine arteries. Then the radiologist will release small sand-sized pellets of synthetic material.

As the pellets lodge in the distal ends they obstruct the blood flow to the fibroid. Uterine artery embolization works by basically starving the fibroid of a sufficient blood supply over the next several months. At this time there have been no adverse effects or allergic reactions reported from these particles. The UAE procedure generally takes about 60–90 minutes. After the procedure your GYN will then do follow up within a few weeks. As a result of mapping the arteries, the UAE technique protects the blood supply to the ovaries, and menopausal symptoms are much less common than they are following surgery.You may experience some strong cramping pain during and after the procedure. More often than not many women can go home that afternoon or stay overnight in the hospital if they require pain management. It usually takes a few days to a week to recuperate and much less than when a patient has the possible side effects of general anesthesia and surgery. The results begin to become noticeable and occur slowly over the next few months.

The US Secretary of State, Condoleezza Rice, had this procedure done in 2004. Although not reported publicly we assume she has had no troublesome side effects and experienced relief from her symptoms. Many of my patients have had this done with wonderful symptom relief, including the size of the fibroid. No one to date has had any serious complications.

There is a very small chance that cancer can be found in the uterus or fibroids, so be sure to discuss this possibility with your doctor. Some women also fail to respond to the technique as desired; the fibroids may also grow back in time or new ones may arise. The good news is that I seldom see this in my practice.

UAE was usually recommended for pre- or perimenopausal women with symptomatic fibroids. Recently the procedure was reported as helpful also for post-menopausal women whose fibroids had not regressed with menopause.

UAE was not recommended for women who might want to get pregnant because it was uncertain how it would affect fertility or what the effects would be on a pregnant uterus. Today, new data has been found that UAE may be safe in certain cases, talking with your gynecologist can help you decide if it’s right for you.

Where can you get UAE?

Interventional radiology is a relatively new specialty which is one of the reasons why UAE is relatively unknown to women. UAE appeals to doctors who want to do more than just read films but are not interested in performing surgery. It is unclear exactly why but from a practitioners perspective, it’s unfortunate that this field seems to attract more male than female doctors. My hope is that more and more women will consider entering this medical field because it holds so much promise.

Interventional radiology suites are being established in many hospitals and some physicians are following this trend and have set up separate centers. Many have same-day or overnight observation units which are providing round-the-clock nursing care, yet with the feel of a comfortable hotel, not a hospital. Information on doctors trained in UAE can be found on-line from the Society of Interventional Radiology (SIR). Many insurance policies will cover the procedure. Five questions you should ask about UAE. At Women to Women we always recommend that a woman call their GYN and ask a few questions or be seen in consultation before deciding on any course of action.

Here are some important questions to ask about uterine fibroid embolization:

• How will I know if I am a good candidate for UAE?
• Will I need to have a pre-procedure ultrasound or MRI?
• How long have you been offering UAE?
• How many UAE procedures do you perform a week? A year?
• What are your statistics on successful shrinkage of fibroids?
• What are your complication rates? (Their statistics should be at least a 40–50% success rate).
• When do your patients usually expect to return to work or daily activities? (Should be in less than a week).
• What are the side effects of UAE and what should I do if I experience any symptoms? (Call your GYN if you experience fever, infection, artery injury, premature menopause. The rate should be under 1%).

For more information on causes and natural treatment of fibroids refer to our articles on this topic.