This article addresses hysterectomy in common benign (not cancerous) disorders, with emphasis on the role of the procedure in endometriosis.
Technically speaking, the surgical treatment of endometriosis rarely requires removal of the uterus (see prior article on ‘the Gold Standard‘). Lesions of ‘endo’ are less common on the uterus, and superficial (serosal) uterine endometriosis can be excised without removing the uterus itself. The primary objective of surgical treatment should be the complete excision of each and every endometriosis lesion. The secondary objectives are the removal of adhesions and restoration of normal anatomy if at all possible (predicated on the degree of irreversible destructive change already present).
The majority of patients are even more interested in pain relief and quality of life than the technicalities of the surgical procedure. Each patient has a unique clinical expression of her disease. This clinical picture is made up of how she feels, where she hurts and when, and her doctor’s observations and examination results. Special tests (like ultrasound, CT and MRI scans, etc.) may add to this picture.
If the ‘gold standard’ surgical treatment of Laparoscopic Excision (LAPEX) is performed and all endo is removed, but the clinical expression of her surgically treated disease remains a problem (despite the successful removal of all endometriosis), the treatment is a failure in the mind of the patient.
In my experience, the overall success of LAPEX in reversing the clinical picture of a patient’s endo is about 80%. This figure is based on our patient follow-up efforts regarding quality of life, any ongoing pain issues, and the frequency and outcomes of any subsequent surgical procedures for persistent pain.
WHEN IS HYSTERECTOMY OFFERED?
In my practice, the patient has always made the decision herself to have the uterus surgically removed, usually after my consultation and often additional consultations. In these patients, I have advised them to consider hysterectomy, because there is evidence that they have additional uterine disease (e.g. adenomyosis) that is part of their clinical picture. Although we may have removed their endo prior to hysterectomy, we have not removed all of their sources of pain. Here are a few examples:
- Adhesion Recurrence: in advanced stage patients, the surgical removal of all endo can leave many injured areas that must heal. The ultimate objective is that each treated area heals completely and independently (i.e not joined to any other structure). The greater the number and size of the areas treated, the more likely it is that tissues will be conjoined in the healing process. The recurrence or new formation of adhesions can cause pain very similar to the pain caused by the endo that we have removed. If these adhesions significantly involve the uterus, repeat surgery may be required for pain relief (about 25% of my stage 4 patients), and of this 25%, a few will choose to have the uterus removed so that it can no longer be encumbered by adhesions.
- Adenomyosis: some patients have secondary problems in addition to endometriosis, such as adenomyosis. From Latin, this term literally means ‘gland in muscle’. If endometrial glands are present in the uterine wall interspersed amongst the smooth muscle fibers normally found in that area, it is called ‘adenomyosis’. If you look at the holes in a common sea sponge, you get a visual idea of what I am referring to. Adenomyosis can cause severe pelvic pain and uterine cramping. Sometimes the degree of pain is intolerable, and the patient may choose hysterectomy. I will blog more about adenomyosis in greater detail in the future, so stay tuned.
- Fibroids=Leiomyomata Uteri: fibroid tumors (usually benign growths of encapsulated muscle in the uterine wall) are typically treated conservatively, but recurrence after conservative treatments (hormone suppression, uterine embolization, myomectomy, etc.) or very large fibroids may require a hysterectomy. This of course can be a problem independent of endo, but I have treated endometriosis and performed a hysterectomy coincidentally at my patient’s request on a few occasions.
There are a few other indications for the consideration of hysterectomy for benign disorders, but this gives you the general idea.
It is critically important to point out that hysterectomy does not cure endometriosis. Each lesion of the disease must also be removed. I have operated on literally dozens of patients who have not only had their uterus removed but also one or both ovaries, only to have the untreated areas of endometriosis that were left behind previously continue to cause pain and ultimately require another surgery to remove the remaining disease.
Hysterectomy may be an option for an indivdual, considering the unique nature of her personal case, after careful and informed discussions with her physician. Stay tuned for the next blog!
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