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What kind of hysterectomy is best for you?

August 04, 2016 | Kristina Lindgren
Female patient and doctor

Your doctor says you need a hysterectomy. What do you need to know?

The first thing you should do, UCI Health gynecologist Dr. Donna Baick says, is to understand the diagnosis and weigh your options, including what kind of procedure is the best for you.

The American Congress of Obstetricians and Gynecologists (ACOG) says the safest, least invasive and most cost-effective way to remove a uterus for non-cancerous reasons is a vaginal hysterectomy, rather than laparoscopic or open surgery.

An estimated 600,000 women a year undergo hysterectomies to treat:

It is the second most common surgery women undergo, after cesarean births.

Open surgery still the norm

Less than a fourth of all hysterectomies are performed vaginally, according to ACOG. About two-thirds of cases are performed with a large abdominal incision, and another 12 percent are performed with special tools called laparoscopes and require a several tiny incisions.

ACOG says the low rate of vaginal hysterectomies is because too few practicing gynecologists have been trained in the technique, and those who have been trained don’t perform them often enough to be comfortable with the procedure.

Baick, who sees patients at UCI Health – Tustin, uses the vaginal approach with her patients whenever she can because there are no external incisions and less bleeding.

Faster recovery

“There are also fewer complications, less chance of injury to the patient and less recovery time,” said Baick, who has had many years of experience using the vaginal approach. So do all of her colleagues with UCI Health Gynecology Services.

“I’ve had patients go back to work within two weeks after surgery, compared with four to six weeks for an abdominal or laparoscopic hysterectomy.”

Jill Donahue, 50, of Orange knows first-hand the difference between recovery from a vaginal hysterectomy and a more invasive abdominal procedure.

Donahue underwent a vaginal hysterectomy — Baick removed her uterus, cervix and fallopian tubes — in September 2015. The regional sales manager for a steel parts company was back on the job in less than a week. She was driving again in a week and a half.

In April 2016, Donahue had her gall bladder removed, this time with robot-assisted laparoscopic surgery. More than eight weeks after that surgery, she was still feeling abdominal pain and tenderness. It wasn’t until early July that she could wear jeans without discomfort.

“I love Dr. Baick,” said Donahue, who had suffered for years from heavy and painful menstrual bleeding. “She knows what she’s doing and she’s a got expert skills. She’s also compassionate. She takes time to talk with you about your options and she explains everything.”

Weigh treatment options thoroughly

Baick advises her patients that a hysterectomy is an irreversible surgical procedure, one that should be considered carefully, especially if a woman is still in her childbearing years. 

“We don’t take surgery very lightly,” she said. “We try to find out first what is causing the problem.”

Tests usually include a pelvic exam, blood and urine analysis, and possibly ultrasound imaging and an endometrial biopsy.

“If the biopsy confirms that excessive bleeding is due to a fibroid tumor or polyp, and it is benign, we discuss alternatives,” she said.

Nonsurgical alternatives

These can include prescribing medication to control the pain or block the production of estrogen, scraping or suctioning away the uterine lining, or performing a procedure called endometrial ablation.

Before her hysterectomy, Donahue tried nonsurgical treatments. Baick performed a dilation and curettage (commonly known as a D&C) treatment to remove the endometrial lining. A year or so later, she underwent an endometrial ablation procedure to remove the lining with heat therapy. When painful cramps and heavy periods returned yet again in 2015, Donahue and Baick agreed it was time to consider a hysterectomy.

Another patient, Marjan Habibian, 48, met with Baick because she was enduring 25-day menstrual periods that were draining her body of iron, calcium and other critical minerals. Her hair was falling out and she was losing her fingernails. The graphic designer was so fatigued that she would run out of steam by 2 every afternoon.

Baick determined that a benign growth in the lining of Habibian’s uterus was causing the excessive blood flows, a condition known as menorrhagia, and gave her several options, including ablation to remove the uterine lining and the growth.

But the Villa Park mother of two had her heart set on a final solution. She didn’t plan to have more children, and a hysterectomy had given an older friend permanent relief from similarly debilitating menstrual cycles. Baick performed a vaginal hysterectomy on Habibian the day before Thanksgiving 2015, removing her uterus, cervix and fallopian tubes, while preserving the ovaries rather than send her into early menopause.

Easy recovery

Habibian went home the next day, expecting to be bedridden and in pain. That didn’t happen. “I didn’t even go to pick up my pain prescription at the pharmacy, and I was back to driving my youngest daughter to school within 10 days,” she said, adding that her hair has grown back in, as have her fingernails, and her energy level is back to normal. “Dr. Baick is an angel.”

Women with scar tissue from a cesarean delivery or other abdominal surgeries, or those with a very large uterus, may not be candidates for a vaginal hysterectomy, Baick said.

Every case needs to be evaluated individually, she said. And patients should consider getting a second opinion. “Women absolutely need to make sure they are making the right choice for themselves,” Baick said.

Types of hysterectomies

Hysterectomies can be partial, complete, include removal of the ovaries, or radical.

  • A partial — or supracervical — hysterectomy involves removal of the upper part of the uterus but leaves the cervix intact.
  • In a complete hysterectomy, both the uterus and cervix are removed.
  • When the ovaries and fallopian tubes are also removed, it is called a hysterectomy with bilateral salpingo-oophorectomy.
  • In a radical hysterectomy, the surgeon removes all the reproductive organs as well as the upper vagina, some lymph nodes and surrounding tissue. This type of hysterectomy is usually performed when there is a cancer diagnosis.

Types of surgical procedures

The traditional hysterectomy is performed with an abdominal incision of about five inches, either vertically or along the bikini line to minimize visible scarring. The surgeon can more easily see the uterus and surrounding area, and this may be an advantage when a fibroid tumor is particularly large. With an open surgery, however, there is usually more pain and a longer recovery time.

In a vaginal hysterectomy, a small internal incision is made at the top of the vagina. Through this opening, a surgeon can separate the uterus from connecting tissue and its blood supply then remove the uterus through the vaginal canal. The cervix may also be removed.

In a laparoscopic hysterectomy, special surgical tools are inserted through small abdominal incisions to remove the uterus in pieces. For robot-assisted procedures, the surgeon controls the laparoscopes with robotic arms.

Sometimes a surgeon may also use a laparoscope during a vaginal hysterectomy to get a better view of the uterus and surrounding organs.

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