Hysterectomies decrease as women have more options

When Sandra Cintron's mother heard how bad her daughter's fibroid symptoms were getting - bleeding that went on for weeks and debilitating pain - she thought she knew where things were heading.

"You're going to need a hysterectomy," Maria Perales said. She had one herself when she was in her 30s.

A lot has changed since then, though, and Cintron, of Northeast Philadelphia, was able to choose a less extreme treatment for the benign growths on her uterus. Last week, she had an embolization at Einstein Medical Center, a procedure that left her uterus intact but cut off the blood supply to the fibroids.

Choices like this are reducing the use of hysterectomies, once a common treatment for aging uterus problems that usually are not life-threatening but can make life miserable for women in the 10 or 15 years before menopause.

Until a generation or so ago, removing the uterus was the "go-to answer for a lot of things if [the patient] couldn't put up with it anymore," said Jean Fitzgerald, director of the department of obstetrics and gynecology at Doylestown Hospital.

A Columbia University study published last month in Obstetrics & Gynecology found that the number of inpatient hysterectomies plunged by 248,000, or 36 percent, from 2002 to 2010, from 681,234 to 433,621. "For a surgical procedure, that's a fairly dramatic decrease," said ob-gyn professor Jason Wright, who led the study.

His team cited an increase in less invasive alternatives for the treatment of fibroids, abnormal bleeding, endometriosis, other benign growths, and pelvic organ prolapse. Hysterectomy is still the preferred treatment for uterine cancer.

The study raised concerns about whether the falling number of hysterectomies could make it harder for new doctors to get enough experience while training or for practicing doctors to maintain their skills. Generally, higher surgical volume is associated with better quality.

Some hysterectomies can now be performed on an outpatient basis and would not be reflected in Wright's statistics. He is now collecting data on outpatient hysterectomies and alternative procedures.

Peter Gearhart, an ob-gyn at Pennsylvania Hospital, said most hysterectomies still require at least one night in the hospital.

He thinks patient attitudes are also contributing to the shift. "I think you have a more empowered patient population," he said. Many patients come to him already knowing they want to avoid a hysterectomy.

On the other hand, he says he still gets some who say: "I want it out. I'm done. I can't take this anymore." Some change their minds when they hear about other options. Some don't.

Fitzgerald said she tries to preserve the uterus whenever possible. The key question, she said, is "Is it behaving badly or is it diseased?"

Einstein ob-gyn Jay Goldberg developed a special interest in alternatives to hysterectomy when his wife lost her first pregnancy at 20 weeks because of fibroids. They researched the alternatives and settled on myomectomy, or surgical removal of the fibroids, because they knew they wanted to have children. She was pregnant with their oldest son six weeks later. They now have three children and Goldberg, who runs the Philadelphia Fibroid Center at Einstein, regularly does the procedure.

Other options for women with bleeding, fibroids, or other common uterine problems include endometrial ablation, which involves destroying the lining of the uterus with heat or cold; low-dose birth control pills; hormones; and the Mirena intrauterine device. Some anti-inflammatory drugs can reduce bleeding enough to make it tolerable.

Sometimes the goal is to make the symptoms bearable until women reach menopause. "These problems all get better with menopause," Fitzgerald said.