MARINA JOHNSON
M.D., F.A.C.E.
MEDICAL DIRECTOR

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IN ENDOCRINOLOGY
& METABOLISM AND
INTERNAL MEDICINE

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Avoiding Hysterectomy

Hysterectomy is the second most frequently performed surgery, after C-section, for women of reproductive age in the United States.  The latest studies show that approximately 600,000 hysterectomies are done each year in the U.S. and HALF of these women also have their ovaries removed at the time of their hysterectomy.  There are presently 20 million US women who have had a hysterectomy.  Women between the ages of 40 and 44 have hysterectomies more frequently than any other age group.

In 2000, an expert panel evaluated this issue as part of the Women’s Health and Hysterectomy Project conducted by the US Department of Health & Human Services.  The panel reported that 70% of the hysterectomies were done inappropriately according to standards set by the American College of Obstetrics and Gynecology.  If you use this 70% estimate, that means that 420,000 women every years might be able to avoid a hysterectomy!  If you add in the fact that 50% of women who get hysterectomies also have their ovaries removed, another 210,000 women are subjected to the health risks that come with loss of estrogen!

Listen now to the latest audio program on the KAT JAMES SHOW with Dr. Marina Johnson – February 11, 2012

It’s important to emphasize that hysterectomy can be life-saving especially in women with cervical, uterine or ovarian cancer.  However, the most common reason for having a hysterectomy is heavy bleeding from a totally benign condition called fibroids.

Why do many women develop heavy bleeding in their 40s?

The heavy menstrual bleeding from fibroids usually starts when a woman gets into her late 30s or early 40s. It’s caused by an imbalance between estrogen and progesterone.  If there’s a shortage of progesterone, it increases the growth of the fibroids and leads to heavy menstrual bleeding. Because women tend to only see their gynecologist once a year, if the bleeding is mild, they often don’t even bother to mention it.  However, as the year goes by, the bleeding often gets worse. By the time the woman gets in for her next yearly check-up, it may have become very severe.   Following is an all-too-common scenario!

Jenny’s Story

Jenny was 45 years old and by the time she got into her gynecologist she was bleeding three weeks out of each month!  She had severe menstrual cramps that doubled her over with pain. The bleeding was so heavy that she couldn’t even leave her home for the first three days because she would gush through the heaviest pads and tampons.  Months of this type of heavy bleeding left her anemic and exhausted.  When she saw her gynecologist, he had no recourse but to do a hysterectomy.  You can be sure that Jenny had NO objection to having a hysterectomy and was elated to get rid of all that pain and heavy bleeding. Her quality of life was much improved after the hysterectomy.

However, I want to give you some options on how you might avoid going down this path. One of the reasons I wrote my book, “Outliving Your Ovaries,” was to empower women to educate themselves about their bodies.  Every single woman will experience menopause at some time in her life. Perimenopause and menopause can be a roller coaster time for many women.  If you know what to expect, it will make for a MUCH smoother transition through this time. We discussed the imbalance between estrogen and progesterone that occurs at the time of perimenopause.  When heavy bleeding develops, it can often be managed with medical treatments or surgical procedures that do not require hysterectomy, e.g. endometrial ablation or myomectomy. Read Carla’s story to learn about one of the medical options.

Carla’s Story

Carla was 40 and she noticed that her periods were starting to come more often.  She had always had regular periods like clockwork – every 28 days.  When she turned 40, she started having periods every 24 days and then they shortened to every 21 days.  Her periods were not awful but heavier than they had ever been before. She developed disturbed sleep and symptoms of premenstrual syndrome (PMS) that she had never experienced before.  Before her periods, she was so grumpy and irritable her family knew to stay away from her!  Carla knew something was not right so she promptly saw me for an evaluation.  It’s so important for women to listen to their body and get checked when the symptoms are still mild.  I prescribed oral progesterone for Carla and instructed her to take it only during the last half of each cycle to mimic the normal rhythm of her body.

After starting the cyclic progesterone, she was delighted to see that her periods got more normal and regular. Her PMS got better and she was now sleeping like a baby!   I want to emphasize that when you give progesterone for this purpose it’s important to ONLY use pharmaceutical progesterone either as pills or vaginal preparations.  Progesterone creams are NOT strong enough to protect the uterus.  The cyclic progesterone made a huge difference in how Carla felt throughout her 40s.

At 48, she noticed that she was still feeling okay during the two weeks she was taking progesterone but not so well during the rest of the month.  At that point, we did blood tests and diagnosed her with menopause.  Her body was telling us that we now needed to add estrogen to the progesterone.  After giving her both estrogen and progesterone, she was back to her normal self!!  Isn’t this a better way to get through this transition in your life?

What can you expect after a hysterectomy and what should you do to maintain your quality of life and optimize longevity?

Some women, especially those who have their cervix removed, report that orgasms have less intensity.  However, in women who had hysterectomies because of painful fibroids or pelvic pain from endometriosis, sexual function may actually be improved.  In either circumstance, women need to know that if the ovaries have been removed, they often develop significant sexual dysfunction within six months of no estrogen.

After hysterectomy, even if the ovaries are left in place, there’s usually a tendency for women to go through menopause earlier than they would have without a hysterectomy.  It’s important to know this because since you’re not having periods, you won’t have that as an indicator that you’ve gone through menopause.  In some women the symptoms of menopause are obvious, like hot flashes and insomnia so they know to go into their doctor because they feel poorly.  However, some women who’ve gone through menopause after a hysterectomy, may have subtle or NO symptoms.  Unfortunately, this absence of symptoms does not protect you from the diseases that can occur to heart, brain and bone tissues when they are deprived of estrogen.  These include heart disease, Alzheimer’s and osteoporosis.  Postmenopausal women who take estrogen have a 39% lower risk of dying than women who don’t take estrogen.

That’s why it’s so important that all women who have had a hysterectomy inform themselves about the risks and benefits of HRT.  Estrogen is most protective when started in the first 10 years after menopause.  Don’t cheat yourself by waiting too long!!


 

References:

1. Kesharvarz H, Hillis SD, Kieke BA, et al, Hysterectomy Surveillance – United States, 1994-1999, Morbidity and Mortality Weekly Report Vol. 51(SS05): 1-8 July 12, 2002

Download Hysterectomy Surveillance – United States, 1994-1999 PDF Study

2. Broder MS, Kanouse DE, Mittman BS et al, The Appropriateness of Recommendations for Hysterectomy, Obstetrics & Gynecology Vol. 95:199-205, 2000

Download Recommendations for Hysterectomy, Obstetrics & Gynecology PDF Study

3. Hysterectomy Fact Sheet, U.S. Department of Health and Human Services Office on Women’s Health, 12-15-09

Download Hysterectomy Fact Sheet PDF Study

4.  Rivera, CM, et al, “Increased cardiovascular mortality after early bilateral oophorectomy,” Menopause, vol. 16(1) (2009): p 15-23

Download Increased cardiovascular mortality after early bilateral oophorectomy PDF Study

5.  Salpeter SR, et al, Bayesian meta-analysis of hormone therapy and mortality in younger postmenopausal women, The American Journal of Medicine Vol 122: 1016-1922, 2008

Download Bayesian meta-analysis of hormone therapy and mortality in younger postmenopausal women PDF Study

6.  Parker, WH and Manson, JE, “Oophorectomy and cardiovascular mortality: is there a link?,” Menopause, vol. 16 (2009): p 1.

7.  Weiner MG, “Hormone therapy and coronary heart disease in young women,” Menopause, vol. 15, no. 1 (2008): pp 86-93

8. Dubey RK, Imthurn B, Barton, et al, Vascular consequences of menopause and hormone therapy:  Importance of timing of treatment and type of estrogen, Cardiovascular Research 66(2005): 295-306

Updated 2-4-12 9:55CST GB

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