Hysterectomy & Alternatives Case Study

June 21, 2011

The last time I had seen Mrs. Martin for a checkup was in the winter of 1995. At that time she weighed nearly 250 pounds. During her visit a year later, to my dismay, she had gained another 40 pounds. That’s a lot of weight for anybody to carry around, and it’s of special concern in a woman who stands just 5’1" in her stocking feet.

Meet Mrs. Martin

The last time I had seen Mrs. Martin for a checkup was in the winter of 1995. At that time she weighed nearly 250 pounds. During her visit a year later, to my dismay, she had gained another 40 pounds. That’s a lot of weight for anybody to carry around, and it’s of special concern in a woman who stands just 5’1" in her stocking feet.

But she hadn’t come to see me because of her weight. Instead she was troubled by the fact that for several months now she had been experiencing very heavy and frequent menstrual periods. In a concerned voice, she told me that the bleeding lasted as long as 7 days and was occurring every 2 weeks. She was using 10 or more pads a day and had noticed that she was passing clots. She also felt quite tired. Her condition was distressing enough to interfere with her ability to function at home and at her job as a data analyst for a brokerage house in eastern Massachusetts.

Mrs. Martin is the 35-year-old mother of 3 children. After the birth of her last child in 1992, she asked me to perform a tubal sterilization. Since then she had had no gynecologic complaints. Now, though, she was worried.

During the examination I performed a hysteroscopy, which involves use of a special viewing scope that allows me to see inside the uterus. I found what I suspected: a large growth called a fibroid tumor. Such tumors are usually harmless – that is, they are not cancerous, although as Mrs. Martin found, they can cause severe bleeding, which in turn can cause anemia and fatigue. Fibroids can also interfere with the ability to get pregnant, but in this instance that was not a concern. I conducted a biopsy (removing a sample of the fibroid tissue) and sent it to a lab; the report confirmed that the growth was benign. Still, something had to be done to relieve her symptoms.

Often, when a woman who is done bearing children develops fibroids, a hysterectomy – surgical removal of the entire uterus – is an option. But abdominal surgery is much riskier in patients who are as heavy as Mrs. Martin. There is a greater chance of damage to other pelvic tissues and organs during the procedure. Afterwards, there is a risk of serious bleeding, phlebitis, or improper healing of the wounds.

Fortunately, modern medicine has made more options available in cases like hers. It might have been possible to control the bleeding through the use of hormones. Such an approach has drawbacks, however. Apart from the cost, she would still have experienced monthly periods for the next 15 years or so, until she reached menopause.

Instead, after careful discussion, Mrs. Martin opted to undergo a procedure called hysteroscopic myometomy with endometrial resection and ablation. During this operation, I insert a special viewing device called a hysteroscope through the vagina and pass it through the cervix (the opening to the uterus). The device includes an electrical tool that allows me to cut away (resect) the fibroid (also called a myoma) and then scrape away (ablate) the lining of the uterus (the endometrium). Then, using the same device, I can destroy any remaining endometrial tissue through a process called coagulation. As a result, the uterus remains in place but it no longer functions – that is, is no longer causes bleeding and cannot support a pregnancy. This method avoids major surgery and is just as effective as hysterectomy.

The Procedure

To make it easier to remove the fibroid, I prescribed treatment with a GnRH agonist, which causes the fibroid to shrink over a period of weeks. Mrs. Martin received injections of the drug once a month for 2 months. This method usually results in a fibroid that is as much as 40% smaller in volume, which makes it easier to remove.

The procedure requires only same-day surgery and does require overnight hospitalization. In some cases it can be done using regional anesthesia, during which the patient is still awake but is numb from the waist down. However, in this case, Mrs. Martin accepted the anesthesiologist’s recommendation to have general anesthesia.

In my practice, I use the OPERA Star system, made by the FemRx company. The device is a disposable hollow sheath that contains several instruments, each with a different purpose. One instrument is the hysteroscope, which allows me to see the uterine cavity, and the resectoscope, which contains the cutting and coagulating wire.

There is also a tube that instills a fluid into the uterus. This fluid helps conduct the electricity to the tissue, and it also expands the cavity so I get a better view. The OPERA Star system has a special monitor called Flowstat, which constantly measures the amount of fluid that enters and leaves the uterus. Normally during procedures of this kind, the patient’s body absorbs a small and harmless amount of fluid. If too much fluid is absorbed, however, there is a chance it can dilute the blood to a potentially dangerous level. The Flowstat system allows us to keep a very close eye on fluid levels at all times during the procedure. Should a problem arise, the operating room staff will be alerted immediately, and we can take simple steps to correct the situation and avoid any serious problems.

OPERA Star also has a tool called a morcellator. Small pieces of tissue removed during the operation are drawn into the tool with suction. The morcellator traps the pieces in a filter, so they can be sent to the lab for study. For us doctors, this method has another advantage. Removing the bits of tissue keeps my field of vision clear. This allows me to continue removing tissue without having to constantly stop to withdraw and clean the instrument. The fewer "passes" I have to make through the cervix, the quicker and safer the procedure.

In Mrs. Martin’s case, the procedure took about 30 minutes. (In comparison, an abdominal hysterectomy in a patient of her size would probably have taken up to 2 hours.) She recovered fully from the anesthesia within 2 hours, and was able to go home the same day.

The procedure took place on a Friday, and by Monday she was back at her desk. Had she undergone major surgery, Mrs. Martin would probably have had to stay at least 3 days in the hospital, and would have missed 4 to 6 weeks of work while she recovered. For this patient, the alternative to hysterectomy meant reduced medical costs, less time in recovery, and much less time away from her job.

Follow-up

At this point, one year after her procedure, Mrs. Martin has had no complications and has experienced only minor occasional spotting. Her energy level has returned.

Now, if only I could convince her to lose some weight. . . .

(To protect patient privacy, the patient’s name and certain identifying details have been changed.)