Uterine fibroids are noncancerous growths that develop in or on the muscular walls of the uterus. Many women have uterine fibroids sometime during their lives but have no symptoms. In the other cases, fibroids can cause symptoms like heavy menstrual bleeding, pelvic pressure or pain, frequent urination, difficulty emptying the bladder, and in some cases, reproductive problems. There are various treatment options for fibroids ranging from medication to surgical procedures. Hysterectomy is the surgical removal of the uterus and is considered when fibroids cause severe symptoms that do not respond to more conservative treatments. The choice of whether and when to have this surgery is highly individualized.
What are the symptoms of fibroids that may require hysterectomy?
Some of the uterine fibroid symptoms that may warrant hysterectomy include:
- Heavy, prolonged menstrual bleeding that causes anemia
- Pelvic pain and pressure that significantly impacts daily activities and quality of life
- Urinary issues like frequency, urgency, retention due to large fibroids compressing the bladder
- Recurrent pregnancy loss or infertility believed to be caused by fibroid-distorted uterine cavity
- Fast growing fibroids
- Fibroids that persistently regrow after surgery like myomectomy
Heavy menstrual bleeding is the most common symptomatic problem. Women with fibroids may lose excessive amounts during menses, resulting in anemia. The monthly blood loss can be many times greater than normal if the fibroids are large. This iron-deficiency anemia causes fatigue, weakness, dizziness, and shortness of breath. Blood transfusions may even be required in some cases.
Large fibroids can compress nearby organs like the bladder and rectum, leading to pelvic pain and pressure, constipation, difficulty urinating or inability to fully empty the bladder. Women may need to urinate more frequently or have the urge to go more often. Sometimes urine retention can happen if a fibroid obstructs the urethra.
Fibroids located within the uterine cavity or distorting its shape can cause complications like infertility, miscarriages, premature labor, and other adverse pregnancy outcomes. This is relevant for women desiring future pregnancy.
When should medication be tried before hysterectomy?
Medications are often tried first to see if they provide adequate relief of fibroid symptoms before doing something as invasive as surgery. Options include:
- Oral contraceptives can reduce heavy bleeding but do not shrink fibroids
- Progestins like depot medroxyprogesterone can eliminate menstruation and related symptoms
- Tranexamic acid reduces excessive menstrual bleeding
- NSAIDs help relieve menstrual cramps and pain
- Gonadotropin-releasing hormone (GnRH) agonists shrink fibroids by suppressing estrogen
Your doctor may prescribe these medicines to help manage your fibroid symptoms for a few months. If they do not relieve symptoms enough or the symptoms return when you stop the medicine, surgical options can be considered.
Issues with long-term medication use
While medications can temporarily manage symptoms, they have some drawbacks with prolonged use like:
- Contraceptives provide only symptomatic relief, they do not treat the underlying fibroids
- Progestins and GnRH agonists induce a menopause-like state and cannot be used for more than 6 months
- Long-term GnRH agonist use causes bone thinning so add-back estrogen therapy is needed
Weighing the risks versus benefits of hysterectomy is prudent if medications provide partial or short-lasting relief. You may choose to move ahead with surgery if the fibroids and symptoms persist.
When is surgical treatment recommended?
If medication does not satisfactorily improve the significant symptoms caused by uterine fibroids, surgery is often the next step. The options include:
- Myomectomy – fibroids are removed while preserving the uterus
- Hysterectomy – surgical removal of the uterus
- Uterine artery embolization – blocks blood supply to fibroids to shrink them
- MRI-guided ultrasound surgery – uses high-intensity ultrasound waves to destroy fibroids
Which procedure is suitable depends on various factors like the size, location and number of fibroids, your age, desire to preserve fertility, and other health conditions. Myomectomy may be attempted first in women who still wish to have children.
If myomectomy cannot be done or fibroids regrow after surgery, then hysterectomy is often recommended. Nearly 1 in 3 women who undergo myomectomy for fibroids require another surgery within 5 years. Recurrent fibroids are common.
When myomectomy is not possible
In certain situations, myomectomy cannot be performed due to technical constraints. These include:
- Large multiple fibroids distorting the entire uterus
- Diffuse adenomyosis where fibroid tissue extensively invades the uterine muscle wall
- Very large blood supply to fibroids increasing surgical risks
- Deep intramural fibroids not easily accessible
- Endometrial scarring from prior procedures
- Lack of surgical expertise to perform complex myomectomy
Here, hysterectomy may be directly advised instead of attempting a complicated myomectomy prone to complications or incomplete fibroid removal.
Failed prior myomectomy
If you have persistent or recurrent fibroids and symptoms after having a myomectomy before, hysterectomy is typically recommended next. This is because:
- Myomectomy can leave microscopic residual fibroid tissue that grows back
- You can develop new fibroids in the future
- Repeated myomectomies are more difficult and increase risks
Rather than doing multiple repeat myomectomies, hysterectomy provides a permanent solution.
How to decide if hysterectomy is the best treatment choice?
The choice of hysterectomy is very individualized and requires detailed discussions with your gynecologist. Some key factors to consider are:
Fibroid symptoms remain severe despite other treatments
If you have severe pelvic pain, heavy bleeding or other symptoms that persist and significantly affect your daily life after trying medication, myomectomy or other options, a hysterectomy may be warranted.
No future pregnancy desired
If you do not want children in the future or are nearing menopause, hysterectomy is an option since it provides permanent relief by removing the uterus itself along with all fibroids.
High chance of fibroid recurrence after myomectomy
Based on your clinical profile and fibroid characteristics like large size, deep location, multiple fibroids, you may be advised to have a hysterectomy if the risk of new or recurrent fibroids after myomectomy is very high.
Other health issues present
If you have other symptomatic conditions that may benefit from removing the uterus like adenomyosis, endometriosis, uterine prolapse, or gynecological cancers, a hysterectomy may be advised.
Risks and benefits
Consider the risks of major surgery, impact on ovarian function, complications like bleeding or injury to nearby organs, pain, infection, and early menopause if ovaries are removed. Discuss whether the expected benefits outweigh the risks in your individual situation.
Alternatives
Evaluate if nonsurgical options like uterine fibroid embolization may be preferable based on your concerns. Get a second opinion if needed before deciding.
Pre-hysterectomy evaluation
The following testing may be done to plan and prepare for hysterectomy surgery:
- CBC – checks for anemia from fibroid bleeding
- Pregnancy test – confirms you are not pregnant
- Imaging – ultrasound, MRI to evaluate the size and location of all uterine fibroids
- Endometrial biopsy – samples the uterine lining to rule out cancer
- Pap smear – screens for cervical cancer or precancerous changes
- Medical history – checks for any conditions or risk factors that may complicate surgery
Discuss the different hysterectomy techniques with your doctor – abdominal, vaginal, laparoscopic, or robotic surgery. The approach depends on the surgeon’s expertise and your specific clinical scenario.
Recovery after hysterectomy surgery
Recovery time after a hysterectomy differs for each woman and depends on the surgical approach. Here is an overview:
- Hospital stay is 1 to 3 days for abdominal and laparoscopic hysterectomy. It may be less than a day with vaginal or robotic surgery.
- You can return to most normal activities in 2 to 3 weeks.
- Avoid strenuous activity and heavy lifting for 4 to 6 weeks.
- Driving may be restricted for 2 weeks if surgery was done through an abdominal incision.
- You may need 4 to 8 weeks off work. Discuss with your employer if you need short-term disability leave.
- Feelings of grief or depression are common after hysterectomy. Joining a support group may help.
- Vaginal discharge, mild pain, and spotting may persist for a few weeks. Call your doctor if it worsens.
- Continue routine follow-up visits as advised to identify any complications early.
Long-term effects
While hysterectomy can greatly improve the symptoms caused by uterine fibroids, it does have some long-term effects to be aware of:
- Infertility – you will no longer have menstrual periods or be able to become pregnant.
- Hormonal changes – depends if ovaries are removed. This may cause symptoms like hot flashes, vaginal dryness.
- Bladder and bowel problems – urine leakage, constipation, or fistula may rarely occur.
- Early menopause – if ovaries are removed, you will experience abrupt estrogen loss.
- Sexual issues – some women report less arousal, satisfaction, or pain with intercourse after hysterectomy.
- Emotional health – increased risk of anxiety or depression has been reported.
Discuss any new symptoms or concerns with your gynecologist during follow-up visits. Certain non-hormonal medications, lubricants, and counseling may help manage some of these long-term effects of hysterectomy.
Conclusion
Uterine fibroids can cause significant symptoms that may severely impact day-to-day functioning and quality of life. Hysterectomy is a proven treatment option that should be considered if medications or less invasive options do not adequately relieve fibroid symptoms, and when future fertility is not desired.
Carefully weigh the risks and expected benefits of hysterectomy with your gynecologist. Get annual pelvic exams and follow-up care even after surgery to monitor for any long-term effects. While challenging, most women feel major relief from fibroid symptoms after hysterectomy and are satisfied with this decision.
