Health Features

A Look at Women’s Reproductive Health

Reproductive health—it’s a topic that may make us feel embarrassed or uneasy. For women especially, sexual health can be immensely private and personal. But while your gut reaction may be to avoid the subject, it’s important that you tackle it head-on. With that in mind, T&S reached out to local health experts to get their perspective on uterine health concerns and hysterectomies.

hysterectomy
“Hysterectomy is one of the most common surgeries among women,” says Dr. David Levine of Mercy Clinic Minimally Invasive Gynecology. Approximately 600,000 are performed annually in the U.S., and according to the Centers for Disease Control, almost 12 percent of women between the ages of 40 and 44 have had one. Dr. Scott Biest, director of minimally invasive gynecologic surgery at Washington University School of Medicine, says that uterine fibroids are the most common reason the procedure is performed, and it also is used to treat uterine prolapse, abnormal bleeding, chronic pelvic pain, endometriosis and gynecologic cancers.

There are three options for hysterectomies. The procedure can be performed abdominally through a large incision or, less invasively, either vaginally or laparoscopically. Biest says the laparoscopic option is the most common. “Typically, the surgery involves removing the uterus and cervix, but in some instances, it is recommended that the fallopian tubes be removed to reduce the risk of gynecological cancer in the future,” he explains. “There also is an option to remove older patients’ ovaries as well, which reduces risk of ovarian cancer.” In most instances, the surgery is performed under general anesthesia, and it often requires an overnight hospital stay but can be done on an outpatient basis.

Recovery depends on how the procedure is performed. Dr. Patrick Yeung, a SLUCare obstetrician and gynecologist at SSM Health St. Mary’s Hospital, says that for abdominal hysterectomy, full recovery is typically four to six weeks, and it’s two to four weeks for the less invasive options. He suggests finding a gynecologic surgeon who is capable of performing the laparoscopic procedure because it benefits the patient, and Biest agrees. “With minimally invasive hysterectomy, the patient typically feels better faster,” Biest notes. “Evidence suggests that such surgeries also have a lower risk of infection, lower rates of blood clots (deep venous thrombosis and pulmonary embolus), shorter hospital stays, less pain and a more rapid return to normal life.”

Levine says after a hysterectomy, women often worry about having symptoms of menopause—hot flashes, vaginal dryness, poor libido—but if the ovaries are left, there shouldn’t be side effects. “By the time a woman is at the point that she needs a hysterectomy, she’s relieved and happy once it’s done,” he says. “Nothing changes sexually if the ovaries are intact.”

uterine fibroids
80 percent of African-American women will develop uterine fibroids by age 50. They are benign tumors that grow in or outside the muscle wall of the uterus. It is unclear why they develop, and there are currently no prevention options. “Fibroid growth is due to estrogen and progesterone, so you can’t inhibit their growth unless you stop the hormones,” Levine
explains. “Most often, you’re not going to do that because it will make patients feel menopausal.” He adds that many women are asymptomatic, but fibroids are fairly easy to diagnose because they can be seen on an MRI or ultrasound.

warning sings of fibroids
>> Abnormal uterine bleeding:  (heavy menstrual flow, bleeding that is prolonged or occurs between cycles)
>> Pelvic pain
>> Back pain
>> Urinary frequency
>> Constipation
>> Discomfort with intercourse

treatment options
>> Hysterectomy. Levine says this is a common solution for women who are finished with childbearing.
>> Uterine myomectomy. If a woman still wants the option of pregnancy, she can have the fibroids removed surgically. Biest says the procedure can be performed through a large incision, laparoscopically or through the vagina, depending on the location of the growths.
>> Uterine artery embolization. The procedure decreases the blood supply to the uterine body by occluding the arteries. “This stops the fibroids’ growth and can shrink their size by 30 to 40 percent,” explains Dr. Megan Mohrman, an obstretrician and gynecologist at St. Luke’s Hospital. “This may be enough to relieve symptoms and make hysterectomy unnecessary.” Biest adds that it often decreases the size of the uterus as well.
>> Birth control. If the most concerning symptom is heavy menstrual bleeding, oral contraceptives or an IUD may be used to suppress ovulation. These treatments, however, will not help with fibroid-related pressure or pain outside the patient’s period.
>> GNRH Agonists. These hormones induce a menopausal state, inhibiting ovulation. Biest notes that in some instances, they temporarily have shrunk fibroids.
>> Tranexamic acid. The medication is used to treat heavy blood loss, including that brought on by heavy menstruation.

endometriosis 
Endometriosis refers to tissue that is similar to the lining of the uterine cavity but grows outside the uterus. Its cause is unknown, but the most common theory is retrograde menstruation, which suggests that during a woman’s period, some of the blood flows backward through the fallopian tubes and implants uterine cells. Yeung notes that there are several issues with this theory. “In rare cases, endometriosis has been found in parts of the body menstrual flow could not reach, and it’s been present in girls before they start their cycle, women after menopause and very rarely men,” he says. “Also, if retrograde menstruation was the cause, there would be a very high recurrence rate because cells would reimplant with each cycle, but evidence suggests this is not happening.” He says a study conducted by Saint Louis University School of Medicine found that after two years, there was no recurrence of endometriosis among patients who had the tissue removed.

According to Mohrman, up to seven percent of women may suffer from the condition, but the only way to diagnose it is surgically. Currently, there is no way to prevent endometriosis, but Mohrman says there are some factors believed to be connected to decreased risk. “Giving birth multiple times, breastfeeding and starting your period later are tied to lower incidence,” she explains. “These all relate to how often your ovaries are being suppressed.”

warning signs of endometriosis
>> Pelvic pain
>> Severe menstrual cramps
>> Pain with intercourse
>> Infertility

treatment options
>> Laparoscopy. To allow a patient to keep her reproductive options open, endometriosis often is removed surgically.
>> Hysterectomy. The uterus may be removed to treat endometriosis, but Yeung cautions that it may not eliminate the problem if the ovaries are left intact, which is often done to prevent surgical menopause. “By definition, endometriosis is outside the uterus, so it’s not going away if you just get a hysterectomy,” he says. “If the ovaries are there, they can stimulate the implanted cells, and the patient still experiences symptoms.” Hysterectomy can be combined with removal of the endometriosis, or if the patient is already close to menopause or has an increased risk of ovarian cancer, the ovaries can be removed as well.
>> Birth control. Mohrman says medical management of the painful periods associated with endometriosis includes oral contraceptives and IUDs to suppress ovulation. “Non-steroidal anti-inflammatories like ibuprofen also may be used at the start of a woman’s cycle,” she adds.
>> GNRH agonists and antagonists. These treatments temporarily induce menopause in the patient. This inhibits the production of hormones and stops the endometriosis from being stimulated.

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