When is it Time to Break Up with Your Uterus?

This is not a blog about hysterectomy. It’s actually a blog about how not to get one for women who don’t need one.

So, when is it time to break up with your uterus? If your uterus is moving out, it’s probably time to let it go. If it has cancer or precancer (post babies), it might be time for splitsville. If your uterus is the size of someone’s who is 4 months pregnant or more and you aren’t pregnant, it’s past time for a breakup. Otherwise, there is alot we can do to help repair the relationship and let you love your uterus again (or maybe for the first time).

I’m going to divide this up by kids and menopause to make the reading easier. For all of these categories, step 1 is history, step 2 is exam, imaging and possibly biopsy, step 3 make a diagnosis and review all your options and make a individually considered plan. While I will discuss options below, not every person will be a candidate for every option and knowing the cause of the problem is absolutely crucial before coming up with treatment plan.

1. Not necessarily done with kids and premenopausal - If you don’t know if you are done with kids, then you certainly shouldn’t give up your uterus unless you have cancer - and even then, you should discuss fertility preservation with your oncologist/gyn onc. So we will be going through conservative treatments in this section.

   1. Bleeding - There are more options than ever in this department. We have the old stand bys - birth control pills and depo provera, and a somewhat newer to the market option - the progesterone IUDs like Mirena. All of these things have additional FDA labeling about their use under these circumstances. There are newer options that are medications that were designed as first line therapy rather than a side effect that we are taking advantage of. These include Lysteda (nonhormonal, taken only when bleeding is happening), Orilisa/Oriahn/Myfembree - shut down the repro system +/- hormone add back used for fibroids, and high dose progesterones (generally only used for endometrial hyperplasia).

   2. Pain - usually secondary to endometriosis and/or adenomyosis - Orilissa does amazing things in this space and there are two doses to help deal with the worst pain symptoms. I also love this drug because it helps you know how much you might benefit from hysterectomy if things go that way.

   3. Fibroids - its all about location, location, location!!! If the fibroids are solely in the uterine cavity, they are probably causing heavy bleeding and the easiest way to deal with them is a hysteroscopic myomectomy where we put a camera in the uterus through the opening in the cervix and then put a tool through it to remove the fibroid. This is an outpatient procedure and works very well to remove the entire fibroid. If it’s hanging off the outside of the uterus, then most symptoms will be pressure from the fibroid pushing on something. This can be removed by doing a laparoscopic or abdominal myomectomy (using small incisions in the abdomen that sometimes have to be enlarged). When they are partly in the wall and partly anywhere else, medical management (using meds described above) is generally preferred because trying to remove them risks damaging the entire uterus. Some managements can help decrease size by 1-2 cm and others will just stop the bleeding, but not change the size.

   4. Prolapse - In this age group, pelvic floor PT is my number one recommendation. If you fail that, we can use pessaries as an interim tool until childbearing is complete, but there’s not alot else we can do, but we should make sure sometime else isn’t causing the prolapse like a fibroid.

   2. Definitely done with kids - premenopausal.

   1. Bleeding - If you are over 40, say good bye to the birth control pills. Otherwise, all of the above is still valid. We have another great option to add though. The Novasure ablation. The Novasure ablation has done more to drop hysterectomy numbers in this country than any other practice change in the last 30 years. An ablation involves putting a camera in the uterus, scraping out any lining that’s there and using a tool to burn the lining of the uterus. The burning takes 60-90 seconds and the whole procedure takes about 8 minutes. You will need some anesthesia, but don’t need to go all the way to sleep. We are excited to be able to offer this at our new office. It’s important to make sure there is no abnormal pathology because this procedure will seal off the uterus, but approximately 92% of women never bleed again. Longest effects are noted in those who are already perimenopausal, but you can do this in younger women. If you get one in your 20s though, it’s unlikely to last all the way to menopause.

      2. Pain - Pretty much the same, but if you get signficant relief with Orilisa, it’s probably better to have the hysterectomy in the long run because you are limited on how long you can take this medication because it can impact the bones when used over longer periods of time.

      3. Fibroids - Pretty much the same, but we hve one more option - the uterine artery embolization. I generally don’t like this procedure because alot of people get negative side effects, but if you have one fibroid that is 5-8 cm, you will probably do ok. It’s also better done if you are within 5 years of menopause because over time, now blood supplys can develop and undo the results.

      4. Prolapse - Time to start thinking about separate lives. Prolapse will likely get worse over time.

   3. Postmenopausal

   1. Bleeding - absolutely do not wait!!!!! You need to be seen by a GYN, have and ultrasound and probably an endometrial biopsy. While cancer isn’t the most common cause, it absolutely must be ruled out before considering any treatment. The most common cause are polyps and these are easily removed using a hysteroscope. If you are brand new to menopause and using HRT and having a hysteroscopy anyway, think about going ahead and getting an ablation as it will make breakthrough bleeding not be a thing later on.

      2. Pain - unless you had significant pain premenopause, it’s unlikely to be helped by a hysterectomy postmenopause unless you also have prolapse or very large fibroids.

      3. Fibroids - will likely get smaller the longer you are in menopause, but again, any bleeding associated absolutely must be worked up.

      4. Prolapse - if you are a good surgical candidate, it’s time to kick this guy to side of the road and get on with your life. If not, well, there are pessaries and they can be helpful, but you will be dealing with it for the rest of your life and routine maintenance will be important.

I hope this has been a helpful guide to give you management options at every age and stage. As always, nothing in this blog should be considered medical advice, but if you need medical advice, I know someone who knows someone.