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| Alternative Treatments | ||
| Question: All About Fibroid Treatments I have been having pain, heavy bleeding, pressure and urinary urgency for over a year. My doctor has done testing and determined that I have a fibroid. It has grown in the past 6 months from the size of a ball to the size of a grapefruit. I have been trying birth control pills to help the bleeding but I am very discouraged. What treatment options are available for uterine fibroids? |
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| Answer: In general, birth control pills and other medical interventions are not very useful in the long-term management of fibroids. Whether or not your fibroid growth constitutes rapid growth is subject to interpretation, but depending on your age and the exact change in fibroid size, additional investigation may be necessary. Even though uterine sarcoma, a malignancy that can sometimes be confused with uterine fibroids even though they are unrelated, is very uncommon (<0.1% risk in most studies), it certainly is something that you may want to discuss with your provider. There are many options for treatment, depending on one's age, desire for fertility, and other factors. Please discuss this with your gynecologist, first to make sure that anything other than a (benign) fibroid is not a significant concern, and secondly to plan treatment options. If you are over 35, it would also be appropriate to undergo some form of endometrial sampling to rule out a premalignant or malignant condition of the uterine lining. Good luck, and thank you for your
e-mail! |
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| Question: Microwave Endometrial Ablation vs Roller Ball Endometrial Ablation What is the most effective treatment? Microwave endometrial ablation or endometrial ablation by roller ball? I would like information on both. |
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| Answer: There is limited data on microwave endometrial ablation, whereas ablation using hysteroscopic methods such as a roller ball (or barrel) device has been subject to long-term studies. I am not aware of any direct, comparative studies of microwave versus rollerball ablation, so it is not possible to state which is more effective at this time. This can only be answered by prospective comparative trials. Please discuss this further with your provider. Thank you for your e-mail! |
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| Question: Endometrial Ablation Surgery Complications I was to have an endometrial ablation done for abnormal bleeding, but when I came out of anesthesia, the doctor told me that all that she could do was a D & C. She told me my cervix was small and would not dilate to allow the instruments needed for the other procedure to be done. In fact, my cervix started to tear and she had to suture it. My question is: Are there other ways to dilate a cervix? Or are some in fact too small to have any of these procedures done? |
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| Answer: There certainly are cervices that are very difficult to dilate mechanically (i.e. with a series of dilators). What works well in this situation is the use of osmotic dilators such as laminaria. Laminaria are little sticks made of seaweed and they remove water from the cervical tissue which results in cervical dilatation. Depending on the type of laminaria, they are inserted several hours or even a day in advance of a surgical procedure. Please discuss this further with your gynecologist, who can provide her own opinion as to whether this is appropriate in your situation. Thank you for your e-mail! |
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| Question:
Premenopausal with Fibroids I am premenopausal and have uterine fibroids. I have read that I maybe able to wait until menopause and the fibroids will begin to shrink. Is this true and under what conditions would it not be a good idea to wait for them to shrink? |
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| Answer: In general, you are quite correct. If there are reasonable concerns that an uncommon form of uterine cancer (sarcoma) may be present rather than benign fibroids, it would not be appropriate to wait. Such cancers (sarcomas) occur in less than 0.1% of women. Another possible reason for intervening would be the level of symptoms, particularly abnormal uterine bleeding. In a woman over 35, it would be important to undergo some form of uterine sampling, such as an endometrial biopsy or D&C/hysteroscopy, to rule out a premalignant or malignant condition within the uterine lining. Please discuss this with your healthcare provider, since you raise some very excellent and important questions and issues. Good luck, and thank you for your
e-mail! |
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| Question:
Rectocoele Treatment I've been researching rectocoele, as I have recently been diagnosed. I am 33 and I have had 3 children vaginally, each about 9lbs. When I was diagnosed with a rectocoele, the doctor told me I would need to have surgery and that I would not be able to have any more children after. Is this true? Does this corrective surgery usually involve a hysterectomy? Thank you so much for your willingness to answer questions. |
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| Answer: In the "old days" (which weren't really that long ago), it was believed that a cystocoele (bladder hernia) or rectocoele (rectal hernia) were symptoms of generalized pelvic floor weakness, and the uterus would inevitably be caught up in this process. Thus, hysterectomy was also often recommended along with repair of any bladder and rectal hernias. This concept has been revised, such that hysterectomy is not necessarily indicated unless coexistent uterine prolapse is also present. In other words, if it ain't broke, don't fix it. As far as surgery for a rectocoele, unless the rectocoele is symptomatic (for example, significant constipation or persistent rectal pressure), the mere presence of a rectocoele may not always require surgical intervention. If surgery is indicated, it usually consists of a repair of the supportive tissue between the rectum and vagina (posterior colporrhaphy) and hysterectomy is not generally necessary unless there is a clear indication for removal of the uterus. I would defer to your doctor on this matter, since any recommendations require a detailed knowledge of your personal medical history. Rectocoele repair does not, however, rule out future pregnancy. Many people would recommend a Cesarean section rather than risk disruption of the rectal repair, but I am not aware that pregnancy is contraindicated in the presence of a previous rectocoele repair. Again, please ask your doctor or a second opinion consultant about these issues. Good luck, and thank you for your
e-mail! |
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| Question:
Treatment for Uterine Prolapse Is there any surgery or procedure for a prolapsed uterus other than hysterectomy? |
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| Answer: Uterine prolapse can certainly be managed effectively with a pessary inserted in the office. A pessary is a diaphragm-like device that remains in the vagina and supports the uterus and other structures. The downside is that intercourse is generally not feasible, and the pessary must be removed and cleaned every month or so. Erosions in the vagina can also occur, but this is an unusual complication, particularly if the pessary is evaluated by a clinician on a regular basis. There have also been descriptions of abdominal procedures to support the uterus and avoid a hysterectomy, but they are perhaps better suited for support of a prolapsed vaginal cuff post-hysterectomy. I would suggest you discuss this in more detail with your gynecologist so that you can receive individualized guidance. Thank you for your e-mail! |
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| Question:
Fibroid Treatment I am 46 years old with a history of fibroid tumors and a more recent history of AUB. I am researching different alternatives of treatment for my problem because my periods are now coming every 14-21 days apart and lasting approximately 8 days and my GYN recommends a hysterectomy. I do not want a hysterectomy as I am nearing menopause and know this problem will improve/resolve with menopause. I also do not want to deal with the complications associated with a hysterectomy. I have considered ablation and embolization. I have read information that is contradictory regarding ablation. Some of what I have read states, it is not recommended treatment for women with fibroids. Is this correct? Also what about embolization - do we have enough information to know the long term consequences? Should I opt for a myomectomy or rectoscope removal instead? I intend to a avoid a hysterectomy and looking for the procedure with the least amount of complications (immediate and long term). Thank you. |
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| Answer: If this has not already been accomplished, it would be important to make sure that the uterine lining does not contain any premalignant cells (since you are over 35 and have abnormal uterine bleeding). Assuming this has been done, there may be other options as you correctly state. You are quite correct regarding ablation; it is not terribly successful in the setting of uterine fibroids except when the fibroids are treated as well. If the fibroids are lying under the uterine lining (Submucous) and are not terribly large, they may be shaved down at the same time as endometrial ablation, also using a hysteroscope. As far as embolization, my personal opinion is that while promising, it has not yet been subject to long-term, prospective controlled studies. That does not mean that it is not a good option, only that any decision must take into consideration any possible uncertainty. Myomectomy may be an option, and I am a great supporter of open myomectomy. However, if you are looking for something that has less complications than hysterectomy, you need to know that myomectomy is still major surgery, and can have complications such as bleeding, infection, etc. You may also want to ask about GnRH agonist treatment. While it can only be used short-term (no more than 6 months unless hormonal "add-back" therapy is coadministered), it might tide you over until you enter a natural menopause. Again, this is only a stopgap and may or may not be appropriate in your situation. Please discuss these options further with your doctor or other healthcare professional. Good luck, and thank you for your e-mail! |
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| Post Hysterectomy | ||
| Question: Post Hysterectomy Surgery Pain I had an abdominal hysterectomy two weeks ago. I am experiencing a severe burning sensation across my inch incision. What could be the cause of this and how long will it take to heal? |
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| Answer: Follow-up regarding postoperative symptoms are best handled by the physician who performed the surgery. There are many possible reasons for your symptoms, including a wound complication, so this is best addressed by contacting your gynecologist ASAP. Good luck, and thank you for your
e-mail! |
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| Question:
Endo. Pain Post Hysterectomy I have been suffering from endometriosis for many years. I had a partial hysterectomy 1 year ago and still am having severe chronic pain. I have been to three doctors. One said I should try birth control or Lupron again. I have been through all this and still had the pain, that is why I opted for surgery. Before the surgery my Dr told me that he was going to take my ovaries but he decided to leave them because the Endo had not invaded them too badly. The newest Dr I went to said I had three option: 1. do nothing, deal with the pain. He said it was my choice. I am only 34 years old and not so sure what to do. I am afraid if I have surgery again the pain will continue just like it did when they did the last surgery. Any suggestions? |
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| Answer: I would suggest that you discuss all options with each of your three gynecologists, since they have access to a more complete picture of your medical situation. In some cases, this really amounts to a judgment call, and there is no prospective right or wrong answer. Nonetheless, it is important that you are fully comfortable with whatever plan of action is undertaken. I'm not sure that doing nothing and "dealing with the pain" is appropriate, although actively pursuing pain management may be very sound judgment in many patients with chronic pelvic pain due to endometriosis. Rather than doing nothing, you may want to ask that doctor about how to manage your pain with any of a number of treatment options. There may be some downside to a second course of a GnRH agonist like Lupron in terms of a risk of osteoporosis, so you should certainly discuss this in much more detail with your doctor. Finally, removing the ovaries may or may not be beneficial, depending on which study is consulted. I would also make sure that there is no significant doubt that active endometriosis is responsible for your pain. If Lupron did not help, it may be that adhesions (which may be due to endometriosis) or some other disorder is responsible for your symptoms. This is important, since removal of the ovaries would not be expected to be of benefit in the case of adhesion-related pain. Please discuss your excellent questions with your doctor, and don't hesitate to obtain yet another opinion in person if necessary. Good luck, and thank you for your
e-mail! |
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| Question:
Granulation after Hysterectomy Eight months after I had a complete, vaginal hysterectomy, I began to bleed vaginally. I was told that the bleeding was due to granulation at the cuff of the vagina. My doctor treated it several times and thought that it was healed. I didn't bleed for about three months and recently began bleeding again. I saw my doctor again this week and a biopsy confirmed that this is again granulation tissue. She has never seen granulation return like this. The area is larger now than the first time it was treated. I take estrogen orally and use a vaginal cream. Is granulation something that returns and has to be dealt with ongoing? What else can be done to prevent granulation and bleeding? |
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| Answer: Granulation is a process by which tissue heals, and takes place in the vagina after hysterectomy. I am not personally aware that it can return once it has healed, but it may be possible. It is good that this was biopsied, however, to confirm the diagnosis and rule out something worse. Regardless, you should discuss this further with your doctor to see how to proceed from here. Good luck, and thank you for your
e-mail! |
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| Question:
Fallopian Tube Prolapse I had a hysterectomy a few months ago but did not have the ovary's removed. I am 40 yrs old and since the surgery I have been in pain and have urine leakage. I have been to my doctor several times for different tests to determine the problem. He told me my Fallopian tube fell and is lodged in vagina and requires surgery to correct. How can this happen? |
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| Answer: You probably should discuss this in more detail with your gynecologist, since he/she can best explain why this happened to you personally. Fallopian tube prolapse is a recognized complication of hysterectomy, and has been reported in the literature several times. Thank you for your e-mail! |
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| Question: Loss of
Libido/Pain Post Hysterectomy My wife is 50 years old, she has had a full hysterectomy about 3 years ago. Since that time she has no desire for sex. She has been to the doctors and they just ignore her questions on the subject . She is also embarrassed to press the issue with them. She does take Progesterone and a Product she has just started called Maxine's Intima, which is a blend of herbs that are supposed to balance her hormones and help with her desire for sex. Upon questioning her, she has told me she has pain when she is aroused and that she can't even masturbate. She also has pain when I try to arouse her by touching her nipples etc. The pain seems only to occur when she starts to become aroused and it seems to be within clitoris. She has no vaginal dryness or pain there. This as a result, gives her no feelings for sex. Can you give us some advise. She does want to have sex but because of the pain it only turns her off. We were very sexually active before the operation. |
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| Answer: Hysterectomy in and of itself may or may not affect libido. The data on this is very contradictory, and it really depends on which study you read. Regardless of the cause, there clearly is a major problem. It is unfortunate that your wife's physicians are not approachable on this subject, and it may be that both of you need to consult with a new set of physicians or other healthcare providers on this issue. It is not possible to determine if this is a physical or psychologic disorder from your e-mail alone. That is a matter best dealt with in person by an appropriate specialist. I would suggest you and your wife pursue one or more healthcare professionals who are more sensitive to these issues, and also inquire as to whether counseling is indicated at this point. The pain may be a physical disorder, such as vulvodynia, so it is imperative that in addition to any proposed counseling, a physical exam by a specialist in vulvar pain disorders or a similar professional be considered. Good luck, and thank you for your
e-mail! |
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| Question: Hysterectomy & Ovarian Function I recently had a TVH (ovaries left in) and see a lot of conflicting views on recovery time and what to expect even among the doctors.1. I am 46 years old and in very good physical shape prior to the surgery. Recovery is going better than I expected but I see opinions all over the boards about what you can or cannot be do at certain points of recovery, regardless of how you feel. What are your thoughts? 2. Have seen many women write on a very popular hysterectomy site, that even when the ovaries are left in, they often shut down for awhile out of shock from the surgery. The writers state they experienced menopausal symptoms until the ovaries get back on line. I asked my doctor, who I consider very knowledgeable and she stated that the ovaries do not stop functioning temporarily as a result of surgery. What are these women talking about? |
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| Answer: Regarding your first question, I would defer to your doctor's instructions as to what you can or cannot do after surgery. I do have my own general guidelines on this, but so does every gynecologic surgeon, and it is a matter of clinical experience and judgment. In other words, many different approaches exist, and most if not all are quite valid. I am not aware of any disruption in ovarian function after hysterectomy. I have seen studies suggesting that the time to menopause may be shortened in women who undergo hysterectomy with ovarian conservation, but I have not heard anything suggesting that the ovaries become temporarily inactive after surgery. Please understand that while there is much good information on the Internet, many forums and Web sites, however well-intentioned, may also contain inaccurate information. It is very important to seek out reputable, reliable sites and consult a healthcare professional about any issues that arise. Good luck, and thank you for your e-mail! David Toub, M.D. |
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| Hysterectomy as Treatment | ||
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Question: Hysterectomy for Migraines
& Dysplasia
I am a 46 year olds and I have experienced increased pain and flow with periods over past 2 years as well as an increase in frequency of migraine headaches. My gynecologist has recommended a total abdominal hyst & bilateral salpingoopherectomy. Twelve years ago, I was diagnosed with Chronic Fatigue Syndrome and carcinoma insitu of my cervix. I underwent laser for removal of a large lesion and have had normal & frequent pap smears since. I am active and work 4 days a week, so the chronic fatigue is pretty well under control most of the time.....on exam 2 weeks ago I had a pap smear which has come back mild dysplasia. I have been considering a hysterectomy in hopes that the pain, flow, and headaches would be improved and now with the recent abnormal smear I feel I should proceed. Would it help the migraines and how will hormone therapy work? |
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| Answer: Hysterectomy, to the best of my knowledge, has no effect one way or another on migraine, and migraine is not an accepted clinical indication for hysterectomy as far as I am aware. I would suggest you discuss all options with your doctor, including alternatives to hysterectomy. A second opinion may also be a consideration with elective hysterectomy. As far as mild dysplasia, no diagnosis is final until a colposcopy has been performed, so it is important that you also discuss this with your doctor. Mild dysplasia either goes away or does not progress in approximately 80-85% of women and with treatment such as CO2 laser or LEEP, over 90% of women can be cured of their mild dysplasia. Regardless, the Pap smear generally should be confirmed with colposcopy, so please discuss this further with your doctor. Good luck, and thank you for your e-mail! David Toub, M.D. |
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| Hysterectomy Information | ||
| Question: All About GYN Exams Post Hysterectomy I had a hysterectomy and have not been to the doctor since. Should I be going for vaginal exams or pap tests? What would be the reason if I no longer have a uterus? |
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| Answer: According to the American College of Obstetricians and Gynecologists, while performing Pap smears after removal of the cervix has not been proven to be cost-effective, periodic Pap smears of the vagina is suggested. There are several reasons why it is hard to come up with a blanket policy for all women: * Some women who have had a hysterectomy still have a cervix present, and therefore have no decrease risk of cervical cancer * If a woman has had abnormal Pap smears in the past, she is still at increased risk of premalignant and malignant (cancerous) disease of the vulva and vagina Even if a Pap smear is not necessary according to one's doctor, a pelvic exam is still advisable at regular intervals. If the ovaries were not removed, pelvic exam is one of the best ways of screening for ovarian cancer and other ovarian disorders. It is also of benefit, since it allows a screening for any vulvar and vaginal problems and is also an appropriate time for a breast examination and mammogram scheduling as indicated. Finally, regular women's health exams allows a woman to discuss any pertinent issues with her provider, including matters relating to menopause, sexual health and other subjects. Please discuss this further with your healthcare provider. Unless you are told otherwise, it is best to undergo regular examinations by your healthcare provider. Good luck, and thank you for your
e-mail! |
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| Question: All About Hormone Replacement Therapy Why or when is a woman required to take HRT? What is it's purpose? If don't take HRT, will it affect me adversely in the long run? |
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| Answer: A woman is never "required" to take hormone replacement therapy (HRT), but there are many situations in which it may be a good idea. All women are at risk for osteoporosis (loss of bone mass) after menopause because of a lack of ovarian estrogen production. Dietary calcium and exercise are both good things to consider, but they are generally not effective in preventing osteoporosis unless estrogen is taken. There are many benefits from taking HRT. Estrogen affects many parts of a woman's body, including the uterus, breasts, bones, pelvic support tissue, and others. It prevents osteoporosis and reduces the incidence of hot flashes and vaginal atrophy. The osteoporosis protection is very important, since older women (and men) can die from hip fractures associated thin, porous bones. There is some debate as to whether HRT can prevent heart disease and Alzheimer's' disease; there is no clear answer at this time, and recent studies have not demonstrated any clear benefits with regard to these disorders. Whether or not any individual woman can be adversely affected by not taking HRT is a question best discussed with one's healthcare provider, since that involves a knowledge of a woman's personal medical history, etc. Some women may be at particularly high risk for osteoporosis-associated bone fractures, as determined by a radiologic test known as a dual-emission x-ray absorptiometry (DEXA) scan. There are risks associated with HRT, including endometrial cancer and possibly breast cancer. It is important to note that endometrial cancer risk increases only when a woman with an intact uterus takes unopposed estrogen. When estrogen is combined with progesterone, a woman's risk of endometrial cancer actually decreases relative to women who do not take hormones. Any breast cancer connection remains controversial, since different studies find different results. There are also women who should not take HRT under any situation, such as women with breast cancer, although there are ongoing studies to determine if HRT may be safe in some women with a history of breast or endometrial cancer. Please discuss your excellent questions further with your healthcare provider. Thank you for your e-mail! |
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| Question: Why Two Procedures? I'm 44 and had trouble with my periods for 2 years. I've had an ultrasound and was told I have a huge fibroid tumor and a big mass on an ovary. My doctor wants to do a D&C, wait 3-4 weeks and do a hysterectomy. He told me he wanted to do the D&C so he could figure which way he wanted to do the surgery. All I want is just one procedure, not two. I've had D&C's before and always end up going back because of the bleeding. What should I do? I'm scared and don't have anyone to talk to lost mother 2 years ago lost grandmother Nov. 2000 Help! |
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| Answer:
I think it would be best if you discussed this more fully with your doctor, and possibly consider a second opinion consultation as well. For starters, any woman over 35 with abnormal uterine bleeding merits some form of endometrial sampling in order to rule out endometrial cancer. A D&C (preferably with hysteroscopy) is quite appropriate in this setting, although you may want to ask your doctor if an office endometrial biopsy might be appropriate as well, since this might avoid having to go the operating room for a D&C. A D&C with hysteroscopy remains the "gold standard," however, although endometrial sampling is also very reliable. Your description of a "big mass" on the ovary concerns me, based on the very limited information. Is it very likely that this represents a benign (noncancerous) tumor, and if not, might an earlier date for surgery be indicated? I don't want to second-guess your doctor, since he/she has considerably more information about you to work with, but you may want to ask if there is reason for concern. Finally, you may also want to inquire about alternatives to hysterectomy, assuming these might be indicated. Please discuss everything fully with your doctor, and do not hesitate to obtain a second opinion if you so desire.
Good luck, and thank you for your e-mail! |
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Question: Laparoscopic Hysterectomy
Information
What is the difference between a "total laparoscopic hysterectomy" and a "laparoscopic assisted hysterectomy?" |
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| Answer: This is more a religious question than almost anything else in pelvic surgery. Depending on the surgeon, there may be considerable or minimal difference between TLH and LAVH (laparoscopic-assisted vaginal hysterectomy). Technically, a LAVH (which is more common) is a procedure in which most of the hysterectomy is performed laparoscopically, and the hysterectomy is then completed vaginally. TLH, according the definition of my former teacher Harry Reich, is a procedure in which the entire hysterectomy is performed with the laparoscope, and the resected specimen is then removed through the vagina. The problem is, different surgeons have different definitions of what constitutes a LAVH vs a TLH. Various classification schemes have been developed, but in practice it still often comes down to some subjective measure. In some cases, only a small portion of the hysterectomy is performed with the laparoscope, yet the surgeon classifies the operation as a LAVH. There are also hysterectomies in which everything is done laparoscopically except for the anterior incision in the vagina (anterior colpotomy) and perhaps a portion of the cardinal ligaments, yet these would also be LAVHs. Obviously, some LAVHs involve more laparoscopy than others. The main guiding principle, however, is to always do what is most appropriate and safe for an individual patient. For someone to stop the laparoscopic portion of the operation early and proceed vaginally may be consistent with excellent medical judgment and common sense. The final result, including the presence or absence of complications, is what really matters. Thank you for your e-mail! |
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| Question: Why Remove Everything during a Hysterectomy? Is it really necessary to remove all my female organs during a hysterectomy, as my Doctor wants to do? She says the ovaries will quit working anyway in just a few more years and why take the chance of ovarian cancer in the future? I am very uncomfortable with doing so for uterine fibroids. |
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| Answer: In a woman over 45, it is not unusual (nor incorrect, in my opinion) to offer a woman the option of removing both ovaries at the time of hysterectomy. This is because there is a 1 in 70 lifetime risk of ovarian cancer in the average woman, and removal of the ovaries can decrease this risk. The key word is "offer," since this is something that must be considered carefully by any individual woman, with a full knowledge of the pros (reduced ovarian cancer risk) and cons (earlier need for estrogen replacement therapy). If you are not comfortable with a decision, so long as you have been fully informed of the pros and cons of removing both ovaries, your doctor must respect your decision. A doctor generally cannot impose his or her preferences upon a patient. You should discuss this further with your doctor, and make her aware of your opinion and preferences on this issue. Good luck, and thank you for your e-mail! David Toub, M.D. |
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| Other Questions | ||
| Question: Lupus and HRT and hysterectomy I am 42 years old, I have lupus cerebritis, antiphosphilipid syndrome, ITP, hypothyroidism, fibromyalia and bipolar illness. In August 2000, I was hospitalized for lupus cerebritis and a mild stroke. I recently was diagnosed with endometrial hyperplasia. I am considering having a hysterectomy and the O.B. suggested HRT (provera). I am very concerned about HRT treatment since I take many other medications. I am told that I am a high risk patient. I had a electocardiogram and my heart seem fine. I am concerned about blood clotting. I do not want to take HRT along with all my other med's. Please give me some advice, is the hysterectomy a safe procedure for someone like me? |
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| Answer:
Whether hysterectomy is safe for you personally is a judgment best made by your own physician or other healthcare professional. I certainly would suggest that in general, someone with SLE, ITP and other medical disorders would be at higher risk for surgery. While I would urge you to discuss this further with your doctor in more detail, a short-term course of high-dose progestin therapy has been shown to reverse endometrial hyperplasia. Whether this is appropriate depends on many factors, including the specific details of any pathology report from a D&C/hysteroscopy or endometrial biopsy. Please speak at length with your doctor about your excellent questions, since it is very important to have all the facts before any significant medical or surgical intervention. Good luck, and thank you for your e-mail! |
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| Question:
Squamous Intraepithelial Lesion What is epithelial cell abnormality/low grade squamous intraepithelial lesion? Does this need to be treated by having a hysterectomy? |
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| Answer: Last question first: No. Assuming further evaluation (i.e. colposcopy with biopsy as appropriate) confirms the Pap smear reading of LSIL, options may generally include observation (since a significant number of such mild lesions either regress on their own or do not progress to cancer) or conservative treatment with either laser or loop electroexcision (LEEP). LSIL is a Pap smear finding that suggests a mild abnormality called "mild dysplasia" (or CIN I in the older terminology). Because the Pap smear is only a screening test and does not provide a definitive diagnosis, it is important to follow-up with your doctor or nurse practitioner regarding colposcopy. This is an office procedure in which a colposcope (which acts like a microscope) is used to accurately determine if dysplasia is present, and the severity of disease. Only upon a definitive diagnosis can appropriate treatment options be determined. Please make sure you follow-up with your healthcare provider on this issue. Good luck, and thank you for your
e-mail! |
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| Question: Abnormal Paps and Hysterectomy At what point in time should a woman consider a hysterectomy when she has had abnormal paps? I have numerous abnormal paps ranging from mild to severe dysplasia. I have had colposcopies and the LEEP procedure. My doctor suggested a hysterectomy. Is this a valid treatment and is there sufficient reason to consider this? Do I have any other options besides repeat LEEP procedures. I am afraid of this turning into cancer and I am seriously considering a hysterectomy. |
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| Answer: This is a fairly individualized issue, so I would defer to your doctor's advice. In general, anything short of microinvasive cervical cancer (e.g. mild, moderate and severe dysplasia) can usually be managed quite well with conservative therapies such as CO2 laser ablation and LEEP. In some cases, cone biopsy may be necessary to rule out disease within the endocervical canal, but again this is also more conservative than a hysterectomy. Hysterectomy is sometimes recommended when a patient has a very strong fear of cancer or when multiple attempts at conservative therapy do not succeed in curing the dysplasia. You may want to ask your doctor if a cone biopsy is appropriate (it may or may not be). Another option is to undergo a second opinion consultation, such as with a gynecologic oncologist. Thank you for your e-mail! David Toub, M.D. |
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Question: HRT & Cancer
History
I have fibroids, ovarian cysts, endometriosis and as of my most recent D&C six weeks ago, endometrial hyperplasia. I am considering a hysterectomy. My mother and both grandmothers had cancer. Obviously, surgical menopause will occur, but HRT does not seem to be an option because of the cancer history. Is hysterectomy/oophorectomy the best answer or will it create more problems in the future? What should a woman generally consider in this situation? |
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| Answer: I would defer to your doctor's judgment, since that really requires a detailed working knowledge of your age, diagnosis and other factors. There are different forms of endometrial hyperplasia, some of which have minimal to no risk of cancer while others have as much as a 25% or higher risk of cancer, so the type of hyperplasia (in particular, if cellular "atypia" is present) is an important consideration, as is age. In appropriate women, treatment with high-dose progestins combined with close and careful follow-up may be a consideration, but this is something that is always best taken up by a woman together with her provider. Good luck, and thank you for your
e-mail! |
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| Question: Lupron Treatment for ORS I can't tell you how excited I was to finally find some information regarding ORS. When the Doctor advised me of this, I honestly had never heard of it. After experiencing a Hysterectomy in Dec. 98 due to large Fibroids, I actually had a pain free 12 months to follow. Since then I have had cysts that were huge and had them aspirated, but kept filling back up with fluid. This caused both ovary's to be removed at separate times. It has now been over a year and I still have constant right sided pain. My Doctor does not want to do any more surgery, as there is a lot of scar tissue and he doesn't know which piece of scar tissue is holding the remnant of an ovary. The way we found this out was, when he took me off of my daily estrogen, with monthly blood work following, it showed my body producing Estrogen. He is treating me a monthly injection of Lupron to hopefully "suppress" the piece of ovary. Do you know of the success rate of this type of treatment? I have now received 4 shots and my monthly blood work does show the estrogen levels dropping. |
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| Answer: Regarding ovarian remnant syndrome, GnRH agonist therapy should, like oral contraceptives, suppress ovulation. However, GnRH agonists cannot be taken for longer than six months without hormonal "add-back" therapy, due to the risk of osteoporosis. You may want to discuss this further with your doctor, including any other possibilities that may exist for medically managing your symptoms. Good luck, and thank you for your
e-mail! |
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