With advances in medical science, hysterectomy need not be a necessity. Women can opt for oral remedies, hormonal injections, intra–uterine devices and endometrial ablation to get rid of problems like heavy bleeding and fibroids. Experts say that doctors should resort to hysterectomy only when all other treatment options fail.

Hysterectomy is the surgical removal of the uterus and,sometimes, the ovaries. This procedure ends menstruation and the patient can never bear children. It can also cause hormonal imbalances.

"Women should know the side effects of hysterectomy, discuss it with their gynaecologists and opt for hysterectomy only when the benefits outweigh the risks," said endocrinologist Mohan Magdum of Poona Hospital and Research Centre.

Gynaecologist Leena Patankar of Patankar Nursing Home said, "Alternative treatment options like MIRENA insertion (a type of intra–uterine device), balloon ablation, TCRE can get rid of problems in many cases. Hysterectomy should only be performed when existing treatment methods have failed to yield results."

Senior gynaecologist Sanjay Gupte, former president of FOGSI, said, "Doctors cite heavy bleeding as a reason for removal of uterus, but they should resort to hysterectomy only when all other treatments fail to give results."

There is rising concern about unnecessary hysterectomies as the complications follow the removal of ovaries. Patients have to be on a Hormone Replacement Therapy (HRT) which does no good to lessen side–effects like mood swings, vaginal dryness, itching, osteoporosis, weight gain and a decrease in libido.

"Though we can treat these changes with estrogen hormones and designer estrogen, it is not fool–proof. In addition we have to give more attention to prevention of osteoporotic fractures and heart disease," said Magdum.

Consultant gynaecologist and vaginal surgeon Pankaj Sarode said, "The incidence of hysterectomy has remained almost the same over a period. Indications for surgery are actually decreasing because of newly invented and advanced conservative mana gement options for gynaecological diseases. The apparent increase may be due to i n – creased incidence of fibroids in uterus apart from malignancy (cancer). This is related to lifestyles involving late marriages, fewer conceptions, prolonged use of contraceptive medications, less duration of breast feeding and food habits and stress," said Sarode.

Gynaecologist Charuchandra Joshi, president of the city chapter of Pune Obstetrics and Gynecological Association (POGS) said, "I have not experienced significant rise in the number of hysterectomies in my practice, as percentage of total number of surgical procedures has remained about the same."

The commonest reasons for hysterectomy are prolonged and heavy menstrual blood loss, presence of fibroids and downward sagging of the uterus, called prolapse. "Uncommonly, cancer of some part of the female reproductive organs may be the reason for hysterectomy," Joshi said.

The age of women undergoing the procedure has also not significantly dropped. "There are two reasons –– an overall trend of hysterectomy only if necessary and patients prefer expert opinions before a final decision. Menstrual disorders have alternative treatments like oral medicines containing safe hormones and intra–uterine devices with hormones," Joshi said.

Women should always consult qualified gynaecologists. "They may take a second opinion and ask questions (questionnaires are on internet) to avoid unnecessary surgeries," Sarode said. A patient need not be alarmed, if hysterectomy has been suggested by a qualified gynaecologist. "The patient may seek a second or a third opinion from other qualified gynaecologists," Joshi said.

The surgical and anasthesia techniques have made surgery safe, provided,it is carried out at a well–equipped place by an expert gynaec surgeon. The patient can walk home in about 3–4 days after surgery and return to work too. A careful follow up after surgery combined with certain lifestyle changes, can prevent untoward effects of the operation to a great extent, he added.

Mirena is a small plastic Tshaped contraceptive device that contains the active ingredient levonorgestrel— a synthetic form of progesterone. Once inserted it steadily releases the levonorgestrel into the womb which prevents the endometrium from thickening each month in preparation to receive a fertilised egg. It reduces the amount of tissue shed each month and makes periods lighter

• Hormonal treatment
• Hormone with intra–uterine devices
• Endometrial ablation and transcervical resection of endometrium
• Trans–cervical resection of endometrium

• Hysteroscopic treatment: For removal of polyps and submucus fibroids
• A few hormonal injections which will shrink the size of fibroid
• High intensity focus ultrasound waves are focused on the fibroid under MRI guidance to dissolve the fibroid

Saroj (40), a homemaker, learned about a big fibroid in her uterus. She had been feeling tired, and the family doctor had diagnosed her condition as anaemia.

But when it came to hysterectomy, Saroj was anxious as she was advised to undergo an abdominal operation with prior blood transfusions which would have kept her away from any activity for six weeks, besides a scar on her tummy postsurgery.

That was when Saroj opted for vaginal hysterectomy called biclamp painless hysterectomy, where she did not need blood transfusion. She was discharged after 24 hours of the procedure. She went back to an active life within seven days.

In this hysterectomy the uterus is surgically removed through the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as well. Such a surgery is called bilateral salpingo–oophorectomy.

The method, according to experts, is a technically feasible and safer alternative to the traditional approach. Blood loss and need for pain medication is less in the newer approach. Several therapeutic options exist to avoid hysterectomy, but some need to undergo this operation when such options fail.

“Painless hysterectomy has been available to women in Europe. It is now available for women in Pune as well,” said vaginal surgeon Pankaj Sarode who trained in Germany and has performed 75 such operations at various city hospitals in the last eight months.

“It allows patients to go home within 24 hours. There are no cuts so it is painless and a boon for women with hypertension, diabetes and obesity. Since abdominal incisions are avoided, subsequent complications are avoided as well. It works well for working women who cannot go on long leave,” Sarode said.

Anaesthesia consultant Sumit Lad said, “We use regional anaesthesia for all painless hysterectomies. The entire procedure takes about 25–40 minutes. So, all complications of prolonged general anaesthesia, such as respiratory depression, post–operative nausea, post–operative pneumonia, aspiration are avoided. The patient is awake and conscious throughout procedure. Post–operative analgesia demand by patients is practically nil.”

(opening of abdomen by a large incision) or

(laparoscopy) ll Most popular ll Widely performed ll Basic surgical technique taught to gynaecologists during training ll Large scars, painful, hernia in future ll Prolonged hospitalisation ll Difficult post–operative recuperation for women with diabetes,

high BP, obese ll Need for blood transfusion THE NEW TECHNIQUE (BICLAMP TECHNIQUE) nn No scar–no pain, minimally invasive, painless nn Shortest hospitalisation nn Post–operative period most comfortable nn Less blood loss–less chance of blood transfusions nn Not for malignancy nn Expertise not readily available nn Not so popular

Only option is hysterectomy followed by chemotherapy or radiotherapy depending upon stage and grade of cancer (source: pune obstetrics and gynaecological society, pune)