A friend recently shared with me a story that troubled me to my core. A friend of hers was diagnosed with anemia, also known as a low blood count. She saw her gynecologist for evaluation and ultimately underwent a hysterectomy, even though her menstrual bleeding, from the little bit of the story I know, did not appear to be excessive. Ultimately, the source of her anemia was found to be from another source, as in NOT her uterus.

She was still left without a uterus.

This story troubled me because a hysterectomy is a big deal, and I wondered if she received appropriate counseling and evaluation before that decision was made. A large study from 2009 involving over 5000 participants followed over 15 years revealed the following as it relates to hysterectomy rates by demographic:

“… hysterectomy among Black compared with White participants were almost four times higher.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622766/

A more recent study published in 2019 revealed similar findings, reporting “African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. ” Click here for the source.

Now this story is not just potentially one of healthcare disparities or racial inequity. After all, the size of the uterus and the number of fibroids can impact a person’s potential need for a hysterectomy and the type of hysterectomy that is done.

Generally speaking, I fight tooth and nail to preserve a person’s uterus.

I will only perform a hysterectomy if I have explored or exhausted other options. In the story I heard above, I was thinking, was she offered this? Did her doctor check that? What else could have been done? AND, why did she allow this to happen without asking more questions?

Welp, she may not have known which questions to ask.

Use this article as a reference and share it with those who may be considering a hysterectomy. My goal is to ensure that we are aware of our options and are making the best choice, given the circumstance we are presented.

#1: If you are anemic, have all causes for anemia been explored?

Heavy menstrual bleeding is a plausible cause of anemia. Heavy menstrual bleeding is defined as loosing greater than 80ml of blood during a menstrual cycle. Quoting another Gyneco-bLogic article that breaks down what that means:

The average blood loss during a period is 35 ml. The average regular tampon or pad takes 5 ml before it is soaked. So if during your entire period you use 7 tampons or pads, SOAKED ones, you’re about average. If you are soaking more than 16 regular pads or tampons during your cycle, you may be bleeding too much.

Let’s run through a scenario…

Day 1, you change a liner or minimally soaked tampon twice during the day. Day 2, you change a soaked tampon every 4 hours, like 3 times during the day and once at night. Day 3 you change a half soaked pad/tampon twice. Day 4 and 5, you are barely bleeding.

Total= about 6 total soaked tampons. Normal, no problem

Scenario #2: Day 1, you change a soaked tampon every 4 hours (3). Day 2, you change a soaked tampon AND pad (to catch overflow) every 2 hours (8), Day 3, same thing, oh and you messed up your bedsheets, which happens sometimes. Day 4, you can get away with a tampon every 3-4 hours. Day 5-7, same but every 5-6 hours.

Total= Okay, I lost count, but you hit 16 just on days 2 and 3, so you’re definitely bleeding too much.

https://gyneco-blogic.com/2019/02/24/about-my-period-how-much-is-too-much-and-how-little-too-little/

If you aren’t bleeding excessively, could blood loss be coming from another source? I would advise you to see a primary care provider and determine if you may need a GI scope to look for an ulcer or polyp that could be bleeding in the GI tract. Are your blood cells normal? Could you have sickle cell trait or thalassemia trait that could cause anemia that is not related to blood loss? What other factors may be in play? These are questions that you can consider asking your provider to ensure other causes are being ruled out.

# 2: If you ARE bleeding excessively from the uterus, is the source structural or hormonal?

A checklist for possible structural causes of heavy bleeding or anemia could include:

1. An up-to-date Pap test to ensure the cervix is healthy. If you had a pap recently, you shouldn’t need another one, but I would consider it if it’s been over a year.
2. A pelvic exam and ultrasound looking for signs of polyps, fibroids, ovarian cyst or masses, etc.
3. Suppose fibroids or polyps are suspected near the inside of the uterus. In that case, a saline ultrasound, or sonohysterogram could be relevant to determine if either of these structures are projecting into the inside of the uterine cavity.

More on the management of those particular structures below, but what if the cause is hormonal?

Hormonal or other blood related causes of abnormal or heavy bleeding can include thyroid abnormalies, anovulatory bleeding like Polycystic Ovarian Syndrome or PCOS, and blood clotting abnormalities like Von Willebrand disease  or other hemophilias. It is reasonable to ask your healthcare provider is any of these causes have been evaluated. Also, take note if you frequently bleed from your gums when brushing your teeth or bruise easily. That could make hemophilia more of a suspect in the cause of your abnormal bleeding.

# 3: If the source appears to be structural, can that problematic structure be dealt with specifically?

Fibroids or polyps that are intracavitary, or submucosal, can cause significant bleeding. Removal of these structures can significantly improve bleeding if they can be reached easily. If a fibroid is located in that cavity of the uterus, it may be able to be removed using a minimally invasive procedure called hysteroscopy. The ones that can be removed hysteroscopically are represented by the (d) in the picture below, know as submucosal fibroids. Some of the (c)s can be removed this way too.

I NEED to take a moment to shout out Senator Kamala Harris for a new Bill introduced about a week ago:

U.S. Senator Kamala D. Harris (D-CA) on Thursday introduced the Uterine Fibroid Research and Education Act, legislation to initiate crucial research and education in relation to uterine fibroids and ensure women get the information and care they need.

https://www.harris.senate.gov/news/press-releases/harris-introduces-legislation-to-support-uterine-fibroids-research-and-education#:~:text=WASHINGTON%2C%20D.C.%20%E2%80%93%20U.S.%20Senator%20Kamala,information%20and%20care%20they%20need.

This is huge. Multiple times EVERY WEEK, I am asked what can be done to prevent fibroids or shrink them or reduce their growth rate. Not a lot is known about why so many people are affected by fibroids- 70-80% of women by the age of 50. We do believe that few lifestyle changes can reduce the growth and symptoms caused by fibroids.

1. Reduce the consumption of simple sugars
2. Reduce the consumption of processed foods
3. Reduce consumption of red meat
4. Exercise regularly
5. Maintain a healthy weight

WebMD has a very well-sourced article about the subject of managing fibroids with behavior choices. Click Here to read it. Even with all of these actions, though, some fibroids will require medical or surgical intervention to improve a person’s quality of life. This legislation and research will undoubtedly help us understand more and affect better changes.

Some fibroids can be treated or removed hysteroscopically. Some can be ablated laparoscopically with a procedure called Acessa. Some can be remove by laparoscopic or abdominal myomectomy. There are many ways to deal with fibroids other than a hysterectomy depending on an individual’s symptoms and circumstances.

# 4: If the individual structure can’t be fixed, are you a candidate for other minimally invasive medical or surgical procedures?

Before we get to surgical management, some medication options for managing anemia or symptomatic fibroids can include:

1. Hormonal birth control can reduce blood loss and cramping
2. NSAIDs like Ibuprofen work chemically to minimize cramping and blood loss, in addition to pain control.
3. Tranexamic acid, which is a medication that slows blood loss by basically controlling the speed in which blood clots.
4. Elagolix is a new medication that creates a reversible menopause-like scenario in your body. This can decrease blood loss, reduce pain and even shrink fibroids.

If none of those are right for your circumstance or don’t work well, some can benefit from other minimally invasive surgical options.

Endometrial ablation is a procedure that burns the inside of the uterine lining. When used appropriately, this can reduce or eliminate blood loss from the uterus for an extended period of time, often years. Another procedure is uterine artery embolization– which is a procedure performed by interventional radiology. This involves blocking the blood supply to the uterus, reducing the size and symptoms caused by fibroids. Neither of these procedures are for everyone, but both have their place as options to control symptoms and avoid major surgery.

# 5: This one is super important. Is the tissue in the uterus normal without any signs of pre-cancer or cancer?

Sometimes the tissue on the inside of the uterus can become pre-cancerous or cancerous. Anyone who is 40 or older or experiencing irregular menses should, in my opinion, undergo an endometrial biopsy or dilation and curettage to sample the uterine lining. I say, “in my opinion” because the American College of Obstetricians and Gynecologists (AGOC) recommends endometrial biopsy for those 45 and older. Some benefit from sampling earlier, and I have detected abnormalities in people younger than 45.

If certain types of pre-cancer or if cancer or found, that uterus needs to go. Certain types of pre-cancer, or atypia, can be managed with medication, especially if fertility is still desired. Make sure that you have had some form of assessment of the uterine lining.

If a hysterectomy is the best option for you, know that there are different types of hysterectomies.

1. Abdominal hysterectomy
2. Vaginal hysterectomy
3. Laparoscopic-assisted vaginal hysterectomy
4. Total laparoscopic hysterectomy

The type that is best for you may be chosen based on your particular uterine status and size, your surgical history, and the skill of your surgeon. Also, whether or not your ovaries, tubes and cervix should be removed should be a part of your pre-operative discussion. There are pros and cons to each decision depending on age and preferences.

“Whether or not your ovaries, tubes or cervix are removed are choices that should be discussed.” – Dr. Wendy

Yes, I just quoted myself, to drive home the point. Lol.

Anywho, I’m sure you’re tired of this article by now, but I hope I’ve left you with some tools and questions to bring to your provider. My goal isn’t to complicate your care or create an uncomfortable or second-guessing relationship between you and your provider. I just want to give tools so that you don’t end up undergoing a procedure that could have been avoided if you had tried another option.

I’m happy to remove a uterus, but only if my patient and I agree that it is our best option considering all risks, benefits, and alternatives. It’s the patient’s decision, but I try to make sure that she understands all of the options.

Thanks, as always, for reading and please follow The Gyneco-bLogic for more.