Question 7
Hi Doctor N,
Before I have a surgical menopause, which they say is needed because I have large fibroids and a cyst on my left ovary, isn't it needed to have a MRI? I have had only a sonogram, and a CA125 blood test which came back normal. Now the DR. said to have a test called IVP. These are the only symptoms besides lower back pain and fullness to the extent of looking 5 months pregnant! There is no bleeding or pain, just pressure and occasional aches. Isn't there any other method of just removing the growths? I've had 2 opinions already by gynecologists. They said that method of just removing the tumors was too bloody. Isn't it more profitable to have a surgical hysterectomy for them? Should I get a 3rd opinion? One Doctor has me coming in to schedule surgery this week for mid Nov. I am 51 and married. I need the hormones, as I am just slowing down to a crawl. Please get back to me ASAP thanks!
Reply:
It is not necessary to have a hysterectomy simply because fibroids are present. If the fibroids are responsible for bleeding, are large and causing discomfort, or causing impingement of other organs, a surgical removal of the uterus may be a consideration. If suspicion of malignancy is a concern, although this is an uncommon occurrence in fibroids, this may be an indication for surgery as well.
Ovarian cysts in a post menopausal woman are also a concern if they are larger that 3 or 4 centimeters and/or they have an appearance that is suggestive of malignancy.
I'm not sure if an MRI would add anything useful in your case, as "state of the art" ultrasound is usually very accurate in delineating ovarian and uterine problems , but I would ask your physician if he feels it would be useful as far your situation is concerned.
I would imagine, your physician would like the IVP test performed to see if the fibroids are interfering with the kidneys, bladder or ureters. An "IVP", an intravenous pylegram is useful in demonstrating if this is a problem. The test requires the intravenous administration of a dye and allergic or other reactions to the dye are possible, but infrequent.
Surgical removal of uterine fibroids as opposed to hysterectomy is a procedure that may be useful in pre menopausal women. Often, this is done if it is felt that the fibroids may interfere with a future pregnancy and/or if the fibroids are causing problems and are in a location and of a type that allows them to be removed without a great deal of difficulty.
If a post menopausal woman has uterine fibroids and they are not causing any problems and are not suspicious for malignancy, there is no reason to remove them. If the fibroids require a surgical removal, hysterectomy is usually the more reasonable choice. Surgical excision of uterine fibroids can be difficult and complicated by bleeding during and after the procedure especially if the fibroids involve the deep tissues of the uterus. I think the reluctance many physicians have in performing the procedure stems from this and a genuine fear that the procedure may put the patient at greater risk than a hysterectomy.
One of the reasons some post menopausal women consider surgical excision of fibroids as opposed to hysterectomy is a fear that removal of the uterus and cervix will interfere either with sexual desire and/or orgasm. If problems of this type occur following surgery they are almost always hormonal in origin. The ovaries which are frequently removed along with the uterus may no longer be producing estrogen but continue to manufacture testosterone for several years after the time a natural menopause would have occurred. This is important as testosterone is the hormone most closely associated with sex drive and sexual response. Often, even if the ovaries are left behind they may become dysfunctional within a few years. In these cases unless appropriate HRT is used and is optimal for the individual, problems can and do occur. One plus of opting for hysterectomy is that following the surgery it is no longer necessary to include progesterone in an HRT regimen as there is no longer a uterine lining to protect. This is a significant benefit to the many women who are progesterone intolerant.
Any surgery, whether an excision of fibroids or a hysterectomy should not be taken lightly. One needs to weigh carefully the potential benefits against the potential risks of any procedure.
I spoke to someone about the price differential between the two procedures and it was their impression that the cost of a hysterectomy was about 10% more. Ideally, any physician patient relationship should be based on mutual trust and the confidence that both parties will choose to make decisions that are mutually beneficial. Your concern that your physician would make any surgical decision on a financial basis suggests that you do not feel that an appropriate physician-patient relationship exists. If this is the case you should carefully consider if you would be more comfortable with another physician.
Dr N