Hysterectomy

Hysterectomy Services

As a surgical practice, NWEPS offers expert hysterectomy services to appropriate patients through our office in Portland, Oregon. Dr. Fogelson has performed hysterectomies for patients throughout Oregon, Washington, Idaho, Utah, and throughout the country. He has completed over 1,000 minimally invasive hysterectomies and is expert in hysterectomy in all clinical situations, including endometriosis, fibroids, adenomyosis, previous surgeries, adhesions, or other complicating factors. Women seeking hysterectomy trust Dr. Fogelson to provide outstanding care for their surgery with quick recovery and minimal chance of complication.

So now that all the search keywords are taken care of :), let's answer some questions about hysterectomy.

What is a hysterectomy?

A hysterectomy is removal of the uterus. In most cases this involves removal of the part of the uterus in the pelvis (the fundus) as well as the part of the uterus in the vagina (the cervix), though in some cases we perform subtotal, or supracervical hysterectomies, which is a hysterectomy where the cervix is left in place. While many people think a hysterectomy also involves removal of the ovaries, it does not. When we refer to hysterectomy alone, it is removal of the uterus only. Removal of the uterus and ovaries is referred to as a hysterectomy with salpingooopherectomy, or hysterectomy with removal of ovaries (when we forget our latin.).

Why would I have a hysterectomy?

The following are the major reasons Dr. Fogelson may recommend a hysterectomy:

Heavy bleeding, with or without fibroids, in a woman no longer desiring fertility
Pelvic pain thought to originate from the uterus
Painful intercourse though to originate from the uterus
Adenomyosis (which is more or less endometriosis in the wall of the uterus)
As part of a pelvic prolapse repair in a woman no longer desiring fertility
Severe endometriosis that involves the uterus.

How are hysterectomies performed?

In our practice, nearly 100% of hysterectomies are performed laparoscopically. Dr. Fogelson is an extremely experienced laparoscopic surgeon and feels that in his hands this is the best way to perform a hysterectomy. Laparoscopy allows magnification of small structures and careful dissection of tissues in a way that no other modality allows. This allows nearly bloodless surgery, where every potential source of bleeding is sealed before it is cut. It also allows the absolute minimum of tissue damage. All of these things make the surgery easier on the body and quicker to recover from. Laparoscopy is also required for visualization and removal of endometriosis, which is present in most of our patients.

ACOG says the primary method of hysterectomy should be vaginal hysterectomy... why do you say laparoscopic is better?

In our opinion this is based on antiquated ideas of surgery and also in complete denial of the effect that residual endometriosis may play in long term health. While it is true that a vaginal hysterectomy leaves no external scars on a patient, it also involves using a narrow passageway to perform surgery and extract the uterus, with minimal visualization. In our experience, vaginal hysterectomy is actually more painful to recover from than laparoscopic hysterectomy, despite the fact that laparoscopic hysterectomy involves small incisions in the abdomen (for laparoscopic instruments). Furthermore, a vaginal hysterectomy absolutely eliminates the opportunity to observe and remove endometriosis, or any other pelvic pathology, which we believe makes the technique fundamentally inferior for the vast majority of cases.

Are there alternatives to hysterectomy?

Absolutely. For a woman who wants to preserve the ability to bear children, or who fundamentally desires to preserve her uterus, a hysterectomy makes no sense. A variety of alternative treatments exist for a wide range of issues, including hormonal treatment, removal of fibroids (myomectomy), fibroid ablation (Acessa procedure), uterine artery embolization, uterine lining ablation and progesterone intrauterine devices.

How long does it take to recover from a hysterectomy?

Women who primary have problems with the uterus are typically back to full activity (except having sex) in 2 weeks after having a laparoscopic hysterectomy. Women that have severe endometriosis that requires more advanced surgery may take somewhat longer to recover.

Is a hysterectomy a treatment for endometriosis?

Not as such. Endometriosis is an issue of the pelvic peritoneum, not the uterus. As such, removal of the uterus is not a treatment for endometriosis, except when there is severe endometriosis on the uterus itself. That said, women who are having issues with pelvic pain and endometriosis may benefit from a hysterectomy along with endometriosis excision. Dr. Fogelson evaluates each endometriosis case individually and recommends hysterectomy in the cases where it makes sense.

My doctor says a hysterectomy will be so difficult that they will have to open me to complete the surgery? Is this true?

The need to open a surgery is somewhat related to the difficulty of the surgery, but greater than that it is related to the skill of the surgeon. One never says never, but we basically do all hysterectomies laparoscopically and almost never have to open. At a certain level of laparoscopic ability, no surgery becomes easier by opening. The only true reason to open is when proceeding laparoscopically is unsafe, and in my hands (Dr. Fogelson) that is a very rare event.

The reality is that a difficult surgery is difficult whether it is done laparoscopically or done open, unless a surgeon isn't as good with a laparoscope or robot as they are with their hands. This is not the case in our practice. In cases of unexpected bleeding, there are many techniques for addressing this without opening as well. So if you have been told you need an open surgery, most likely we can do it without opening.

My doctor keeps trying all kinds of different things and doesn't want to do a hysterectomy. Will you do a hysterectomy if I want one?

Most likely yes. I (Dr. Fogelson) think that the idea that hysterectomy is some kind of last resort surgery comes from the mindset where hysterectomies are some kind of big surgery with long recovery and high risk. This just isn't the case anymore. We do hysterectomies through tiny holes and people are on their feet the same day and usually go home the same day. Never in my life have I seen a more appreciative and happy patient than the woman who has been plagued by terrible bleeding who no longer bleeds every month. While there are other treatments to offer, if a woman doesn't plan to use her uterus to have more children and is having problems that originate from the uterus, a hysterectomy is a reasonable option. Furthermore, in most cases a hysterectomy that is performed in the outpatient environment (outpatient hospital or in anambulatory surgical center) does not require insurance pre-approval and can be quite cost effective compared to "hysterectomy alternatives" such as uterine ablation. As such, there is little reason to deny a hysterectomy to a woman who wants one.

I have bleeding and have heard of "uterine ablation". Is that better/safer than a hysterectomy?

I don't think so. Ablations came onto the market at a time when most hysterectomies were done open with 6 week recovery periods and significant chance of complication. At that time, it made sense to avoid a hysterectomy by burning the lining of the uterus. The problem is that in this day and age with with skilled surgeons, recovery from hysterectomy is quick, and for most problems the cure rate is 100%. Ablations on the other hand have significant failure rates, and in many cases cause problems such as cyclic pain and sometimes recurrent bleeding. Furthermore, ablations do not preserve the uterus for childbearing, as they burn out the lining that is required for healthy pregnancy. I have done many hysterectomies for women who previously had ablations that have failed in one way or another. This is not to say that ablations are never appropriate, as some women do great with them.

The other reason ablation are big in the market is because they are a big money maker for physicians. Ablations can be done in the office, which moves the biggest financial piece of a procedure (the facility fee) from the hospital into the physician's office. Manufacturers have thus pushed ablation as a way for physicians to address their patient's needs while making more money than a hysterectomy. That's all well and good, but in the end I want to recommend the best procedure for my patient, and if she is having uterine problems and doesn't want to have more kids, I usually think a minimally invasive hysterectomy will serve her better than an ablation.

My uterus is huge. How can you get it out of tiny holes?

The first step in removing a large uterus is to isolate the blood supply and seal it. Then one separates the uterus from the body, leaving it free in the abdomen. At that point, one either gets it out through the vagina or through one of the port sites. In the past, we used to cut up a uterus in the abdomen to get it through port site holes. Over time we have found that this brings in a small element of risk in that very rarely there could be a cancer in a uterus that we spread by cutting it up. For this reason, we now do all morcellation in a contained bag, which allows large uteruses to be removed through a 2-3 cm incision, without exposing any part of the morcellated uterus to the inside of the abdomen. Using this technique, we can remove very large uteruses through very small incisions for quick recovery and minimal chance of incision complication, which is much more common with larger incisions.

My physician takes my insurance, why would I come to Dr. Fogelson?

In a word: Experience. Dr. Fogelson has performed over 1,000 minimally invasive hysterectomies and has a complication rate that is a fraction of the national average. Furthermore, in the extremely rare incidence of complication, Dr. Fogelson has the surgical skill to repair urinary tract or bowel injuries without opening thus maintaining a successful minimally invasive surgery.

Whoever does your hysterectomy, makes sure they do many of them a year, ideally over 50 and even over 100. In the US, the average general OB/GYN does 10 or fewer hysterectomies a year. There is clear evidence that this volume of surgery is inadequate to maintain optimal skills and minimize complications. Make sure your surgeon has a high degree of skill in minimally invasive surgery. In 2019 benign hysterectomies should almost never be performed open, and if it is suggested you need an open surgery you may consider a second opinion.

For more details, read Dr Fogelson's blog post on the subject: On High Volume Gynecologic Surgery, and How to Pick A Surgeon for Your Hysterectomy

What are the fees for a hysterectomy in the NWEPS practice?

Minimum collected fees for laparoscopic hysterectomy are $4500-$5500 depending on complexity. Patients with out of network benefits will likely have some of this covered by their insurance, possibly all of it. We will evaluate your case and give you a specific estimate as needed. In most cases patients pay $2000-$3000 more than they would with an in-network physician.

I have no insurance and need a hysterectomy. Is there an all-in cash rate for everything?

We have many patients who have no insurance, self-insure, or choose not to have insurance, including patients who have community health pool type insurance ( ie Medi-Share ) or other community pools. Care in major hospital systems for such patients can involve exorbitant facility fees, often exceeding $30,000. Because most physicians work within these systems and hospitals do not effectively offer care for cash patients, options are limited.

Our practice has an arrangement with a local ambulatory surgery center than allows us to perform a typical hysterectomy for substantially less than that, typically in the range of $15,000 including professional fees, facility fees, anesthesia, and pathology. If you have no insurance please contact us for a free phone consultation and quote for surgery. Many patients travel to see Dr. Fogelson under these arrangements and have successful and cost-effective surgeries with us in Portland for this reason.