Some brief thoughts on hysterectomy

I have often heard that hysterectomy does not treat endometriosis, and it's true, it does not. But I've always felt that was an incomplete statement, because I've sure seen a lot of patients who really seemed to benefit from hysterectomy as part of their surgery.

The issue is why a hysterectomy is being recommended.

Physicians who do not have a very detailed way of thinking about pelvic pain may have a very binary thought process. Pelvic pain? try some hormones? didn't work? ok let's do a hysterectomy.

That's a problem, and what people are trying to discourage against when they talk about hysterectomy not being part of treatment for endometriosis.

But when one takes a more specific analysis of pelvic pain, once can identify the patient who really will benefit from a hysterectomy.

The uterus is primarily innervated through sympathetic nerves that go up near the uterosacral ligaments and then up the sympathetics plexuses. Signals carried through these nerves create a dull, aching pain. This pain may radiate into the back as well. Reliably so, a patient will indicate the location of this pain with their entire hand over their lower pelvis, as opposed to a single finger over a specific point of pain.

Uterine pain generally gets much worse with menstruation. In, fact if it doesn't get worse with menstruation I think its probably not coming from the uterus.

Uterine pain is more common in women who have had children, and the more children the more common it is.

Most uterine pain will also be associated with deep aching pain with intercourse, particularly if the uterus is retroverted. And I think most important, one should be able to squeeze on the uterus during a pelvic exam and have the patient say "YES that is the pain that I am feeling!"

Many of these symptoms can also be from non-uterine pain as well, which can sometimes complicate the diagnosis. Endometriosis around the sympathetic nerve trunks from the uterus may mimic uterine pain. Similarly, uterosacral endometriosis will also cause pain with deep intercourse (though typically this would be a sharper point type pain).

I recently had a patient who came to see me for whom I recommended a hysterectomy and endometriosis excision. Her previous physician had recommended the same, but because that plan had not been explained with a very specific reasoning that made sense, the woman did not really accept the advice. I saw her and made the same recommendation, but because I was able to really explain why I came to that conclusion, it was much more acceptable to the patient.