About 20 unpleasant questions to the surgeon

It is no secret that when choosing a method for treating uterine fibroids, most often the patient has to make a choice between surgical treatment and embolization of the uterine arteries. Surgical treatment of uterine fibroids has been around for more than 100 years, as if it is considered classic and objectively correct, so surgeons can feel quite confident during consultations, since, in fact, they reflect the “majority opinion”.

If there are symptoms of uterine fibroids, 95 gynecologists out of 100 will offer the operation.

In fact, if there are symptoms of uterine fibroids, 95 out of 100 gynecologists will offer surgical treatment, another couple of people will prescribe medication, someone will offer observation. Only a few people will remember about EM. This dominance of surgery, of course, corrupts, so I decided to suggest that you ask surgeons some important questions that are often omitted at the time of consultation, and they are very important.

For each question, I will give the correct answers, the truth of which can be confirmed by a simple search on the Internet. I do not want to denigrate the surgical method of treating uterine fibroids, it is just not always an increase in the abundance of menstruation, pressure on the bladder, or just a change in the numbers on the ultrasound form justify the risks and consequences that the proposed method of treatment carries.

QUESTION 1. Tell me, doctor, what are the complications of General anesthesia?

ANSWER: There are not many complications, they are quite rare, but they are still there: tooth damage during intubation; lung infection; allergic reaction to an anesthetic; eye damage; nerve damage; psychological trauma (if the patient wakes up during the operation); every year there are deaths caused by General anesthesia (one case per 10 thousand narcoses).

QUESTION 2. Tell me, doctor, what will my condition be like after the operation?

ANSWER: After anesthesia, the patient often experiences severe tremors, nausea, dizziness, confusion, itching, pain in the throat, muscles, in the clavicle, abdominal pain, in the suture area, and very pronounced weakness. The patient spends the first hours after the operation in the intensive care unit.

QUESTION 3. Tell me, doctor, what will happen next, after returning to the ward, and when will I be discharged?

ANSWER: In the first days after the operation, there will be abdominal pain, weakness, nausea, and it will be difficult to go to the toilet. You will be injected with painkillers, antibiotics, and monitor for possible complications in the early postoperative period. Discharge will be possible on day 2-3 (laparoscopy) or day 5-7 (laparotomy).

After oral surgery, a woman experiences abdominal pain, weakness and nausea, and dizziness.

QUESTION 4. Tell me, doctor, what are these complications?

ANSWER: Early postoperative complications include intra-abdominal bleeding, peritonitis (due to an injury to the intestine or ureter, infection), pulmonary embolism, intestinal obstruction, violation of the outflow of urine from the kidney (accidental ligation of the ureter) – all these complications are very severe, require urgent surgical actions, are rare. A little later, pneumonia may occur, as well as inflammation in the suture area.

QUESTION 5. Tell me, doctor, how long will it take me to recover from the operation?

RESPONSE: After laparoscopy-3-4 weeks, after laparotomy-up to two months.

QUESTION 6. Tell me, doctor, if you are going to remove only nodes, why are you asking me to sign a paper that I do not object to removing the uterus?

RESPONSE: In fact, in rare cases, severe bleeding occurs during node removal, and the uterus has to be removed in order to save the patient. This occurs when removing nodes located in the thickness of the uterine wall (intramural, intramural-subserous, growing into the uterine cavity, and those located on the edge), as well as in the presence of many nodes.

QUESTION 7. Tell me, doctor, are you sure that you will remove all the nodes in the uterus, and if not all, why do the ones you are going to remove affect my health / ability to get pregnant?

ANSWER: In fact, sometimes surgeons go into the abdomen and remove only large surface nodes that often play no role in the clinical picture of the disease, and those that are convenient to remove from the wall. Small nodes in the thickness of the uterus are left (referring to the fact that they are not dangerous). In fact, it is from these small nodes that a relapse of the disease often occurs, since the injury of the uterus during surgery is a powerful stimulus for the growth of nodes.

QUESTION 8. Tell me, doctor, what is the risk of recurrent uterine fibroids after removal of nodes?

ANSWER: the Risk is quite high, on average 7-14 % per year, but most often you can see the statistics that three years after surgery, relapse is 51 %, the need for repeated surgery is 17-26 %. Relapse is especially high if not all nodes are removed from the uterus.

QUESTION 9. Tell me, doctor, will I need to take any medications after the operation?

ANSWER: Yes, of course, for eight months (if you are planning a pregnancy), you will take hormonal medications to prevent relapses, and if you are not planning a pregnancy, you will have to take hormonal medications constantly to reduce the likelihood of relapse. That is, when removing nodes, a temporary effect is achieved, which must be constantly maintained by taking hormonal drugs.

QUESTION 10. Tell me, doctor, what is the probability that after removing the nodes, I will become pregnant?

ANSWER: The average frequency of pregnancy after node removal is from 39 to 56 %.

QUESTION 11. Tell me, doctor, is there a risk during pregnancy after surgery to remove nodes of uterine fibroids?

ANSWER: Yes, although small, but there is. The risk of uterine rupture is 0.3 %. However, it is important to remember that you will give birth by cesarean section, that is, you will have another operation. It is extremely rare for obstetricians to decide to deliver through the natural birth canal in women with a scar on the uterus.

QUESTION 12. Tell me, doctor, what other possible complications after removing the nodes that may affect my ability to get pregnant?

RESPONSE: After any operation on the uterus, there is a risk of developing an adhesive process, as a result of which the fallopian tubes may become impassable. This can potentially lead to infertility or increase the risk of ectopic pregnancy. Now we use modern anti-adhesive materials, the technique of operations has changed, but still the risk of formation of adhesions is unpredictable.

After surgery on the uterus, there is always a risk of formation of adhesions, although today anti-adhesive materials are used.

QUESTION 13. Tell me, doctor, and in addition to the tubes, the uterus itself can suffer?

ANSWER: Yes, there is a risk. If the node is located on the border with the cavity or grows into it, when it is removed, the opening of the uterine cavity is possible, which subsequently leads to the formation of junctions in the uterine cavity (synechiae), which prevent the onset of pregnancy.

QUESTION 14. Tell me, doctor, if the node is in the cavity and it is removed by hysteroresectoscopy, are there any risks?

ANSWER: Yes, it is extremely rare for air to enter the vessels of the uterus and then into the lungs (a rather unpleasant complication), a serious violation of the electrolyte balance when excess glucose enters the body (it is its solution that is used during the procedure), damage to the lining of the uterus (cut off along with the growth layer), which leads to uterine infertility. Yes, not all nodes can be removed at one attempt, often they are cut off and then wait for several months to repeat the intervention.

QUESTION 15. Tell me, doctor, is complete removal of the uterus really such a simple operation, since some people call it “student”?

RESPONSE: There are no simple operations, but among gynecological operations it is basic. During removal of the uterus, all of the above complications may occur (injury to the intestine, bladder, ureteral ligation, bleeding from ligatures that have flown from the uterine arteries). No matter what access is used, laparoscopy only accelerates the recovery period.

Removal of the uterus is called a “simple” operation, but it is not as easily tolerated by patients as it may seem. Possible postoperative complications and long-term consequences.

QUESTION 16. Tell me, doctor, do I really not need a uterus at all if I am not planning a pregnancy, and after removing it I will feel good?

ANSWER: No, this is not true. In 30-80 % of patients after removal of the uterus with or without appendages, “posthysterectomy syndrome” develops – a serious condition associated with the abrupt cessation of female sex hormone production. This is a severe syndrome in which there are asthenic depressions with characteristic complaints of severe fatigue, reduced performance, lethargy, pronounced weakness, increased tearfulness, “hot flashes”. 25 % of patients develop a feeling of anxiety, accompanied by an unmotivated fear of sudden death. The termination of menstrual and childbearing functions at the reproductive age is often perceived as a loss of femininity; there is a sense of fear, fear of family breakdown, and an assessment of yourself as an inferior sexual partner. In 30-35 % of patients complaining of poor tolerance to high temperature, there were also attacks of palpitations at rest, shivering, chills, a feeling of numbness and creeping goosebumps, sleep disorders, vestibulopathy, increased sweating, a tendency to edema, transient hypertension.

QUESTION 17. Tell me, doctor, if, as you say, we leave the ovaries, will these symptoms still develop?

ANSWER: Yes, the development of “post-hysterectomy syndrome” does not depend on whether the ovaries are removed or not. If the ovaries are left, this syndrome develops slightly less often.

QUESTION 18. Tell me, doctor, are these all the consequences of removing the uterus or are there any long-term complications?

ANSWER: You are right, in addition to early changes in the body, there are also delayed ones. As shown by a large study that included more than 700 thousand women, removing the uterus with or without ovaries in women of reproductive age for a year increases the risk of cardiovascular diseases (heart attacks, strokes, hypertension). In addition, some women develop a metabolic syndrome, which is manifested by an increase in body weight and other problems. The risk of developing breast cancer increases. After removal of the uterus, problems may occur during sexual life (dryness in the vagina, sensitivity disorders, difficulties in achieving orgasm).

QUESTION 19. Tell me, doctor, will it be possible to somehow cope with this condition?

ANSWER: Yes, you will be prescribed hormone replacement therapy for treatment, which will need to be taken for several years.

QUESTION 20. Tell me, doctor, why do surgeons often do not recommend resorting to uterine artery embolization, claiming that this method is dangerous, difficult to tolerate and limited effective?

ANSWER: In fact, the problem is that EMMA gynecologists and surgeons do not perform. This operation is performed by endovascular surgeons, that is, doctors of another specialty. Thus, not all gynecologists are ready to “let go” of the patient, perhaps because they mistakenly see their inability to help them, while forgetting about the patient’s interests. In fact, there are quite a lot of worthy and very experienced surgeons who differentially approach the choice of treatment method and when they see the appropriate clinical situation, they definitely recommend to clarify the possibility of uterine artery embolization.

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