Key Lecture
Hysterectomy 2017 and Alternatives John J. SCIARRA Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA Abstract Over 450,000 hysterectomies are performed annually in the United States and this represents a decrease of 40% in the past decade. This decrease is largely due to available alternatives that include myomectomy, uterine artery embolization, MRI guided focused ultrasound, endometrial ablation, the Levonorgestrel IUD, and new surgical and medical therapies. Abdominal myomectomy is complicated today by the morcellation issue, but hysteroscopic myomectomy remains very effective. Uterine artery embolization is 80-90% effective in decreasing menorrhagia. Follow up of over 2,000 patients for 3 years reveals a 9.8% rate of subsequent hysterectomy and a 2.8% rate of subsequent myomectomy. MRI guided focused ultrasound is a new technique for treatment of uterine fibroids. With endometrial ablation, reduction of menstrual flow is adequate symptom control, and achievement of amenorrhea is not important. The hysterectomy rate following endometrial ablation is at least 24% within 4 years following the procedure. The Levonorgestrel IUD has proved useful in the management of menorrhagia because of the direct progestational effect on the endometrium. A new surgical technique for fibroid therapy is laparoscopically directed radio frequency ablation. New medical therapies for uterine fibroids include the use of aromatase inhibitors and progesterone receptor modulators, especially Ulipristal Acetate that is now available in many countries. In conclusion, while hysterectomy is 100% effective in treating benign uterine pathology, alternative methods are not. Accordingly, when considering alternatives to hysterectomy, the options should be presented to the patient, and the patient should be involved in the decision making process. Experience indicates that approximately 30% of hysterectomies can be avoided by utilizing appropriate alternatives.