Uterine polyps don't warrant a hysterectomy

April 08, 2007|By Tribune Media Services

Q. I am 70 and have a large uterine polyp. Because I had profuse bleeding during menopause and painful biopsies after abnormal Pap smears, I would like to have a hysterectomy and be done with the problem. But my doctor doesn't think it's necessary. Is it reasonable to have a hysterectomy for a benign polyp?

-- Everett, Wash.

A. Most uterine polyps are not only benign, they usually stay that way. But they can grow, as yours apparently has, and be a source of abnormal bleeding. Also, although the probability of a polyp becoming malignant remains small, it does increase with age.

Thus to rid yourself of the uterine polyp is a good idea, though to do it by having the entire uterus removed -- by undergoing hysterectomy -- is not a good idea. A hysterectomy is a serious operation, with a national average mortality rate of 1 in 1,600. Other, non-lethal complications include infections, blood clots, cardiac events, transfusion reactions and complications of the surgery itself.

Hysterectomy usually is indicated for more serious conditions, such as uterine cancer, or conditions for which no simpler option is available, but it would be an overreaction in cases like yours. Moreover, the past problems you cite -- bleeding during menopause and painful biopsies after abnormal Pap smears -- are annoying but minor, have nothing to do with the uterine polyp and would not merit hysterectomy unless they were long-standing and unresponsive to simple measures.

In the past, women and their doctors tended to regard the eventual need for a hysterectomy as virtually inevitable. It was a kind of rite of passage, a matter of "When did you have yours?" Today we are moving away from such assumptions, as they so often represent needless surgical procedures and unnecessary risks -- especially for most uterine polyps, which can be handled in much simpler and safer ways.

The preferred means for removing uterine polyps is through the outpatient procedures of hysteroscopy, curettage (often referred to as "D&C," for dilation and curettage), or, increasingly, the two methods in combination.

In a hysteroscopy, the doctor inserts a thin, flexible, lighted scope (hysteroscope) through the vagina and into the uterus. This technology not only allows the doctor to examine the uterus for the presence of polyps but also makes it possible to remove them at the same time, as long as they're not too large. He or she does the excising with tiny cutting instruments inserted through the hysteroscope.

The time-honored D&C is still the method of choice, especially for larger polyps. It involves the insertion of a long metal instrument with a loop on the end (curet) to scrape the walls of the uterus and thus remove polyps. D&C may be performed on its own (blind curettage), which can make the finding of uterine polyps more difficult, or with the guidance of a hysteroscope, which enables the doctor to visualize the inside of the uterus and thus locate any polyps and be assured of having removed them.

Uterine polyps are thought to sometimes recur. But it may well be that the "recurrence," in many cases, is actually a different polyp. In the past, some polyps were undoubtedly missed or incompletely removed with a blind D&C. With greater concurrent use of hysteroscopy for actually seeing inside the uterus, such oversights will decrease -- and so will the rate of apparent recurrence.

Because it is not known why uterine polyps form, we have no dependable way of preventing them. All a woman can do is be aware of abnormal vaginal bleeding. Although such monitoring may not be so simple for younger women, it is relatively easy for postmenopausal women -- among whom any vaginal bleeding at all is considered abnormal. When it occurs, this is a warning sign not only of uterine polyps but also for the possibility of gynecological cancers. Prompt evaluation is thus very much in order.

-- Bobbie S. Gostout, M.D., Obstetrics & Gynecology, Mayo Clinic, Rochester, Minn.

