Hysterectomies are among the most common surgeries performed on women in the United States, being used in the treatment not only of uterine cancers but of benign tumors and, in some instances, of uterine prolapse. Several surgical techniques for performing hysterectomy have been developed – each of which offers a distinct set of both risks and benefits. How the risks will weigh against the benefits is often less a matter of absolute determinacy and more a question of the “fit” between the specific procedure for hysterectomy and cancer risk or other potential concerns present in an individual case. Preoperative screening is key to identifying those factors across the board, but especially with respect to the assessment of a woman’s risk for uterine cancer, as elevated cancer risk may be a deciding factor in determining surgical approach. Women who have undergone hysterectomy without adequate preoperative screening and consultation may be at an increased risk for metastasis of highly aggressive cancers. Call Erin Marshall Law at 505-218-9949 to speak with our New Mexico team about the legal implications of the latest medical guidance.
Why Are Hysterectomies Performed?
Hysterectomies are the leading non-obstetric surgical procedure performed on women in the United States, according to a 2023 article in the American Journal of Obstetrics and Gynecology, available through the National Institutes of Health (NIH), with roughly 600,000 procedures annually. These surgeries may be performed for a variety of reasons, but the removal of uterine tumors is one of the most common.
There are a few types of uterine cancers, any of which may require surgical removal; benign uterine tumors, however, are overwhelmingly identified as leiomyomas. Hysterectomy to remove tumors is handled differently depending on whether malignancy (cancer) is suspected, so preoperative screening is crucial to determine how to proceed.
What Kinds of Preoperative Screenings Are Performed for Hysterectomy?
Preoperative screenings for hysterectomy may be grouped into the following three types:
- Screening for indications of possible cancer
- Screening for risk of infection (often treatable prior to surgery)
- Screening for overall patient health and fitness for recovery
All of the above types of screenings are important to ensuring strongly positive patient outcomes. However, the relative ease of assessing patients’ fitness for surgery and the relative availability of treatment for most types of infections today mean that preoperative screenings for uterine cancers, which are notoriously difficult to diagnose but can have an enormous impact on patient outcomes if not discovered prior to hysterectomy, may be especially significant.
What Are Leiomyomas?
Leiomyomas are a common form of usually benign tumor frequently found in the uterus. These tumors may be fully within the uterus, embedded within the uterine wall, or growing on the outer surface of the womb. In most cases, leiomyomas – also known as uterine fibroids – are thought to cause no symptoms, although the diagnostic picture can be complicated by the fact that many of the symptoms with which these tumors are sometimes associated can also be caused by other conditions.
Symptoms of Uterine Fibroids
Symptoms that have been linked to uterine leiomyomas include:
- Excessive bleeding
- Painful periods
- Bowel symptoms, such as constipation, diarrhea, and cramping
- Bladder dysfunction
- Pelvic and abdominal pain or pressure
- Back pain, especially in the lower regions
Leiomyomas are sometimes found in patients who have no symptoms (asymptomatic patients) in the course of routine exams, or while a patient is being treated for another condition. Because leiomyomas are almost always benign (noncancerous), even after diagnosis they are not usually treated unless the patient is reporting significant symptoms.
Treatment Options for Uterine Fibroids
When a patient reports bothersome symptoms consistent with uterine fibroids and a diagnosis of leiomyoma is confirmed, generally speaking a medical team will first attempt to manage the patient’s symptoms via non-surgical methods, before proceeding to evaluate the patient for surgery. Non-surgical options for the treatment of uterine fibroids may vary depending on reported symptoms, but commonly include non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain, often in combination with hormonal contraceptives to manage heavy bleeding. The formation of leiomyomas is thought to be be linked to hormones associated with female fertility, so some medical professionals will also recommend trying these as a tool for reducing fibroid growth; results for this particular outcome can vary widely by patient and the overall effectiveness of this application has, to date, been difficult to assess because of the multiple variables present in individual cases.
When non-surgical methods have failed to provide relief, then a woman’s health care team may consider surgical intervention. The two main surgeries used in the treatment of uterine fibroids are hysterectomy (removal of entire uterus) and myomectomy (surgical excision of the fibroid tumors from the uterine wall). By contrast to known or suspected sarcomas, which tend to be treated aggressively due to their exceedingly harmful effect on overall survival rates, leiomyomas demand a more measured approach, weighing the risks of the surgery itself against the hope of improving a patient’s symptoms and therefore quality of life. Careful preoperative screening may be especially important if morcellation is a planned part of the procedure.
What Is Morcellation?
Morcellation is a surgical technique sometimes applied in both hysterectomy and myomectomy, especially when the tumors involved are especially large. Although morcellation can be performed manually with standard laparoscopic tools such as scissors, in many cases a specialized device known as a morcellator is used to cut the tumor (in myomectomy) or the uterus (in hysterectomy) into smaller pieces prior to removal from the abdominal cavity. Because some of the possible complications from an abdominal surgery, and much of the expected recovery time, will be directly related to the size of the incision or incisions made in the abdominal wall, many surgeons feel that there is a strong argument in favor of using morcellation to reduce the size of the incision needed for removal of tissue, especially in cases involving large fibroids.
Morcellation and Cancer Risks
Use of powered morcellators during hysterectomy or myomectomy can increase the risk of spreading cancerous or precancerous cells throughout the abdominal cavity, according to the United States Food and Drug Administration (FDA). Consequently, morcellation is not normally considered in cases where the patient has known or suspected malignancy. However, the much smaller incisions (often as small as two centimeters, according to the FDA) needed for “minimally invasive” procedures like laparoscopically assisted hysterectomy reduce both postoperative recovery times and the risk of complications such as infection compared to more traditional techniques.
Patients who develop cancer after undergoing a hysterectomy involving morcellation face a difficult health battle, often unfortunately complicated by the high costs associated with treatment. Because medical professionals have a responsibility to appropriately evaluate, and adequately inform, their patients, you may wish to consider a conversation with a women’s healthcare attorney at Erin Marshall Law to discuss whether you have legal options for covering the costs of your medical care.
Risks and Benefits of Morcellation in Hysterectomy
Many of those advantages may be reduced in proportion to the degree to which the surgical aperture must be enlarged to remove tissue, so it is not surprising that many surgeons have continued to prefer morcellation in cases where the patient may have one or more large leiomyomas, but malignancy is not suspected. In the last few years, however, accumulating findings from research on the relationship between morcellation in hysterectomy and cancer risk have begun to raise concerns that the incidence of “hidden” uterine or endometrial sarcoma (a type of cancer) among patients receiving hysterectomy or myomectomy to remove benign leiomyomas may be significantly higher than previously suspected. Failure to adequately screen patients for malignancies prior to using a power morcellator during surgery can result in the unintentional propagation of cancerous or precancerous cells within the patient’s abdomen.
Preoperative Screening To Identify High-Risk Patients
In 2017, the FDA reported that estimates of the overall prevalence of uterine sarcoma in patients undergoing surgical procedures (hysterectomy or myomectomy) for tumors presumed to be leiomyomas ranged from one patient in 225 to one in 580, depending on the type of cancer and the methodology used. For leiomyosarcoma, a highly aggressive soft tissue sarcoma that can affect the uterus as well as other smooth muscle tissue, according to the National Cancer Institute, the same guidance documented an estimated prevalence ranging from one in 495 to one in 1,110. The breadth of the estimated range for each type underscores the need for more comprehensive research, but uterine sarcomas generally are associated with poor patient outcomes and low five-year survival rates.
Keeping Pace With Research
The aggressive nature of leiomyosarcoma in particular, and the ease with which this cancer spreads in the types of smooth muscle tissue found in the abdominal cavity, led the FDA as long ago as 2014 to issue guidance discouraging the use of electric morcellators in patients at increased risk of malignancy undergoing myomectomy or hysterectomy for presumed fibroids, even if no malignancy was suspected prior to surgery. However, the important advantages of minimally invasive surgery continued to prompt further investigation. In 2024, the American College of Obstetricians and Gynecologists (ACOG) reaffirmed its guidance to medical professionals that laparoscopically assisted hysterectomy be performed in candidates who met FDA-specified criteria for the procedure, in a committee opinion which incorporated the FDA’s recommendation that any use of powered morcellation devices be implemented only within an approved “containment” system – essentially, a small bag or sack deployed around the surgical area to prevent the spread of cells during morcellation, and removed prior to suturing.
Current Guidance
Under current guidance women, including those who are postmenopausal, over 50 years of age, or have suspected uterine or endometrial cancers, are not considered candidates for laparoscopically assisted hysterectomy performed with morcellation. This last category is often the hardest to identify during preoperative screening because uterine cancers are frequently asymptomatic in their earliest stages. If you are approaching a hysterectomy and otherwise meet the FDA’s updated criteria for minimally invasive surgery, you may wish to consider discussing possible screening options, including diagnostic imaging, with your medical team prior to choosing a path forward.
Compassionate Support for Hysterectomy Patients
A hysterectomy can be a life-changing surgery. In the best cases, this operation can eliminate disease or reduce the symptomatic burden of benign tumors. There are several surgical options for performing hysterectomy, however, and the factors present for an individual patient can have an enormous impact on which procedure offers the strongest benefits with the lowest level of risk in a particular case. Careful preoperative screening is essential to identifying the factors that might affect a woman’s postoperative outcomes – but administrative hurdles and poor doctor-patient communication can sometimes lead important variables to remain overlooked. At Erin Marshall Law, we offer understanding and support to women who are struggling through the aftermath of badly chosen or poorly performed hysterectomies, and we take pride in providing thoughtful responses to your legal questions regarding hysterectomy and cancer. Call our Albuquerque office today at 505-218-9949 to connect with our team.
