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Uterine Preservation: Balancing Medical, Ethical & Patient Perspectives

Author Olivia Reid covers Uterine Preservation: Balancing Medical, Ethical & Patient Perspectives on BackTable OBGYN

Olivia Reid • Mar 13, 2024 • 31 hits

The traditional approach of a hysterectomy is questioned by Dr. Suzette Sutherland, a urologist specializing in women’s health, as this method involves the disruption and subsequent reconstruction of natural support structures. This paradox gives rise to considerations outside of the medical realm, including profound psychological and cultural implications. The Value of Uterus Questionnaire (VALUS), a tool designed to empower patients to articulate their sentiments regarding potential uterine loss, was developed with the assistance of OBGYN, Dr. Olivia Chang, in response to the historical dependence on hysterectomies in gynecology. VALUS illuminated correlations between uterine preservation and sexual function and desire. Furthermore, it showed that geographical, cultural, and psychosocial factors are all influential in patients' preferences for uterine-sparing procedures.

Uterine-sparing procedures offer an alternative to hysterectomy, necessitating thorough evaluation, particularly in cases of abnormal bleeding or cervical pathology. Drs. Sutherland and Chang advocate for continued research efforts to delineate practice guidelines, understand the multifaceted impacts of removing a woman’s uterus, and further information on the ethical dimensions of these procedures.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

•The removal of the uterus through a hysterectomy brings about questions regarding the disruption and subsequent reconstruction of natural support structures.

•Collaboration with Cleveland Clinic yields the Value of Uterus questionnaire (VALUS), empowering patients to articulate sentiments on potential uterine loss, revealing correlations between uterine preservation and sexual function and desire.

•Geographical, cultural, and psychosocial factors emerge as influential in patients' preferences for uterine preservation, prompting ongoing research initiatives.

•Despite the absence of definitive guidelines, practitioners draw insights from analogous procedures like the LeFort colpocleisis, emphasizing the need for continued research to establish clear practice guidelines in the evolving field of uterine preservation.

Uterine Preservation: Balancing Medical, Ethical & Patient Perspectives

Table of Contents

(1) Patient-Centric Approach to Uterine Preservation in Pelvic Organ Prolapse

(2) Uterine Preservation: Clinical Nuances & Patient Selection Criteria

Patient-Centric Approach to Uterine Preservation in Pelvic Organ Prolapse

Traditionally, hysterectomy has been the default solution for various gynecological issues in women. However, Dr. Sutherland brings into question the rationale behind disrupting natural support structures only to reconstruct them later. Beyond the medical aspects, the decision to remove a patient's uterus carries significant psychological and cultural implications. Dr. Chang's collaboration with the Cleveland Clinic resulted in the development of the Value of Uterus questionnaire (VALUS), enabling patients to express their feelings about potential uterine loss. VALUS evaluates patients' values regarding sexual function, identity, relationships, and self-perception. Research using VALUS has uncovered correlations between uterine preservation and sexual function and desire, challenging the conventional focus solely on hormonal factors in these areas. Moreover, geographical, cultural, and psychosocial factors play pivotal roles in shaping patients' preferences, emphasizing the importance of ongoing research endeavors. The Society of Gynecologic Surgeons is presently conducting a mixed-method study to delve into patients' attitudes toward uterine preservation across diverse demographics, aiming to tailor treatment approaches accordingly.

[Dr. Suzette Sutherland]
Yes, and that's a great way to talk to patients about it too. I often say that "Why would I disrupt your natural support only to recreate it?" Right? Even if there's some prolapse, but predominantly it is a cystocele, but there's also some apical prolapse coming down maybe halfway, at the same time, I'm going to disrupt all of the support that they have, but then have to recreate it. Yes, they understand that I think.

There are some other reasons, of course, why a woman doesn't want to give up her uterus. We know that there's some very personal reasons or often cultural reasons. Some of them are based on some real factual things, other things, just a feeling that a woman has. Can you speak to some of those things? I know there's some data out there looking at these concepts that people have sort of poo-pooed in the past. Now, we see there's actually been some studies to look at these more psychosocial or emotional aspects of the uterus in a woman.

[Dr. Olivia Chang]
Sure. Actually, this has been a passion of mine for a very long time. When I was a fellow at Cleveland Clinic, I noticed that there was no good way to ask the patient how they felt about their uterus. A lot of times, people would just ask, "Do you want to keep your uterus?" It becomes a very binary yes or no question, but for many of the patients, it might not be something that they actively think about on a daily basis. The analogy I have is somebody asking me about whether I value the carbonator in my car. I would say, "What is that? Do I need it? I don't know. I don't even know what that is. Do I even have a carbonator in my car?”

What we did when I was a fellow, is that we actually developed a questionnaire. It's called the Value of Uterus questionnaire. Short form is called VALUS. It was published in the American Journal of OB-GYN. It's a six-question survey instrument that allows you to quantify how a woman values her uterus. Within this questionnaire, we're asking people about how they value their uterus with regard to sexual function, their personhood, their womanhood, their relationship to others, and their sense of self. We ask these questions because, in the existing literature, these are the themes that have been shown to be valuable to women when they describe personal traits or qualities and values that they place on the uterus. We validated this instrument, and it is an excellent instrument for predicting whether a woman would choose a uterine-preserving procedure. In our field, I know we give out lots of questionnaires and instruments for patients to fill out and this can be another tool that could really streamline your clinic visit, rather than asking that binary question of, "Do you want to keep your uterus?" You can give them this six-minute questionnaire so that you can visually see what is valuable to the patient. It also gives patients that feedback about where they rank amongst others with regard to how they feel about their uterus.

We actually applied this questionnaire to people in Cleveland, and we did a cross-sectional survey and what we found was that the major predictor for placing high value on the uterus was a desire to be sexually active. There's some correlation there that people do associate or value their uterus with sexual activity and sexual desire. Whether there is a biological explanation to that, there's none in my opinion, but for the patient, that's something that they value.

[Dr. Suzette Sutherland]
That brings up another really interesting point, I think, especially when we're talking about the uterus in sexual function, I think that there's not a lot in the literature to support the role of the uterus in sexual function, especially when it comes to the idea of sexual desire. We think of that as more of a hormonal issue, right? We know that removing the ovaries and deplenishing a woman's source of estrogen, progesterone, and testosterone can certainly affect the hormonal milieu and affect her sexual desire, her libido, but just isolating the uterus, that shouldn't do that. We still see a lot of women still tied to their uterus and with respect to sexual function. We also hear, anecdotally, reports of women who say, "Ever since my hysterectomy, even though I still have my ovaries and I'm not postmenopausal, I've had issues in the area of sexual functioning." Have you had that same kind of experience or you want to address some of that as well?

[Dr. Olivia Chang]
You're absolutely right that with sexual desire and sexual function, most of it is driven by ovarian function and testosterone production as well in women. The thing is, a lot of people do associate some of these changes in their symptoms after a hysterectomy. I do think that for some patients it's hard to sometimes take inventory of what was taken out at the time of hysterectomy, whether it's a full hysterectomy, meaning cervix, uterus, the ovaries, versus a partial. It can be very confusing for the patients.

You bring up a really good question because we've seen that in patients who've had a hysterectomy, there may be some influence to the blood supply of the ovary. Now, what does that mean? There are some small studies that show that there is a slightly earlier menopause for people who've had a hysterectomy, possibly because of the disruption of the collateral blood supply to the ovaries. Now, whether that's clinically significant or not, we don't really know, and that's not really something that people actively counsel for or against at the time of hysterectomy. However, in our patient population for pelvic organ prolapse, most of our patients are really beyond the age of natural menopause, so this is really less relevant of a problem.

I do want to bring up what you asked about earlier about the geographical and cultural valuation of the uterus. We just don't know much about that. If you ask people from around the country, they'll say, "Where I practice, everybody wants a hysterectomy," versus the other extreme where maybe a place like Seattle, maybe people didn't want a hysterectomy as much. There's really just not a lot of truth to that. There hasn't been good robust data to really suggest and confirm that that is a thing.

That's why one of the studies that I'm doing with the Society of Gynecologic Surgeons is that we're actually interviewing women across the United States in a mixed-method study to openly talk about how they feel about their uterus. I do think this data will just shed more light onto, who are the people that place value on the uterus, who are the people who don't? Is it a cultural thing? Is it a geographical thing? Is it a racial thing? Is it an educational thing? All of this information will just help us better identify who are the patients who value their uterus so that we can appropriately offer this surgical treatment option for their prolapse, or if you don't provide uterine preserving prolapse surgeries, to refer onto somebody who does so that we can really place the patient's values at the forefront of their surgical treatment.

Listen to the Full Podcast

Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang on the BackTable OBGYN Podcast)
Ep 32 Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang
00:00 / 01:04

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Uterine Preservation: Clinical Nuances & Patient Selection Criteria

The decision to remove a patient’s uterus encompasses ethical considerations, as many patients express a desire to preserve the integrity of their bodies, making organ removal contradictory to their wishes. This highlights the necessity for careful deliberation before opting for such a procedure.

While uterine-sparing procedures offer an alternative to the traditional approach of hysterectomy, it is crucial to discern appropriate candidates through comprehensive evaluation, particularly in cases involving abnormal uterine bleeding or cervical pathology. Moreover, the need for routine imaging or biopsies in asymptomatic patients remains uncertain, as definitive guidelines are lacking, leaving decisions largely to the discretion of practitioners. The existing assumptions about preoperative testing protocols draw from data on procedures like the LeFort colpocleisis, which involves hysteropexy, wherein the uterus is retained. Doctors Sutherland and Chang stress the importance of further research to establish clear practice guidelines in this dynamic field.

[Dr. Suzette Sutherland]
We talk about this often, and I think we often attribute some things to cultural differences because we just don't know. We say, "It's a cultural thing," but is it really a cultural thing, or is it more of a female thing regardless of the culture or the race? It'll be very interesting to see that data. There are many women who just say, "I want to leave this world with all the parts that God gave me at the beginning, if that's possible," and the uterus is one of those. And so, just removing different organs without really having concrete reason to, I think no matter what part of the body we're working in, we just need to be careful about that.

You've given us lots of good information about why to save the uterus when it's possible. Not only patient issues but also other anatomical issues and surgical outcomes issues. Let's just talk about one more category here about what might be some contraindications to uterine sparing procedure. When might we not want to leave the uterus in? Can you speak to that?

[Dr. Olivia Chang]
That's a great question, and it's important to really identify who are the good candidates and who are not the good ones. The patients who are not good candidates are those with abnormal uterine bleeding that has not been worked up because there's a concern for cancer. Part of the workup would be an ultrasound and the necessary biopsy to make sure you understand the source of the abnormal uterine bleeding before you suspend or keep the uterus. The scene for people with abnormal cervical pathology, so, people with abnormal pap smears that haven't been resolved. If my patient has either of these concerns, I would fully work that up before recommending uterine preservation, but even with recommendation of uterine preservation, I explain to them that the workup can be limited, and this is the opportunity for shared decision-making so that we can decide whether it makes sense to preserve the uterus or to perform a hysterectomy.

[Dr. Suzette Sutherland]
Along the same lines then, I know that this is debated back and forth, but what are your thoughts about, if you're leaving the uterus in, an obligatory transvaginal ultrasound to make sure everything looks copacetic in the side before making a decision about leaving it in? Do you think every woman needs that or needs an endometrial biopsy before deciding to leave it in? If she doesn't have any other untoward symptoms like postmenopausal bleeding or heavy bleeding.

[Dr. Olivia Chang]
Another great question. For these folks, I really employ a symptom and risk stratification approach. I work things up if they are symptomatic. If they are bleeding, I will work them up. However, if they're beyond the age of requiring a pap smear, if they don't have any bleeding, I do not routinely obtain a pelvic ultrasound or a pap.

[Dr. Suzette Sutherland]
Are there specific guidelines for that, do you know, either through AOGs or ACOG, that speaks to that specifically?

[Dr. Olivia Chang]
Yes, the ACOG does recommend workup for abnormal uterine bleeding, not so much in the context of prolapse repairs, but just abnormal uterine bleeding in general. I think what you're getting at, Dr. Sutherland, is the preoperative workup for somebody who does not have postmenopausal bleeding, and there's really no firm guidelines on this. This is really practitioner-dependent. The best data that we have to extrapolate this from is actually a preoperative workup before a LeFort colpocleisis. As you know LeFort colpocleisis is an obliterative procedure where we keep the uterus in. That's another form of hysteropexy that we often don't immediately think about. In that case, again, you don't have to do an ultrasound beforehand. In my practice, I do get an ultrasound before I leave the uterus in, at the time of a colpocleisis, because it is a very challenging procedure to do if you were to remove the uterus afterwards.

[Dr. Suzette Sutherland]
Yes, that would be a little more difficult in that scenario. That's a great project for someone to undertake to really look at the literature and come up with some concrete practice guidelines in this area because I know I get this question all the time, and it'd be nice to have some practice guidelines.

Podcast Contributors

Dr. Olivia Chang discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Olivia Chang

Dr. Olivia Chang is an assistant professor of clinical urology and the chief of female urology, pelvic reconstructive surgery and voiding dysfunction in the department of Urology at UC-Irvine in California.

Dr. Suzette Sutherland discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Suzette Sutherland

Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 13). Ep. 32 – Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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