Uterine Preservation: Balancing Medical, Ethical & Patient Perspectives

[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.