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I believe in giving patients all of their options for treatment from the most conservative to the most invasive (along with the relative risks / benefits) at the beginning of our treatment discussions.  

Because the majority of hysterectomies in this country are done for "benign" (non-cancerous) conditions, it is usually about one's "quality of life" that is being addressed.  Is it necesssary to fail all methods of non surgical treatment (ie.  months of birth control pils, spending money on a treatment option that the patient doesn't want only so they can say they "failed" at that treatment?) before proceeding to more difinitive surgical therapy?  

Clearly, if the symtoms do not represent a significant problem for the patient, then no treatment is the best option; however, these are not the patients that I see.  I can not tell you how many patients I have seen that have been tried on multiple pills, progestins, IUD, NSAIDs and even narcotics before their provider even began discussing possible surgical options, if they ever did.

I am all for attempts at non-surgical management as long as the patient understands ALL of her options and agrees/desires that approach.  If we as doctors do not talk about minimally invasive options like Mirena IUS, endometrial ablation and SILS hysterectomy, who will?

RCM