A hysterectomy is an operation to take out the uterus (womb), and sometimes the cervix and occasionally other reproductive organs.
When surgery does not involve removing the cervix, it may be referred to as a subtotal hysterectomy. A radical hysterectomy involves the surgical removal of the uterus, ovaries, cervix, oviducts, lymph nodes and lymph channels.
In all cases, if the woman is pre-menopausal, menstruation will stop and she will not be able to bear children.
In this article, we will look at why and hysterectomies are performed and the side effects and long-term implications.
Fast facts on hysterectomies
Here are some key points about hysterectomies. More detail and supporting information is in the main article.
- Hysterectomies are the second most common operation carried out on women
- There are a number of reasons to carry out a hysterectomy including prolapse of the uterus and cancer
- Other reasons for the operation include particularly heavy menstruation and endometriosis
- The two most common types of hysterectomy are vaginal and abdominal
- A hysterectomy can be carried out using keyhole surgery (laparoscopy)
- A robot-assisted hysterectomy can increase surgical precision
- Quitting smoking before the operation reduces the risk of blood clots during and after the procedure
- After the operation, the patient will be on a drip and a urinary catheter
- Side effects of a hysterectomy can include painful wind, vaginal discharge and menopausal symptoms.
Why are hysterectomies performed?
There are a number of reasons why hysterectomies are carried out.
According to the NHS (National Health Service), UK, approximately 20% of all 55-year-old women have had a hysterectomy.
In the US, 600,000 hysterectomies are performed each year, at a cost of $5 billion per year.
It is the second most common major surgery among women of child-bearing age.
The main reasons for having a hysterectomy are heavy and painful periods, pelvic inflammatory disease, endometriosis, prolapse of the uterus and cancer.
Heavy and painful periods
Some women's periods may be so heavy that their blood loss leads to anemia - when the number of red blood cells or concentrations of hemoglobin are low. If this is accompanied with menstrual pains or stomach cramps (dysmenorrhea) the quality of life of the woman can be seriously affected.
A specialist may recommend a hysterectomy if:
- The patient has not responded to other treatments including:
- Watchful waiting - when the menopause arrives periods will stop.
- Tranexamic acid - encourages blood coagulation in the uterus, which reduces bleeding.
- NSAIDs (non-steroidal anti-inflammatory drugs) - these are painkillers which also reduce bleeding.
- Endometrial ablation - surgery which thins the lining of the uterus. The woman will subsequently have no more periods and will not be able to bear children.
- Hormone therapy - the contraceptive progestogen is sometimes prescribed to interrupt the menstrual cycle. Hormone therapy can also stop the lining of the uterus from growing too fast.
- Myomectomy - surgery to remove fibroids.
- The patient's quality of life is severely affected by menstrual bleeding.
- The patient does not want to have any (more) children.
Pelvic inflammatory disease (chronic pelvic pain)
If detected early it can be treated with antibiotics. However, if it spreads and damages the fallopian tubes and uterus it can result in chronic episodes of pain (in medicine "chronic" means long-term, for life).
Women who no longer wish to bear children may choose to opt for a hysterectomy. In many cases, women who wish to have children may be able to control the pain with analgesics.
Endometriosis is a condition in which cells that are normally found inside the uterus (endometrial cells) are found growing outside it. That is, the lining of the inside of the uterus is found outside of it.
Endometrial cells are the cells that shed every month during menstruation, and so endometriosis is most likely to affect women during their childbearing years. The cellular growth is not cancerous, but benign. Though there are not always symptoms, it can be painful and lead to other problems.
Problems may occur if released blood gets stuck in surrounding tissue and damage it, causing severe pain, irregular periods and infertility. If the patient has not responded well to other treatments, such as hormone therapy or laser surgery, and symptoms are severe, hysterectomy is an option to consider.
Prolapse of the uterus
If the muscles that support the uterus weaken, the uterus may drop down into the vagina. This may be caused by childbirth or heavy lifting.
As changing hormone levels after the menopause can make muscles less elastic, uterine prolapses are more common among post-menopausal women. However, it can also affect younger women. If a woman has a prolapse she may experience back pain, incontinence and painful sex.
HRT (hormone replacement therapy) can strengthen the muscles that support the uterus. Some surgical techniques can also strengthen the muscles and ligaments. On the other hand, if the ligaments and muscles are severely weakened, it may be advisable to have a hysterectomy.
The following cancers may lead to a need for a hysterectomy:
- Cancer of the cervix
- Cancer of the fallopian tubes
- Cancer of the ovaries
- Cancer of the endometrium.
The earlier these cancers are detected, the less likely it is that the patient will need a hysterectomy.
How is a hysterectomy performed?
Both vaginal and abdominal hysterectomies are common.
A hysterectomy can be performed in various ways:
- Vaginal hysterectomy: the uterus and cervix are removed through the vagina. The uterus and cervix are pulled through a hole that is made in the top of the vagina.
Surgical instruments are placed into the vagina to remove the uterus from ligaments that hold it in place. After the uterus has been removed, surgeons then remove the cervix. The incision at the top of the vagina is then closed with stitches.
Most surgeons will recommend this procedure because it is less invasive than an abdominal hysterectomy, and the patient recovers much faster.
However, if the patient has many fibroids in her vagina it is not recommended. Sometimes, if there is a reason to remove the ovaries coming in through the abdomen may be better.
For women who have never given birth the passage may be too narrow for this procedure.
- Abdominal hysterectomy: the uterus is removed through a cut in the abdomen. Abdominal hysterectomy requires longer healing time than vaginal, but it allows the surgeon to have a good look at the uterus and other organs during the operation.
If the patient has tumors or suspected tumors the doctor will need to look around.
Laparoscopy and robotic surgery
Laparoscopy is also known as keyhole surgery, Band-aid surgery or minimally invasive surgery, and is used in many different types of surgical procedures, including hysterectomies. Between two to four small incisions less than half an inch wide are made in the abdomen, one usually in the belly button.
A needle goes into the first incision and fills the abdomen with CO2 (carbon dioxide) so that the abdomen is buoyed up and away from the organs, allowing for better viewing and maneuverability. Also a long thin tube, called a laparoscope which has a video camera at the end so that the surgeon can see the organs, blood vessels, muscles, ligaments, and other tissue in fine detail, is inserted.
Various instruments are then inserted into the additional incisions to retract, cut, suture and staple. As incisions are much smaller with laparoscopic surgery there is less scarring, bleeding, and post-operative pain. Hospital stays are shorter compared to traditional surgery involving a much larger abdominal incision.
A robot-assisted hysterectomy uses a robot, the most common one today is called the da Vinci Surgical System. It allows gynecologists to operate with amazing precision, vision and control. As with manual laparoscopy, small incisions are made in the abdomen, etc.
However, the robot handles the laparoscope and instruments, while the surgeon sits looking into a screen, wearing glove-like devices which respond to finger movements and twists of the hands and wrists.
Most surgeons agree that for complex hysterectomies, robot-assisted surgery is more effective and less invasive. The surgeon needs special training to be able to use this device.
- Laparoscopically Assisted Vaginal Hysterectomy (LAVH): laparoscopic surgical techniques are used to remove the uterus and/or tubes and ovaries through the vagina. When the tubes and ovaries have to be removed it used to be necessary to cut through the abdomen.
LAVH increases the possibility of doing this through the vagina. Patients usually need to have benign conditions that lead to hysterectomy and have a uterus that is not too large.
LAVHs are becoming more popular for patients with a uterine prolapse. Surgeons say that traditional vaginal hysterectomies give them less room to operate and no proper opportunity to look at the pelvic organs - the camera at the end of the laparoscope allows him/her too see inside the abdomen.
- Laparoscopic Supracervical Hysterectomy (LSH): this procedure leaves the cervix and its lubricating glands in place - avoiding vaginal dryness; a common post-hysterectomy complaint.
- Laparoscopic total hysterectomy: this is similar to LSH; but this time the cervix is removed as well. This could also be done vaginally if the uterus is not too large.
Main types of hysterectomy
- A subtotal hysterectomy: only the body of the uterus is surgically removed. The cervix stays
- A total hysterectomy: the body of the uterus and the cervix are both surgically removed
- A total hysterectomy with bilateral salpingo-oophorectomy: the uterus, fallopian tubes, cervix, and ovaries are all surgically removed. This is also known as a radical hysterectomy.
NICE (National Institute of Clinical Excellence), UK, the public body that approves National Health Service treatments, says patients should only have their ovaries removed when there is a significant risk of associated diseases, such as ovarian cancer.
On the next page, we look at how to prepare for the operation, recovery and side effects.