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.
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.
Preparing for your operation
- Get fit: if you have time and your doctor believes your state of health will allow it, try to get as fit as possible before the operation. Do some daily exercise, even a daily 30 minute walk will help.
Smoking: it is better to stop smoking completely before and after the operation. Smoking raises the risk of heart, chest or blood vessel problems during and after the operation.
Nicotine, as well as some other chemicals present in cigarettes narrow the blood vessels. The risk of blood clots is greater for some time after surgery - narrowed blood vessels may increase the risk of complications. If you cannot stop, try to cut down. If you smoke it is important that your surgical team know this.
- Be informed: find out as much as you can from the medical team about your operation. Do not be afraid to ask questions; they are used to this and should gladly explain everything and respond to any queries you may have.
- Get help: if you live alone, or the other household members are not very agile, try to arrange for a friend or relative to help you for the first week or two back home after the operation.
- Transport: make sure you have transport to and from hospital organized well in advance. In many countries you may be entitled to assistance from health authorities or your local council.
- Your little important things: organize your home for when you return. Place all your most used objects in an easy-to-access place, such as your TV remote, radio, telephone, medications, tissues, address book, spectacles, pens, paper, etc.
- Organize your provisions: make sure you have plenty of canned, frozen, and easy-to-prepare foods for your return. If somebody is going to help look after you, check this with them.
- Hygiene: have a shower and put clean clothes on before you leave the house to the hospital. This helps prevent bringing unwanted bacteria into the hospital.
- Nails: make sure your finger and toenails are well clipped. During your operation you will be under general anesthetic; you will be moved around on a trolley unable to prevent a toe or finger from sticking out of the side. I am surprised at how many patients write to me saying that they broke a nail in hospital. When I woke up after my prostatectomy (surgical removal of the prostate) the nail of my little toe was bent right back.
- Dietary requirements: if you are vegetarian, vegan, or have any special dietary requirements, it is important that you let the hospital know about this well in advance. When you get to the hospital check they have not forgotten.
What may happen when you get to hospital?
Before surgery, blood and urine are likely to be tested.
Before the hysterectomy the following may occur:
- A blood and urine sample will be taken for testing
- The patient may receive an enema
- The abdominal and pelvic areas may be shaved (or partly shaved)
- Antibiotics will be given
- A needle will be attached to the patient's arm or wrist. This will be attached to an IV line that supplies the body with medication, fluids or blood
- Before applying the anesthesia, the patient may be attached to a monitor
- A urinary catheter will be placed in the bladder (this happens while the patient is asleep).
Recovering from the operation
Patients generally wake up feeling tired and with a certain amount of pain - this will depend on several factors, including the type of hysterectomy, the reason for it, and the state of health of the patient. Most likely the patient will also be on a drip and a urinary catheter. Some patients will notice a tube coming out of their abdomen - this is a drainage tube to take away any blood around the wound.
Within a day or so, patients are usually encouraged to walk; this is to reduce the risk of blood clots in the legs. By the second or third day most patients are walking around.
Most women who have had a vaginal hysterectomy go home after three to four days, while those who had an abdominal hysterectomy may require from five to about seven days.
It is important for the patient not to put anything in her vagina for at least the first six weeks - this includes, douching, tampons or having sex.
In the majority of cases, a follow-up appointment will be arranged for about six weeks after the operation.
For a period of 6-8 weeks, the patient's body is recovering, and she should not carry any heavy shopping or undertake physically demanding household tasks.
Side effects after the operation
- Painful wind: this will gradually get better. If it is troublesome tell your doctor; there are medications to treat it.
- Brownish-red vaginal discharge: this will be present for about four weeks after the operation and is normal. Sanitary pads can be used after the surgery. The discharge should not have a foul smell or contain puss - tell your doctor if this is the case as it could be due to an infection.
- Menopausal symptoms: women who have had their ovaries removed will probably experience severe menopausal symptoms after three to four days. These may include hot flashes (UK/Ireland/Australia: flushes), confusion, sweating, anxiety and a desire to cry. Some patients may be given HRT injections, tablets or implants - these will start having an effect within about a week.
- Body weight: some patients put on weight after a hysterectomy. Doctors say it is not the operation itself that may cause this, but rather because of post-operative lack of physical activity. Patient's who eat a well-balanced diet while at the same time watching their calorie intake will not put on weight. If you want to do some exercise it is important to tell the medical team.
Other problems: The risk of problems related to a hysterectomy is among the lowest for major surgery. If problems do occur, they may include the following:
- Blood clots in the lungs or veins
- Bleeding - possibly during or after surgery
- Bowel blockage
- Urinary tract injury
- Problems with the anesthesia.
Some women may notice a difference in how they respond to sex after the operation. Uterine contractions, which were present during orgasm, will no longer be there; giving the orgasm a different sensation.
Some women find sex after the operation more enjoyable. Experts say this could be due to many factors, for example, there is no more worry about becoming pregnant, or the discomfort from heavy bleeding is gone.
Depending on the type of hysterectomy, for example if ovaries are removed, some women may experience vaginal dryness. Estrogen, or other vaginal lubricants may help.
Women who undergo a total hysterectomy, in which both the uterus and the cervix are removed, are no more likely to experience sexual difficulties or urinary or bowel problems after surgery than women who have only their uterus removed, researchers from the University of Auckland in New Zealand found.
Emotional and psychological effects
The psychological effects of a hysterectomy can be substantial.
Most women will feel some sadness and a sense of loss after a hysterectomy. Doctors say the emotional impact may be stronger among women of child-bearing age with cancer whose only option was a hysterectomy.
Pre-menopausal women who have a hysterectomy may have a sad feeling that a milestone in life arrived too early - not being able to have children any more. In some cases this can progress to a feeling of no longer being "womanly," which may progress to clinical depression.
It is important that any mental or emotional symptoms are reported to the doctor if they either persist or grow. Doctors may not only be able to provide treatment, but they may also be able to direct the patient to support groups. Meeting other women who share similar experiences and feelings can be a great help.
Decline in memory and thinking skills
Women who have both their ovaries removed before the natural onset of menopause have a higher risk of experiencing a decline in memory and cognitive skills, researchers from Harvard Medical School, Boston, explained at the American Academy of Neurology's 65th Annual Meeting in January 2013.
The procedure, an oophorectomy, involves the removal of both ovaries. The researchers said that there is a clear association between oophorectomy and the risk of cognitive decline.
Team leader Dr. Riley Bove added that women who undergo an oophorectomy and are then put on extensive hormone therapy are affected considerably less.
Dr. Bove said:
"While we found a link between surgical menopause and thinking and memory decline, women on longer hormone replacement therapies had slower declines. Since hormone replacement therapy is widely available, our research raises questions as to whether these therapies have a protective effect against cognitive decline and whether women who experience early surgical menopause should be taking hormone replacement therapies afterward."
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