Hysterectomy

Hysterectomy (Greek, hystera womb; Greek, ektome - excision) is the removal of the womb. It is a frequently performed operation. There are 625,000 hysterectomies performed annually in the USA and 90,000 in the UK. These figures for hysterectomy do not seem to be falling despite the advent of endometrial ablation (the lining of the womb is destroyed - endometrial ablation).

You may wish to consider:

The indications for hysterectomy

Risks of hysterectomy

Types of hysterectomy

Sub-total hysterectomy

Conservation of the ovaries at hysterectomy

Time in hospital for hysterectomy

Smear tests after hysterectomy

Surgical alternatives to hysterectomy

Hysterectomy and endometrial ablation compared

Psychological effects of hysterectomy

What are the indications for a hysterectomy?

Hysterectomy may be indicated for a variety of reasons including:

Heavy periods and other Vaginal blood loss problems that do not respond to medical treatment. This is the most frequent reason that hysterectomy is performed whether there is a suspected cause such as fibroids or not.

Pelvic pain associated with the womb, ovaries or Fallopian tubes, is another common indication. This may be related to fibroids, endometriosis or pelvic inflammatory disease.

Large fibroids when fertility is not required.

Premenstrual syndrome. Removal of the ovaries and uterus may prove to be the last resort in treatment for severe premenstrual syndrome.

An ovarian tumour in a woman who has reached her later forties. Hysterectomy including removal of both the ovaries and Fallopian tubes (Q 24.23) is usually recommended as the chance of malignancy increases with age. The exact nature of an ovarian tumour cannot be determined without microscopic examination. When an ovarian tumour is removed in younger women, it is appropriate to try to conserve fertility.

Cancer of the endometrium and cervix.

Utero-Vaginal prolapse. The uterus may need to be removed Vaginally as part of surgery for prolapse (Vaginal hysterectomy - Q30.6).

On rare occasions, there may be uncontrollable bleeding following childbirth or miscarriage and an obstetric hysterectomy may be life-saving if other treatments are proving ineffective.

Related Medical Abstracts - Click on the paper title:-

Treatment of menorrhagia before hysterectomy in a district general hospital. A retrospective review (2001)

The epidemiology of hysterectomy: findings in a large cohort study. (1992)

 101 Handy Hints for a Happy Hysterectomy

What are the risks of hysterectomy?

A hysterectomy is a commonly performed and generally safe surgical procedure. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications. The recovery time post hysterectomy depends on the type of procedure, complications and the individual patient. Women who are overweight, for example, take longer to recover. Exercise and care with diet pre and post hysterectomy can speed up your recover. With laparoscopic hysterectomy, many women have made a complete recovery within 2-3 weeks. When discussing the pros and cons of hysterectomy with your gynaecologist you should take into account possible problems inclusding side effects and complications.

Complications

The risks of surgical procedures in general are discussed in surgery risks. This is when problems occur during or after the operation. The majority of women are not affected. The possible complications of any operation include an unexpected reaction to the

• anaesthetic,
• excessive bleeding,
• infection or
• developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Bleeding after hysterectomy occurring during the first 24 hours is called a primary haemorrhage and occurs if a ligature has slipped.

Secondary bleeding after hysterectomy tends to occur about 10 days after surgery when the wound has become infected and eroded a vessel, usually quite a small one, but sometimes a larger one.

One of the purposes of monitoring a patient immediatelay after an operation is to watch for primary haemorrhage by regularly recording the pulse and blood pressure.

Specific complications of hysterectomy are uncommon but can include

• damage to other organs and tissues in the abdomen,
• particularly the bladder and ureters (tubes that carry urine from the kidneys to the bladder).

Further treatment such as returning to theatre to stop bleeding or to repair a damaged organ, antibiotics to treat an infection, or a blood transfusion to replace lost blood may be needed.

The urinary tract (bladder and ureters) are closely related to the uterus and may be damaged. The bowel is normally free from the uterus but may be adherent to it if there has been infection, endometriosis or previous surgery.

Infection in the urinary tract is a relatively common complication requiring antibiotics.

Thromboembolism (surgery risks) has been reduced by encouraging early mobilisation after surgery and the use of anticoagulants.

Bladder symptoms are common following hysterectomy. Antibiotics will help if there is infection. Otherwise these symptoms usually settle with time.

 The Complete Guide To Hysterectomy

Side-effects

These are the unwanted, but mostly temporary effects of a successful procedure, for example, feeling sick as a result of the general anaesthetic.

After surgery (abdominal hysterectomy), you will have some pain, swelling and bruising in the abdomen area. These side-effects usually clear up within a few days. You will have a permanently visible scar. Although this will be red and slightly raised to start with, it should soften and fade over the following weeks and months.

It is natural to worry that a hysterectomy might affect your sex life. For the majority of women hysterectomy does not diminish sexual activity or enjoyment. Some may be pleased that they can no longer conceive.

If your ovaries are removed, you may develop menopausal symptoms (see hysterectomy and the menopause) such as hot flushes and Vaginal dryness. You would then need to consider hormone replacement therapy (HRT). If sexual intercourse becomes painful because your vagina is dry, local oestrogen or lubricants (available from most chemists) can help.

Related Medical Abstracts - Click on the paper title:-

Hysterectomy and the menopause.

The menopause is defined as the final natural menstrual period and compares to the menarche which is the first period. The menopause is only one event of the climacteric just as the menarche (pubertyerty) is one event during puberty when there are a whole range of physical and emotional developments. The physical and psychological changes experienced around the menopause relate to the fall in hormone output from the ovaries, most notably oestrogens.

If your ovaries are removed at the time of hysterectomy, you may develop menopausal symptoms such as hot flushes and Vaginal dryness. You would then need to consider hormone replacement therapy (HRT). If sexual intercourse becomes painful because your vagina is dry, local oestrogen or lubricants (available from most chemists) can help.

There is some evidence, that even if the ovaries are conserved at the time of hysterectomy, the ovaries lose their function earlier.

The association of hysterectomy and menopause: a prospective cohort study.(2005-01)

FSH levels in relation to hysterectomy and to unilateral oophorectomy.(1999-01)

What is vault granulation?

Granulation is wet scar tissue, which may cause bleeding or discharge. The Vaginal vault is the top of the vagina following total abdominal hysterectomy. During this operation, the cervix is removed and the top of the vagina is sutured (stitched). The granulation may be cauterised with silver nitrate by your gynaecologist in the clinic at your postoperative visit. This is a painless procedure taking just a few seconds.

What are the different types of hysterectomy?

A hysterectomy is a commonly performed and generally safe surgical procedure.

Abdominal Hysterctomy: Unless there is uterine prolapse, most gynaecologist's remove the womb through the abdominal wall (abdominal hysterectomy).

Vaginal hysterectomy indicates that the uterus has been taken out through the vagina. When there is prolapse of the uterus and heavy periods, Vaginal hysterectomy and pelvic floor repair (Q30.6) may solve two problems.

Figure 24.4 shows the options available at abdominal hysterectomy.

A total hysterectomy is when all of the womb, including the neck of the womb (cervix), is removed (Q 24.24).

In subtotal hysterectomy, the body of the uterus is removed but the neck of the womb is left in place. Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the removal of the ovaries and tubes (Q 24.25).

More complex surgery may be required when the hysterectomy is performed for malignancy.

Lymphadenectomy is the removal of the local lymph glands. During a Wertheim's hysterectomy, required for some women with early cancer of the neck of the womb (cervical cancer), connective tissue adjacent to the uterus is removed together with the local lymph glands (lymphadenectomy).

Laparoscopic Hysterectomy: Some gynaecologists have been trained to remove the uterus vaginally with the assistance of laparoscopy (laparoscopically assisted Vaginal hysterectomy). As with all minimally invasive procedures (Q4.23), we are only just coming out of the pioneering stages. Usually, three or four small incisions are required to introduce all the instruments that are necessary. It has, however, been shown that if the uterus is not enlarged, an abdominal scar of no more than 10cm is required to perform a conventional hysterectomy and many gynaecologists remain comfortable with this approach. Laparoscopic hysterectomy may require less pain relief after surgery but the operation lasts one hour longer.

Caesarean Hysterectomy: Sometimes, complications occur during childbirth or caesarean section and a caesarean hysterectomy is required.

There is some evidence that vaginal hysterectomy has advantages over abdominal and laparoscopically assisted vaginal hysterectomy.0609

Related Medical Abstracts - Click on the paper title:-

Is it essential to remove the neck of the womb at hysterectomy and what is the place of sub-total or partial hysterectomy?

It had become routine practice to remove the cervix when performing abdominal hysterectomy in the United Kingdom and in the majority of other countries. The arguments in favour of removing the cervix are:-

cancer of the cervix cannot develop later.

the cervix may be the cause of pain or discharge if it is not removed.

there is a greater chance of a blood collection (haematoma) in the pelvis soon after surgery with the subtotal hysterectomy complicating recovery a concept that does not seem to have strong foundation.

if the cervix is not removed, there is a greater chance of prolapse in years to come but there are no comparative trials to demonstrate this.

In a partial or subtotal (supracervical = above the cervix) hysterectomy, the ovaries and/or cervix are left intact. These procedures, too, can be performed either abdominally, vaginally, or laparoscopically. Unfortunately, many women aren’t even told about these options. Some doctors remove the cervix automatically as a precaution against cervical cancer.

At our practice, we’ve seen that the benefits of retaining your cervix (more sexual enjoyment and sounder inner pelvic architecture) outweigh the relative risks. For one, evidence exists that an intact cervix may actually benefit proper Pap smear technique. If you do choose to keep your cervix, you will need to continue regular annual screenings and Pap tests.

A partial or subtotal hysterectomy - The cervix is conserved.

There are, however, times when it may be safer to conserve the cervix.

Occasionally, it may be densely adherent to the bowel (usually the rectum) particularly if there is severe endometriosis in the area. If the gynaecologist believes the risks to the bowel or urinary tract may outweigh the advantages, it may be decided during the operation that leaving the cervix in place (sub-total hysterectomy) is in the patient's best interest.

Many French women prefer to have the cervix conserved at the time of hysterectomy as there is a suggestion that this prevents reduction of sexual satisfaction. The argument in favour of removing the cervix pre-dates cervical smears. If smears have been abnormal removing the cervix would seem appropriate but if there have been regular smears showing no abnormality sub-total hysterectomy should cause less anxiety in this regard. Some believe that conserving the cervix (sub-total hysterectomy) reduces the likelihood of bladder symptoms in the long-term.  

A woman of forty presented with heavy periods and premenstrual syndrome. She had always been keen on a conservative approach. Endometrial ablation had provided temporary improvement but within a couple of years she felt that further surgical intervention was required. She had read extensively and elected to have a sub-total hysterectomy with removal of the ovaries and tubes. Her cervical smears had been normal. The operation was uneventful and she was home on the fourth day. She elected to take HRT tablets (oestradiol 2mg daily). She returned to her work with children by the third week and when we saw her six weeks after surgery she felt like a new woman absolutely wonderful. She will continue to have her routine cervical smears as her cervix has not been removed.

From the late 1990's, gynaecologists in the UK have become increasingly inclined to discuss the question of the subtotal procedure with their patients when counselling them with regard to hysterectomy.

Related Medical Abstracts - Click on the paper title:-

Should my ovaries be removed at hysterectomy?

If the hysterectomy is undertaken abdominally, there is a choice of conserving or removing the ovaries (Figure 24.4). When the hysterectomy is undertaken vaginally as part of treatment for prolapse, the ovaries are not usually removed. 

In a young woman, the ovaries are likely to have longer remaining function than in a woman around the age of fifty. There is, therefore, more advantage in conserving the ovaries in a young woman compared to a woman approaching her menopause. Some women, even beyond the age of fifty are very keen to keep their ovaries, if they appear healthy. Provided they have had the opportunity to make an informed choice, their decision must be accepted.

After the menopause, the ovaries produce very little oestrogen but they continue to produce a significant amount of androgens. By removing the ovaries, androgen production is reduced and this could result in reduced sex drive.

In recent years, it has been found that following hysterectomy, ovaries that have not been removed lose their function, usually within five years. This observation may be partially explained by the fact that some women develop heavy periods within the few years leading up to the menopause and the ovaries appear to lose their function early after the hysterectomy because the menopause was imminent anyway.

Even if there is no history of pelvic pain before hysterectomy, many women (about 1 in 20) will develop pain if their ovaries are conserved and return to have a second operation to remove the offending ovaries later.

Statistically we now know that when the ovaries are conserved at the time of hysterectomy, one woman out of every two hundred and fifty is likely to develop cancer of the ovary at some time in her life. This is not as a result of the hysterectomy but simply reflects the chance of a woman developing this disease. Once or twice each year I see women in their fifties or sixties with ovarian cancer who have had their ovaries conserved at the time of hysterectomy.

Cyclical symptoms (premenstrual syndrome Premenstrual Syndrome - PMS) are usually improved or cured when the ovaries are removed and hormone replacement therapy is commenced.

Finally, hormone replacement therapy has advanced to the stage that, with few exceptions, an entirely satisfactory treatment is available following removal of the ovaries. Every patient undergoing hysterectomy should give these facts careful consideration and indicate at the time of signing consent for operation whether she wishes to keep her ovaries if they appear healthy. If the ovaries appear unhealthy the gynaecologist would generally wish to remove them.

Related Medical Abstracts - Click on the paper title:-

How long will I be in hospital after my hysterectomy?

Patients undergoing abdominal hysterectomy have traditionally stayed in hospital for at least 6 days. It is increasingly recognised that early discharge from hospital has several advantages:

Patients, understandably feel more comfortable in their own environment.

There is probably less risk of infection away from the hospital.

Early mobilisation reduces the risks of deep venous thrombosis (a blood clot developing in the deep veins of a leg or in the pelvis) or pulmonary embolism (the clot in the vein breaks away and travels to the lung).

Early discharge allows optimum utilisation of hospital staff and facilities.

The majority of our patients are home within four or five days and many patients are back to full activity including work within three or four weeks.

Related Medical Abstracts - Click on the paper title:-

Do I still need to have PAP tests (cervical smear) after hysterectomy?

If there have been smears showing moderate or severe abnormality before the hysterectomy, further smears for up to five years are advisable even if the cervix has been removed; these smears are taken from the Vaginal vault. If the cervix has been removed and there were no smear test problems before hysterectomy further smears are not justifiable. If the cervix has been conserved (sub-total hysterectomy) smears should continue along the same programme as for women who have not had a hysterectomy.

If you have had a vaginal hysterectomy, the cervix will usually have been removed. 

Related Medical Abstracts - Click on the paper title:-

Support Groups

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

• relating personal experiences,
• listening to others' experiences,
• providing sympathetic understanding and
• establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

This page was last updated: 6th December 2006

HystereCity

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The Hysterectomy Association

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Dorchester

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