Hysterectomy is the surgical removal of the uterus. In a total hysterectomy, the uterus and cervix are removed. In some cases, the fallopian tubes and ovaries are removed along with the uterus (called hysterectomy with bilateral salpingo-oophorectomy). In a subtotal hysterectomy, only the uterus is removed. In a radical hysterectomy, the uterus, cervix, ovaries, oviducts, lymph nodes, and lymph channels are removed. The type of hysterectomy performed depends on the reason for the procedure. In all cases, menstruation stops and a woman loses the ability to bear children.
Description
There are two ways that hysterectomies can be performed. The choice of method depends on the type of hysterectomy, the doctor's experience, and the reason for the hysterectomy.
Abdominal hysterectomy
About 75% of hysterectomies performed in the United States are abdominal hysterectomies. The surgeon makes a four to six inch incision either horizontally across the pubic hair line from hip bone to hip bone or vertically from navel to pubic bone. Horizontal incisions leave a less noticeable scar, but vertical incisions give the surgeon a better view of the abdominal cavity. The blood vessels, fallopian tubes, and ligaments are cut away from the uterus, which is lifted out.
Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.
The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy and the recovery period is longer.
Vaginal hysterectomy
With a vaginal hysterectomy, the surgeon makes an incision near the top of the vagina. The surgeon then reaches through this incision to cut and tie off the ligaments, blood vessels, and fallopian tubes. Once the uterus is cut free, it is removed through the vagina. The operation takes one to two hours. The hospital stay is usually one to three days, and return to normal activities takes about four weeks.
The advantages of this procedure are that it leaves no visible scar and is less painful. The disadvantage is that it is more difficult for the surgeon to see the uterus and surrounding tissue. This makes complications more common. Large fibroids cannot be removed using this technique. It is very difficult to remove the ovaries during a vaginal hysterectomy, so this approach may not be possible if the ovaries are involved.
Vaginal hysterectomy can also be performed using a laparoscopic technique. With this surgery, a tube containing a tiny camera is inserted through an incision in the navel. This allows the surgeon to see the uterus on a video monitor. The surgeon then inserts two slender instruments through small incisions in the abdomen and uses them to cut and tie off the blood vessels, fallopian tubes, and ligaments. When the uterus is detached, it is removed though a small incision at the top of the vagina.
This technique, called laparoscopic-assisted vaginal hysterectomy, allows surgeons to perform a vaginal hysterectomy that might be too difficult otherwise. The hospital stay is usually only one day. Recovery time is about two weeks. The disadvantage is that this operation is relatively new and requires great skill by the surgeon.
Any vaginal hysterectomy may have to be converted to an abdominal hysterectomy during surgery if complications develop.
Who Performs the Procedure and Where Is It Performed?
Hysterectomies are usually performed under the strict conditions of a hospital operating room. The procedure is generally performed by a gynecologist, a medical doctor who has specialized in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics.
Questions to Ask the Doctor
Why is a hysterectomy recommended for my particular condition?
What type of hysterectomy will be performed?
What alternatives to hysterectomy are available to me?
Will I have to start hormone replacement therapy?
Definition
Hysterectomy is the surgical removal of all or part of the uterus. In a total hysterectomy, the uterus and cervix are removed. In some cases, the fallopian tubes and ovaries are removed along with the uterus, which is a hysterectomy with bilateralsalpingo-oophorectomy. In a subtotal hysterectomy, only the uterus is removed. In a radical hysterectomy, the uterus, cervix, ovaries, oviducts, lymph nodes, and lymph channels are removed. The type of hysterectomy performed depends on the reason for the procedure. In all cases, menstruation permanently stops and a woman loses the ability to bear children.
Purpose
The most frequent reason for hysterectomy in American women is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus that can cause pelvic, low back pain, and heavy or lengthy menstrual periods. They occur in 30–40% of women over age 40, and are three times more likely to be present in African-American women than in Caucasian women. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.
Treatment of endometriosis is the reason for 20% of hysterectomies. The endometrium is the lining of the uterus. Endometriosis occurs when the cells from the endometrium begin growing outside the uterus. The outlying endometrial cells respond to the hormones that control the menstrual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding tissue, leading to pain and scarring.
Twenty percent of hysterectomies are done because of heavy or abnormal vaginal bleeding that cannot be linked to any specific cause and cannot be controlled by other means. Another 20% are performed to treat prolapsed uterus, pelvic inflammatory disease, or endometrial hyperplasia, a potentially pre-cancerous condition.
About 10% of hysterectomies are performed to treat cancer of the cervix, ovaries, or uterus. Women with cancer in one or more of these organs almost always have the organ(s) removed as part of their cancer treatment.
Demographics
Hysterectomy is the second most common operation performed on women in the United States. About 556,000 of these surgeries are done annually. By age 60, approximately one out of every three American women will have had a hysterectomy. It is estimated that 30% of hysterectomies are unnecessary.
The frequency with which hysterectomies are performed in the United States has been questioned in recent years. It has been suggested that a large number of hysterectomies are performed unnecessarily. The United States has the highest rate of hysterectomies of any country in the world. Also, the frequency of this surgery varies across different regions of the United States. Rates are highest in the South and Midwest, and are higher for African-American women. In recent years, although the number of hysterectomies performed has declined, the number of hysterectomies performed on younger women aged 30s and 40s is increasing, and 55% of all hysterectomies are performed on women ages 35–49.
In a hysterectomy, the reproductive organs are accessed through a lower abdominal incision or laparoscopically (A). Ligaments and supporting structures called pedicles connecting the uterus to surrounding organs are severed (B). Arteries to the uterus are severed (C). The uterus, fallopian tubes, and ovaries are removed (D and E). (Illustration by GGS Inc.)
Description
A hysterectomy is classified according to what structures are removed during the procedure and what method is used to remove them.
Total Hysterectomy
A total hysterectomy, sometimes called a simple hysterectomy, removes the entire uterus and the cervix. The ovaries are not removed and continue to secrete hormones. Total hysterectomies are usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy.
In addition to a total hysterectomy, a procedure called a bilateral salpingo-oophorectomy is sometimes performed. This surgery removes the ovaries and the fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.
Subtotal Hysterectomy
If the reason for the hysterectomy is to remove uterine fibroids, treat abnormal bleeding, or relieve pelvic pain, it may be possible to remove only the uterus and leave the cervix. This procedure is called a subtotal hysterectomy (or partial hysterectomy), and removes the least amount of tissue. The opening to the cervix is left in place. Some women believe that leaving the cervix intact aids in their achieving sexual satisfaction. This procedure, which used to be rare, is now performed more frequently.
Subtotal hysterectomy is easier to perform than a total hysterectomy, but leaves a woman at risk for cervical cancer. She will still need to get yearly Pap smears.
Radical Hysterectomy
Radical hysterectomies are performed on women with cervical cancer or endometrial cancer that has spread to the cervix. A radical hysterectomy removes the uterus, cervix, above part of the vagina, ovaries, fallopian tubes, lymph nodes, lymph channels, and tissue in the pelvic cavity that surrounds the cervix. This type of hysterectomy removes the most tissue and requires the longest hospital stay and a longer recovery period.
Methods of Hysterectomy
There are two ways that hysterectomies can be performed. The choice of method depends on the type of hysterectomy, the doctor's experience, and the reason for the hysterectomy.
Abdominal Hysterectomy
About 75% of hysterectomies performed in the United States are abdominal hysterectomies. The surgeon makes a 4–6-in (10–15-cm) incision either horizontally across the pubic hair line from hip bone to hip bone or vertically from navel to pubic bone. Horizontal incisions leave a less noticeable scar, but vertical incisions give the surgeon a better view of the abdominal cavity. The blood vessels, fallopian tubes, and ligaments are cut away from the uterus, which is lifted out.
Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.
The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons tend to have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy, and the recovery period is longer.
Vaginal Hysterectomy
With a vaginal hysterectomy, the surgeon makes an incision near the top of the vagina. The surgeon then reaches through this incision to cut and tie off the ligaments, blood vessels, and fallopian tubes. Once the uterus is cut free, it is removed through the vagina. The operation takes one to two hours. The hospital stay is usually one to three days, and the return to normal activities takes about four weeks.
The advantages of this procedure are that it leaves no visible scar and is less painful. The disadvantage is that it is more difficult for the surgeon to see the uterus and surrounding tissue. This makes complications more common. Large fibroids cannot be removed using this technique. It is very difficult to remove the ovaries during a vaginal hysterectomy, so this approach may not be possible if the ovaries are involved.
Vaginal hysterectomy can also be performed using a laparoscopic technique. With this surgery, a tube containing a tiny camera is inserted through an incision in the navel. This allows the surgeon to see the uterus on a video monitor. The surgeon then inserts two slender instruments through small incisions in the abdomen and uses them to cut and tie off the blood vessels, fallopian tubes, and ligaments. When the uterus is detached, it is removed though a small incision at the top of the vagina.
This technique, called laparoscopic-assisted vaginal hysterectomy, allows surgeons to perform a vaginal hysterectomy that might otherwise be too difficult. The hospital stay is usually only one day. Recovery time is about two weeks. The disadvantage is that this operation is relatively new and requires great skill by the surgeon.
Any vaginal hysterectomy may have to be converted to an abdominal hysterectomy during surgery if complications develop.
Diagnosis/Preparation
Before surgery the doctor will order blood and urine tests. The woman may also meet with the anesthesiologist to evaluate any special conditions that might affect the administration of anesthesia. On the evening before the operation, the woman should eat a light dinner and then have nothing to eat or drink after midnight.
Aftercare
After surgery, a woman will feel some degree of discomfort; this is generally greatest in abdominal hysterectomies because of the incision. Hospital stays vary from about two days (laparoscopic-assisted vaginal hysterectomy) to five or six days (abdominal hysterectomy with bilateral salpingo-oophorectomy). During the hospital stay, the doctor will probably order more blood tests.
Return to normal activities such as driving and working takes anywhere from two to eight weeks, again depending on the type of surgery. Some women have emotional changes following a hysterectomy. Women who have had their ovaries removed will probably start hormone replacement therapy.
Risks
Hysterectomy is a relatively safe operation, although like all major surgery it carries risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, damage to other organs such as the bladder, and post-surgery infection.
Other complications sometimes reported after a hysterectomy include changes in sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other symptoms of menopause can occur if the ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for heart disease and osteoporosis (a condition that causes bones to be brittle). Women with a history of psychological and emotional problems before the hysterectomy are likely to experience psychological difficulties after the operation.
As in all major surgery, the health of the patient affects the risk of the operation. Women who have chronic heart or lung diseases, diabetes, or iron-deficiency anemia may not be good candidates for this operation. Heavy smoking, obesity, use of steroid drugs, and use of illicit drugs add to the surgical risk.
Normal Results
Although there is some concern that hysterectomies may be performed unnecessarily, there are many conditions for which the operation improves a woman's quality of life. In the Maine Woman's Health Study, 71% of women who had hysterectomies to correct moderate or severe painful symptoms reported feeling better mentally, physically, and sexually after the operation.
Morbidity and Mortality Rates
The rate of complications differs by the type of hysterectomy performed. Abdominal hysterectomy is associated with a higher rate of complications (9.3%), while the overall complication rate for vaginal hysterectomy is 5.3%, and 3.6% for laparoscopic vaginal hysterectomy. The risk of death from hysterectomy is about one in every 1,000 women. The rates of some of the more commonly reported complications are:
excessive bleeding (hemorrhaging): 1.8–3.4%
fever or infection: 0.8–4.0%
accidental injury to another organ or structure: 1.5–1.8%
Alternatives
Women for whom a hysterectomy is recommended should discuss possible alternatives with their doctor and consider getting a second opinion, since this is major surgery with life-changing implications. Whether an alternative is appropriate for any individual woman is a decision she and her doctor should make together. Some alternative procedures to hysterectomy include:
Embolization. During uterine artery embolization, interventional radiologists put a catheter into the artery that leads to the uterus and inject polyvinyl alcohol particles right where the artery leads to the blood vessels that nourish the fibroids. By killing off those blood vessels, the fibroids have no more blood supply, and they die off. Severe cramping and pain after the procedure is common, but serious complications are less than 5% and the procedure may protect fertility.
Myomectomy. A myomectomy is a surgery used to remove fibroids, thus avoiding a hysterectomy. Hysteroscopic myomectomy, in which a surgical hysteroscope (telescope) is inserted into the uterus through the vagina, can be done on an outpatient basis. If there are large fibroids, however, an abdominal incision is required. Patients typically are hospitalized for two to three days after the procedure and require up to six weeks recovery. Laparoscopic myomectomies are also being done more often. They only require three small incisions in the abdomen, and have much shorter hospitalization and recovery times. Once the fibroids have been removed, the surgeon must repair the wall of the uterus to eliminate future bleeding or infection.
Endometrial ablation. In this surgical procedure, recommended for women with small fibroids, the entire lining of the uterus is removed. After undergoing endometrial ablation, patients are no longer fertile. The uterine cavity is filled with fluid and a hysteroscope is inserted to provide a clear view of the uterus. Then, the lining of the uterus is destroyed using a laser beam or electric voltage. The procedure is typically done under anesthesia, although women can go home the same day as the surgery. Another newer procedure involves using a balloon, which is filled with superheated liquid and inflated until it fills the uterus. The liquid kills the lining, and after eight minutes the balloon is removed.
Endometrial resection. The uterine lining is destroyed during this procedure using an electrosurgical wire loop (similar to endometrial ablation).
Resources
Periodicals
Kovac, S. Robert. "Hysterectomy Outcomes in Patients with Similar Indications." Obstetrics & Gynecology 95, no. 6 (June 2000): 787–93.
Organizations
American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org.
American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org.
National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. http://www.nci.nih.gov.
Hysterectomy is the term used to describe an operation involving the removal of the uterus. This normally involves excision of the body of the uterus and the cervix (total hysterectomy). Occasionally just the body of the uterus is removed, leaving the cervix (subtotal hysterectomy). The ovaries and Fallopian tubes may also removed during a hysterectomy (total hysterectomy with bilateral salpingoopherectomy) .
Hysterectomy was first described in the fifth century bc when Soranus of Ephesus is said to have amputated a gangenous uterus through the vagina. Vaginal hysterectomy was reported in the medical literature sporadically over the next 2000 years. Perhaps the most famous of these was Faith Howard, who in around 1670 amputated her own uterus which repeatedly prolapsed out of her vagina. Not only did she survive this, but she went on to live for several years afterwards, despite having rendered herself incontinent from a hole in her bladder.
This operation was first established as acceptable practice in Britain by Isaac Baker Brown and Spencer Wells, surgeons working in London in the late nineteenth century. At this time vaginal surgery was considered the safest way for the operation to be performed, since abdominal surgery had a very high mortality rate and was to be avoided wherever possible. Abdominal hysterectomy was first described by Charles Clay in Manchester in 1843, when a massive fibroid uterus was mistaken for an ovarian tumour and an abdominal incision had already been made. Unfortunately this patient died, and it was another 10 years before a woman successfully survived this operation.
The advent of antiseptics and anaesthetics meant that abdominal surgery began to become safer, and the abdominal hysterectomy was established in the latter part of the nineteenth century, principally through Lawson Tait, Scottish gynaecologist working in Birmingham. In 1884 Tait published his series of 1000 abdominal operations including 54 hysterectomies, the first such report in the medical literature. Subsequently this has become the most frequently used route for this procedure, as it allows easier access, especially if the uterus is enlarged. Today the most common form of abdominal hysterectomy is performed through a transverse cut in the lower abdominal wall (bikini line incision). This approach allows easy removal of the ovaries, which is not always possible vaginally.
Vaginal hysterectomy is still used in around 1 in 5 hysterectomies in the UK, and allows a quicker recovery. This operation is usually preferred for prolapse or heavy periods where removal of the ovaries is not essential and the uterus is of normal size (although some surgeons will remove some enlarged wombs vaginally).
Hysterectomies are performed for a variety of benign (non-cancerous) conditions, most commonly including heavy, painful periods and prolapse of the uterus. The painful, heavy periods can be caused by a variety of conditions including endometriosis, fibroids, chronic pelvic infections, and adhesions. A hysterectomy may also be advised when a woman has an ovarian cyst or where she has precancerous changes to the cervix that have not resolved with simple treatments.
A more radical type of abdominal hysterectomy, called a Wertheim's hysterectomy, is used to treat women with cancer of the cervix. (It was named after the Austrian gynaecologist who pioneered it in 1900.) This operation allows the wider removal of the tissue either side of the uterus and the removal of lymph nodes to check whether the cancer has spread. Hysterectomy is also used in the treatment of cancer of the uterus or ovary.
Over the last 20 years interest has grown in minimal access or ‘keyhole’ surgery. This led Dr Reich, a gynaecologist in Pennsylvania, to perform the first laparoscopic hysterectomy in 1989. This operation allows the easier removal of the ovaries vaginally at the time of the hysterectomy and the removal of a larger uterus vaginally. Total and subtotal laparoscopic hysterectomies have also been described, although none of these are commonly performed at the present time.
Surgical removal of the uterus, either completely (total hysterectomy) or leaving the cervix (subtotal hysterectomy). It is performed in the presence of cancer or a benign fibroid tumour if the fibroid is large or rapidly growing, causes excessive bleeding or discomfort, or seems to be breaking down. Hysterectomy may also be performed after cesarean section in cases of complications such as uncontrolled bleeding, gross infection, or pelvic cancer.
hysterectomy (hĭstərĕk'təmē) , surgical removal of the uterus. A hysterectomy may involve removal of the uterus only or additional removal of the cervix (base of the uterus), fallopian tubes (salpingectomy), and ovaries (oophorectomy). It may be performed through a conventional abdominal incision or through the vagina. It is performed in cases of malignant tumors, endometriosis, prolapsed uterus, or fibroids that cause bleeding and pain. An emergency hysterectomy is sometimes necessary to end uterine hemorrhaging.
Removal does not physically interfere with sexual activity, but it does eliminate the uterine contractions of orgasm. It also eliminates the possibility of childbearing and precipitates menopause in premenopausal women. Surgical removal of the ovaries eliminates their production of estrogen and progesterone along with these hormones's protective benefits to the heart, bones, and skin.
Some women's health advocates have questioned what they feel is the overuse of hysterectomy in the United States, where it is the second most common surgical procedure. Some studies have judged that up to 25% of hysterectomies performed in the United States are unnecessary and that more conservative treatments (laparoscopic surgery, hormone therapy, or simple removal of fibroids) would suffice in these cases.
A hysterectomy (from Greekὑστέραhystera "womb" and εκτομίαektomia "a cutting out of") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions.[1] Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons. [2]
Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes her hormonal levels considerably, so the surgery is normally recommended for only a few specific circumstances:
As a prophylactic treatment for those with either a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from such cancers
Severe and intractable endometriosis (overgrowth of the uterine lining) and/or adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall) after pharmaceutical and other non-surgical options have been exhausted
Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta accreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive postpartum bleeding
Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids with reconstruction of the uterus, has been performed for over a century.[specify]
The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age.
Some women's health education groups such as the Hysterectomy Educational Resources and Services (HERS) Foundation seek to inform the public about the many consequences and alternatives to hysterectomy, and the important functions that the female organs have all throughout a woman's life. [3][4][5]
According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60.[6] There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.[6]
In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are removed in about 20% of hysterectomies.[7]
Indications
Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.[8]
Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); uterine artery embolization, high intensity focused ultrasound or watchful waiting. In mild cases, no treatment is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4 cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4 cm, and fibroids located in other parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.
Technique
Hysterectomy can be performed in different ways. Traditionally, it has been performed via either abdominal incision (total abdominal hysterectomy, or TAH, via laparotomy) or vaginal canal (vaginal hysterectomy). However, the vaginal route cannot be used if the "supracervical" procedure is desired. With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because the procedure is much less invasive and the post-operative recovery is much faster with fewer complications. LAVH is performed such that the final removal of the uterus (with or without removal of the ovaries) was via the vaginal canal. Thus, LAVH is also a total hysterectomy, namely, the cervix must be removed with the uterus. The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. Total laparoscopic hysterectomy (TLH) involves disconnecting the uterus, and other structures as needed, by operating only through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports." Then all tissue to be removed is passed through the vagina or through the tiny half-inch abdominal incisions. For large multifibroid uteri total laparoscopic hysterectomy can still be performed with the use of in situ morcellation by gynecologists who are experienced in laparoscopic techniques.[9] Total abdominal hysterectomy can be safely replaced by total laparoscopic hysterectomy if the surgeon has the required laparoscopic skills and the intention to do it.[10]
Most hysterectomies in the United States and in most parts of the world are done via laparotomy. A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.
Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated, without data, that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings[11]:
1. There was no difference in the rates of incontinence, constipation or measures of sexual function.
2. Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates.
3. Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy.
4. There was no difference in the rates of other complications, recovery from surgery, or readmission rates.
In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse[12]. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smears to check for cervical dysplasia or cancer.
Types of Hysterectomy:
Radical hysterectomy : complete removal of the uterus, upper vagina, and parametrium
Subtotal hysterectomy : removal of the fundus of the uterus, leaving the cervix in situ
Total hysterectomy : Complete removal of the uterus including the corpus and cervix
Benefits
Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylacticoophorectomy.[13] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only hormone replacement therapy (HRT) to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT.[14]
The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.[15]
One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[16]. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome.[citation needed] Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder[17].
Risks and side effects
The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average.[18] This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally-occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce natural female hormones even after the cessation of menstrual periods.
When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies.[19][20][21][22][23][24] This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.
Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.[specify]
Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact.[25] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[26] while increased testosterone levels in women are associated with a greater sense of sexual desire.[27] Hysterectomy has also been found to be associated with increased bladder function problems, such as urinary incontinence.[28] Hysterectomies have also been linked with higher rates of heart disease and weakened bones.[29]
Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.[30]
Alternatives
Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding (DUB) may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed and the uterus reconstructed. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically.[31] Various other techniques (such as uterine artery embolization, Myolysis, radio frequency ablation, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.[32]
Uterine artery embolization is described as a minimally-invasive procedure to control bleeding in conditions like postpartum hemorrhage[34] and for treatment of uterine fibroids. It is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally-invasive procedures under radiological guidance. The radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter-like a piece of spaghetti) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (fluoroscopy). A mass of microspheres or polyvinyl alcohol (PVA) material (an embolus) is injected into the uterine arteries in order to block the flow of blood through those vessels. The embolic material then becomes permanently lodged in the uterine arteries making this an irreversible procedure. Significant adverse effects resulting from uterine artery embolization have been reported in the medical literature[1][2]. Death from embolism, or septicemia (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure.[35] Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for administration of intravenous antibiotics. [36] Misembolization from microspheres or polyvinyl alcohol (PVA) particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body. [37] Ovarian damage resulting from embolic material migrating to the ovaries. Loss of ovarian function, infertility[38], and loss of orgasm. Failure of embolization surgery- continued fibroid growth, regrowth within four months. Menopause - iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels. [39] Post-Embolization Syndrome (PES) - characterized by acute and/or chronic pain, temperatures of up to 102 degrees, malaise, nausea, vomiting and severe night sweats. Foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus. Hysterectomy due to infection, pain or failure of embolization. [40] Severe, persistent pain, resulting in the need for morphine or synthetic narcotics. [41] Hematoma, blood clot at the incision site. Vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion (fibroids pushing out through the vagina), unsuccessful fibroid expulsion (fibroids trapped in the cervix causing infection and requiring surgical removal), life threatening allergic reaction to the contrast material, and uterine adhesions.
Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of sex reassignment surgery for transmen. Some in the FTM community prefer to have this operation along with hormone replacement therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition.[42] Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy)[43] to avoid undergoing multiple separate operations.[44]
^ Roopnarinesingh R, Fay L, McKenna P (2003). "A 27-year review of obstetric hysterectomy". Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology23 (3): 252–4. PMID 12850853.
^ Lethaby, A, Ivanova, V, Johnson, NP. Total versus subtotal hysterectomy for benign gynecological conditions. Cochrane Database Syst Rev 2006; CD004993
^ Thakar, R, Ayers, S, Clarkson, P, Stanton, S, et aI. Outcomes after Total versus Subtotal abdominal hysterectomy. N Engl J Med 2002; 347;1318
^ Farquhar CM, Sadler L, Harvey SA, Stewart AW (2005). "The association of hysterectomy and menopause: a prospective cohort study". BJOG : an international journal of obstetrics and gynaecology112 (7): 956–62. doi:10.1111/j.1471-0528.2005.00696.x. PMID 15957999.
^ Kelsey JL, Prill MM, Keegan TH, Quesenberry CP, Sidney S (2005). "Risk factors for pelvis fracture in older persons". Am. J. Epidemiol.162 (9): 879–86. doi:10.1093/aje/kwi295. PMID 16221810.
^ van der Voort DJ, Geusens PP, Dinant GJ (2001). "Risk factors for osteoporosis related to their outcome: fractures". Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA12 (8): 630–8. PMID 11580076.
^ Watson NR, Studd JW, Garnett T, Savvas M, Milligan P (1995). "Bone loss after hysterectomy with ovarian conservation". Obstetrics and gynecology86 (1): 72–7. doi:10.1016/0029-7844(95)00100-6. PMID 7784026.
^ Durães Simões R, Chada Baracat E, Szjenfeld VL, de Lima GR, José Gonçalves W, de Carvalho Ramos Bortoletto C (1995). "Effects of simple hysterectomy on bone loss". São Paulo medical journal = Revista paulista de medicina113 (6): 1012–5. PMID 8731286.
^ Hreshchyshyn MM, Hopkins A, Zylstra S, Anbar M (1988). "Effects of natural menopause, hysterectomy, and oophorectomy on lumbar spine and femoral neck bone densities". Obstetrics and gynecology72 (4): 631–8. PMID 3419740.
^ Menon RK, Okonofua FE, Agnew JE, et al. (1987). "Endocrine and metabolic effects of simple hysterectomy". International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics25 (6): 459–63. PMID 2892704.
^ Laughlin GA, Barrett-Connor E, Kritz-Silverstein D, von Mühlen D (2000). "Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: the Rancho Bernardo Study". J. Clin. Endocrinol. Metab.85 (2): 645–51. doi:10.1210/jc.85.2.645. PMID 10690870.
^ Jassal SK, Barrett-Connor E, Edelstein SL (1995). "Low bioavailable testosterone levels predict future height loss in postmenopausal women". J. Bone Miner. Res.10 (4): 650–4. PMID 7610937.
^ Segraves R, Woodard T (2006). "Female hypoactive sexual desire disorder: History and current status". The journal of sexual medicine3 (3): 408–18. doi:10.1111/j.1743-6109.2006.00246.x. PMID 16681466.
^ McPherson K, Herbert A, Judge A, et al. (2005). "Self-reported bladder function five years post-hysterectomy". Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology25 (5): 469–75. doi:10.1080/01443610500235170. PMID 16183583.
^ Vashisht A, Studd JW, Carey AH (2000). "Fibroid Embolisation: A Technique Not Without Significant Complications". British Jounral of Obstetrics & Gynecology107: 1166–1170.
^ de Block S, de Bries C, Prinssen HM (2003). "Fatal Sepss after Uterine Artery Embolization with Microspheres". Journal of Vascular and Interventional Radiology14 (6): 779–783.
^ Dietz DM, Stahfeld KR, Bansal SK (2004). "Buttock Necrosis After Uterine Artery Embolization". Obstetrics & Gynecology104: 1159–1161.
^ Robson S, Wilson K, David M (1999). "Pelvic Sepsis Complicating Embolization of a Uterine Fibroid". The Australian and New Zealand Journal of Obstetrics and Gynaecology39: 516–517. doi:10.1111/j.1479-828X.1999.tb03150.x.
^ Common AA, Mocarski E, Kolin A (2001). "Leiomyosarcoma". Journal of Vascular & Interventional Radiology12: 1449–1452.
^ Soulen MC, Fairman RM, Baum R (2000). "Embolization of the Internal Iliac Artery: Still More to Learn". Journal of Vascular & Interventional Radiology11: 543–545. doi:10.1016/S1051-0443(07)61604-2.
