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.
(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 the Greek word histera, meaning "womb") 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"). In
2005, there were 617,000 hysterectomies performed in the USA. During a hysterectomy, in the last
decade, an average of 73% of surgeons removed ovaries and fallopian tubes during the same
operation, a procedure known technically as bilateral salpingo-oophorectomy and less
formally as ovariohysterectomy.
This surgery is exclusively performed on those who are chromosonally female. Removal of the uterus renders the patient unable
to bear children (as does removal of ovaries and fallopian tubes), and changes their hormonal levels considerably, so the surgery
is normally recommended for only a few specific diseases and circumstances:
Certain types of reproductive system cancers (uterine, cervical, ovarian);
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 intractible 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;
Female to male transsexuals, a.k.a. "transmen", as
part of their gender transition.
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 that leaves the uterus
intact, 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. 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 genetic females can be expected to have
a hysterectomy by age 60.[1] There are currently an estimate of 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.[1]
Both the uterus and the ovaries have important life-long functions in the maintenance of a woman's health, and there is never
an age or a time when the uterus and ovaries are not essential to health and well-being.[2] Additionally, the removal of otherwise healthy ovaries is a form of
castration because it involves removal of the female gonads[3], which many opponents and even some supporters of hysterectomy[4] do not support.
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 (overgrowth of the uterine lining), 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.[5]
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); or uterine artery embolization. In mild cases, no treatment
is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4cm, 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
Most hysterectomies in the United States and in most parts of the world are done via laparotomy, sometimes called the "open technique" or "open hysterectomy". The abdominal wall is sliced open,
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. An increasing number of uterine removals not
involving removal of the ovaries are done through the cervix ("supracervical"), reducing the size of the incision and the
recovery time as well. In this technique, the uterus is accessed either via the vaginal canal or through an incision inside the
navel (or sometimes both, depending on the uterine problem being addressed by the surgery). The uterus itself is detached at the
top of the cervical neck and pulled back through the vaginal canal (or out through the navel incision if fibroids or other
indications prevent it from being able to pass through the cervix) , after which the cervical neck is stitched shut. This
provides the patient with a comparatively normal-length vagina which helps provide some support to the bladder, as well as a
significantly decreased recovery time.[6] The main drawback with supracervical hysterectomy is the increased risk of cervical
prolapse due to the removal of the much stronger uterus (which would normally support the organs around it to prevent prolapse).
This surgery also does not eliminate the possibility of cervical cancer, since the
cervix itself is left in place; those who have undergone this procedure must still have regular PAP smears to check for cervical
cancer.
The newest technique is robotic-assisted laparoscopic hysterectomy. Instead of a large incision, a few tiny incisions are made
through which thin instruments are passed. This new technique significantly reduces scarring, pain, healing time, blood loss, and
duration of hospital stay when compared to open technique.
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.[7] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows
estrogen-only 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.[8]
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 intractible gynecological problems that had not responded to non-surgical intervention,
hysterectomy may be beneficial to their overall health and wellness.[4]
One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[9]. This is particularly true for women who
have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome. 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[10].
Risks and side effects
The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier
than average.[11] 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. Although
sometimes referred to as surgical menopause, that is incorrect and misleading because it implies that its effects are the same as
with natural menopause. In fact, those who are naturally menopausal have the benefit of the functions of their uterus and ovaries
(which continue to produce small amounts of hormones even after natural menopause), while those who undergo hysterectomy and/or
removal of the ovaries have a permanent loss of their functions.
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.[12][13][14][15][16][17] 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.
Many women also find that their sex drive is reduced or eliminated after hysterectomy, especially if an oophorectomy was part
of the procedure.[citation needed] 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.[18] Reduced
levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[19] while conversely, increased
testosterone levels in women are associated with a greater sense of sexual desire.[20] Hysterectomy has also been found to
be associated with increased bladder function problems, such as incontinence.[21]
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[22].
Alternatives
Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding 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 without removing the uterus. This procedure is called a
"myomectomy." A myomectomy may be performed through an open incision or, in appropriate
cases, laparoscopically.[23] Various other techniques (such
as Fibroid Artery Embolization, Myolysis, HALT, 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.[24]
Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of Transman (sometimes called "female-to-male" or "FTM") gender
reassignment surgery. Some in the transman community prefer to have this operation along
with testosterone 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.[26] 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)[27] to avoid undergoing multiple separate operations.[28] Many FTM never complete "bottom surgery" for a number of reasons, and
instead choose to have their breasts and reproductive organs removed to eliminate all outward appearances of their
femininity.[29]
References
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^ Rebbeck TR, Lynch
HT, Neuhausen SL, et al (2002). "Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations". New England Journal of Medicine346 (21): 1616-22. DOI:10.1056/NEJMoa012158. PMID 12023993. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. PMID 10690870. Retrieved on
2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
^ 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. Retrieved on 2007-06-07.
