September 14, 2011

Hysterectomy means the surgical removal of the uterus, or womb. According to the latest statistics from the Centers for Disease Control and Prevention (CDC; published in 2000), about 600,000 hysterectomies are performed annually, making it the second most common operation among women of reproductive age (cesarean section is first). Approximately 20 million U.S. women have had a hysterectomy. Half of all hysterectomies are in women under 45 years. The overall rate of hysterectomy is 5.5 per 1,000 women and half of all hysterectomies are accompanied by removal of the tubes and ovaries also.


The internal female genitalia consists of the uterus, the fallopian tubes, the ovaries, and the supporting ligaments and blood vessels. The cervix, which resides in the upper vagina, is connected to the lower part of the uterus. The endometrium is the tissue lining the uterine cavity.


Commonly, a hysterectomy is referred to as either a “complete” or a “partial.” These terms are nonmedical. A “complete” hysterectomy means that the uterus, the cervix, the tubes, and the ovaries have all been removed. There is no single medical term to describe this. Instead, the equivalent medical terms are a total hysterectomy, which means removal of the uterus and the cervix, combined with a bilateral salpingooophorectomy, which means the removal of both sets of tubes and ovaries. A “partial” hysterectomy means removal of just the uterus and the cervix, and the medical term for this is a total hysterectomy. If the uterus is removed but the cervix is left in place, it is called a subtotal or supracervical hysterectomy. If the hysterectomy is performed for cervical cancer, then a radical hysterectomy might be done. This is the removal of the uterus and cervix plus additional surrounding ligaments and lymph node tissue. This is a highly specialized procedure generally performed by gynecologic oncologists.


There are many different ways that a hysterectomy can be performed, including abdominal, vaginal, laparoscopic, or a combination of these.

Most hysterectomies are performed using an abdominal incision. Removal of the uterus, cervix, tubes, and ovaries using an abdominal incision is a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

A hysterectomy can also be performed entirely through the vagina. A total hysterectomy performed though the vagina is abbreviated TVH (total vaginal hysterectomy). If the tubes and ovaries are also removed, the procedure is called a TVH-BSO (total vaginal hysterectomy-bilateral salpingo-oophorectomy). The vaginal approach is sometimes combined with a laparoscopy. Laparoscopy is when small incisions are made, usually in the area of the belly button and the lower abdominal area. A narrow scope attached to a video monitor is inserted and very narrow instruments are used to perform surgery. If laparoscopy is combined with a vaginal hysterectomy, it is called a laparoscopicassisted vaginal hysterectomy.


Hysterectomy is considered major surgery and there are potential risks to keep in mind. These risks include, but are not limited to, risks from anesthesia, development of an infection, development of a blood clot in the circulation (an embolism), injury to another internal organ such as the bladder, intestines, or ureter (the tube connecting the kidney to the bladder), heavy loss of blood possibly requiring a transfusion, development of a fistula (connection between bladder and vagina or rectum and vagina), development of internal scar tissue that can lead to bowel obstruction (even years later), and complications during recovery, which may necessitate a second operation. Despite the variety of possible complications, in reality the risk of serious complications from hysterectomy is about 1%.

Another risk is that the procedure that is ultimately performed may not be the same that is begun. For example, some patients start out with a planned laparoscopic subtotal hysterectomy, but because of unanticipated developments end up with a total abdominal hysterectomy, considerably lengthening their expected recovery period.

Recovery from hysterectomy depends on the exact procedure used. In uncomplicated cases, generally expect full recovery to be 6-8 weeks for abdominal hysterectomy, 4-6 weeks for vaginal hysterectomy, 24 weeks for laparoscopic-assisted vaginal hysterectomy, and 1-2 weeks for laparoscopic supracervical hysterectomy. Keep in mind that these are average estimates and that individuals vary quite a bit in their recovery from surgery.


The most common indications for performing hysterectomy are fibroids, endometriosis, and uterine prolapse. These three indications account for almost 75% of all hysterectomies. Other indications are chronic pelvic pain, heavy menstrual bleeding, and uterine or ovarian cancer.


Depending on the medical problem, there are other procedures or treatments that can sometimes prevent the need for a hysterectomy. These include endometrial ablation, uterine artery embolization, and hormone therapy.

Endometrial ablation is a procedure that can be used when the problem is longstanding heavy menstrual bleeding and there are no fibroids. The endometrium is the lining of the uterine cavity. Menstrual bleeding occurs when this lining is shed during a menstrual period. Normally, this lining regrows every month. Ablation means that this lining is mostly or completely destroyed. Then it will not grow back, and very little menstrual bleeding will occur. There are many safe and effective techniques for performing endometrial ablation. These include using a balloon inside the uterine cavity filled with hot water, irrigation of the uterine cavity with heated water, using electrical cautery, and using a freezing technique.

Uterine artery embolization (UAE) is a procedure that can be used when the problem is either large fibroids causing discomfort or heavy menstrual bleeding. UAE is performed by specially trained interventional radiologists and is usually an outpatient procedure. Using x-ray guidance, a narrow catheter is inserted into a blood vessel in the groin and then carefully advanced until it is in an artery directly providing blood to a fibroid. Then a substance is injected consisting of small synthetic particles (called microspheres) that cause the artery to become blocked. This cuts off the blood flow to the fibroids, resulting in their shrinkage (loss of blood causes the cells to die), which usually results in greatly reduced bleeding, often preventing the need for a hysterectomy.

Hormone therapy can be used when the main problem is longstanding heavy and/or irregular bleeding with or without fibroids or pelvic pain associated with endometriosis. In many cases women with irregular bleeding, even if they also have fibroids, can be placed on hormones (such as low-dose birth control pills) to regulate their bleeding, preventing the need for hysterectomy. Many insurance companies will not pay for hysterectomy if the indication is abnormal bleeding, unless the patient has been shown to have tried hormone therapy first and failed it. Some patients have conditions where they cannot safely take hormones, so this approach is not always feasible. Birth control pills can also help reduce the pain from endometriosis, in some cases preventing the need for hysterectomy.


Many people have misconceptions about hysterectomy. These are addressed below in a question and answer format.

Q: Doesn’t hysterectomy always lead to menopause? After all, the periods are gone.

A: Hysterectomy does lead to elimination of menstrual periods. However, if the woman is not in menopause at the time of the hysterectomy, and if her ovaries are not removed, then she will not experience menopause after the hysterectomy. Menopause will occur naturally, when her ovaries stop producing estrogen, about age 51. If the ovaries are removed at the time of hysterectomy in a woman who is not yet in menopause, she will become menopausal, referred to as a surgical menopause. Estrogen therapy is usually given postoperatively to minimize the side effects of surgical menopause.


Q: I heard that after a hysterectomy, women lose interest in sex and no longer enjoy sex.

A: The capacity for female orgasm does not change after hysterectomy because the clitoris, which provides most of the nerve stimulation leading to orgasm, is not involved in the hysterectomy. Studies have shown that some women do have difficulties with their sex life after hysterectomy, but only a small percentage. Most women report that orgasm feels “different” due to the loss of the uterus, since the uterus does cramp with orgasm, but that overall the sensation is not less pleasurable. If the ovaries have been removed during the hysterectomy, then the woman’s sex life may change because she has been abruptly placed into menopause. This risk can be greatly reduced if supplemental estrogen is begun shortly after the hysterectomy.


Q: My husband says that because of my hysterectomy, I am no longer a woman.

A: Your husband deserves a good, swift kick in the groin. Hopefully, a woman and her husband have discussed issues such as this prior to the surgery. Husbands need to go with their wives to the doctor before the surgery to ask questions, express concerns, and learn all that they can about the reasons for the surgery and what to expect afterward.

SEE ALSO: Cervical cancer, Dilation and curettage, Endometriosis, Laparoscopy, Menstrual cycle disorders, Sexual organs, Ultrasound, Uterine cancer, Uterine fibroids, Vaginal bleeding


Category: H