Hysterectomy

Hysterectomy is a way of treating problems that affect the uterus. Many conditions can be cured with hysterectomy. Because it is major surgery, you may want to explore other treatment options first. For conditions that have not responded to other treatments, a hysterectomy may be the best choice. You should be fully informed of all options before you decide.

This pamphlet explains:

• reasons for having a hysterectomy
• how hysterectomy is performed
• risks of hysterectomy
• recovery after surgery

Reasons for Hysterectomy

Hysterectomy is the surgical removal of the uterus. It is the second most common type of major surgery performed on women of childbearing age (the most common is cesarean delivery). Hysterectomy may be done to treat many conditions that affect the uterus:

• Uterine fibroids
• Endometriosis
• Pelvic support problems (such as uterine prolapse)
• Abnormal uterine bleeding
• Cancer
• Chronic pelvic pain

Hysterectomy is major surgery, and as with any major surgery, it carries risks. For many of the problems listed previously, other treatments can be tried first. After hysterectomy, you no longer are able to become pregnant. Discuss all of the treatment options for your specific condition with your health care provider.

There are several kinds of hysterectomy:

• Total hysterectomy—The entire uterus, including the cervix, is removed. In a total radical hysterectomy, the entire uterus and support structures around the uterus are removed. It often is done to treat certain types of cancer.
• Supracervical (also called subtotal or partial) hysterectomy—The upper part of the uterus is removed but the cervix is left in place.
• Hysterectomy with removal of the fallopian tubes and ovaries—A hysterectomy does not include removal of the ovaries and fallopian tubes. Surgery to remove the ovaries is called an oophorectomy. Surgery to remove the fallopian tubes is called a salpingectomy. One or both of these procedures can be done at the same time as a hysterectomy. Sometimes, only one ovary or tube is removed.

How Hysterectomy Is Performed

A hysterectomy can be done in different ways. The way a hysterectomy is performed depends on the reason for the surgery and other factors, including your general health. You and your doctor will decide which route is safest and best for your situation (see box “Comparing the Different Ways Hysterectomy Is Performed”).

Sometimes it is not possible to know before the surgery how the hysterectomy will be performed. In these cases, the decision is made after the surgery begins and the surgeon is able to see whether other problems are present.

Vaginal Hysterectomy

In a vaginal hysterectomy, the uterus is removed through the vagina. With this type of surgery, you will not have an incision (cut) on your abdomen. Because the incision is inside the vagina, the healing time may be shorter than with abdominal surgery. There may be less pain during recovery. Vaginal hysterectomy causes fewer complications than the other types of hysterectomy and is a very safe way to remove the uterus. It also is associated with a shorter hospital stay and a faster return to normal activities than abdominal hysterectomy.

A vaginal hysterectomy is not always possible. For example, women who have adhesions from previous surgery or who have a very large uterus may not be able to have this type of surgery.

Abdominal Hysterectomy

In an abdominal hysterectomy, the doctor makes an incision through the skin and tissue in the lower abdomen to reach the uterus. The incision may be vertical or horizontal.

This type of hysterectomy gives the surgeon a good view of the uterus and other organs during the operation. This procedure may be chosen if you have large tumors or if cancer may be present. Abdominal hysterectomy may require a longer healing time than vaginal or laparoscopic surgery, and it usually requires a longer hospital stay.

Laparoscopic Hysterectomy

In a laparoscopic hysterectomy, a laparoscope is used to guide the surgery. A laparoscope is a thin, lighted tube with a camera that is inserted into the abdomen through a small incision in or around the navel. It allows the surgeon to see the pelvic organs on a screen. Additional small incisions are made in the abdomen for other instruments used in the surgery.

There are three kinds of laparoscopic hysterectomy:

1. Total laparoscopic hysterectomy—A small incision is made in the navel for the laparoscope, and one or more small incisions are made in the abdomen for other instruments. The uterus is detached from inside the body. It then is removed in small pieces through the incisions, or the pieces are passed out of the body through the vagina. If only the uterus is removed and the cervix is left in place, it is called a supracervical laparoscopic hysterectomy.
2. Laparoscopically assisted vaginal hysterectomy (LAVH)—A vaginal hysterectomy is done with laparoscopic assistance. For example, the ovaries and fallopian tubes may be detached using laparoscopy, and then the uterus is detached and all of the organs are removed through the vagina.
3. Robot-assisted laparoscopic hysterectomy—Some surgeons use a robot attached to the laparoscopic instruments to help perform the surgery. Experience using this technology is limited. More information is needed to see if robotic surgery has added benefits over the other methods.

Laparoscopic surgery has some benefits over abdominal surgery:

• The incisions are smaller, and there may be less pain.
• The hospital stay after laparoscopic surgery may be shorter.
• You may be able to return to your normal activities sooner.
• The risk of infection is lower.

There also are disadvantages. It often takes longer to perform laparoscopic surgery compared with abdominal or vaginal surgery. The longer you are under general anesthesia, the greater the risks for certain complications. Also, there is an increased risk for bladder injury in this type of surgery.

What to Expect

It is helpful to know what to expect before any major surgery. You will need to have a physical exam a few weeks before your surgery. Also, you may need lab tests. Depending on your health and your age, a chest X-ray or electrocardiography (ECG) may need to be done. Your doctor may tell you to take a laxative and to eat lightly the day before. On the day of your surgery, the following things may happen:

• A needle is placed in your arm, wrist, or hand. It is attached to a tube called an intravenous (IV) line that will supply your body with fluids, medication, or blood.
• You will be given an antibiotic to prevent infection.
• Special stockings or devices may be placed on your lower legs to prevent deep vein thrombosis (DVT). This condition is a risk with any surgery. Women at high risk of DVT may be given a drug to prevent blood clots from forming in the legs.
• Monitors will be attached to your body before anesthesia is given. You may be given general anesthesia, which puts you to sleep, or regional anesthesia, which blocks out feeling in the lower part of your body.
• Pubic hair may be clipped. You may be awake or asleep while this is done.
• Before you are given anesthesia, you likely will be asked to state your name, the type of surgery you are having, or other information. This standard procedure, called a “time-out,” is done to ensure that the right surgery is being done on the right patient.
• A thin tube called a catheter will be placed in your bladder. The catheter will drain urine from your bladder during the surgery.

Risks

Hysterectomy is one of the safest surgical procedures. But as with any surgery, problems can occur:

• Infection
• Bleeding during or after surgery
• Injury to the urinary tract or nearby organs
• Blood clots in the veins or lungs
• Problems related to anesthesia
• Death

Some problems related to the surgery may not show up until a few days, weeks, or even years after surgery. These problems include bowel blockage from scarring of the intestines or formation of a blood clot in the wound. These complications are more common after an abdominal hysterectomy.

Some people are at greater risk of complications than others. For example, if you have an underlying medical condition, you may be at greater risk for problems related to anesthesia. Your health care provider will assess your risks for complications and may take preventive measures. You should understand all of your specific risks before you have a hysterectomy and discuss any concerns you have with your health care provider.

Your Recovery

If you have a hysterectomy, you may need to stay in the hospital for a few days. The length of your hospital stay will depend on the type of hysterectomy you had and how it was performed.

You will be urged to walk around as soon as possible after your surgery. Walking will help prevent blood clots in your legs. You also may receive medicine or other care to help prevent blood clots.

You can expect to have some pain for the first few days after the surgery. You will be given medication to relieve pain. You will have bleeding and discharge from your vagina for several weeks. Sanitary pads can be used after the surgery.

During the recovery period, it is important to follow your health care provider’s instructions. Be sure to get lots of rest, and do not lift heavy objects until your doctor says you can. Do not put anything in your vagina during the first 6 weeks. That includes douching, having sex, and using tampons.

Work with your health care provider to plan your return to normal activities. As you recover, you may slowly increase activities such as driving, sports, and light physical work. If you can do an activity without pain and fatigue, it should be okay. If an activity causes pain, discuss it with your doctor.

Even after your recovery, you should continue to see your health care provider for routine gynecologic exams and general health care. Depending on the reason for your hysterectomy, you may still need pelvic exams and cervical cancer screening.

Effects of Hysterectomy

Hysterectomy can have both physical and emotional effects. Some last a short time. Others may last a long time. You should be aware of these effects before having the surgery.

The ovaries are the glands that produce estrogen, a hormone that affects the body in many ways. Depending on your age, if your ovaries are removed during hysterectomy, you will have signs and symptoms caused by a lack of estrogen (see box “Removal of the Ovaries During Hysterectomy”).

Physical Effects

After hysterectomy, your periods will stop. If the ovaries are left in place and you have not yet gone through menopause, they will still produce estrogen and will continue to do so until they stop functioning naturally.

Emotional Effects

It is not uncommon to have an emotional response to hysterectomy. How you will feel after the surgery depends on a number of factors and differs for each woman.

Some women feel depressed because they can no longer have children. If depression lasts longer than a few weeks, see your health care provider. Other women may feel relieved because the symptoms they were having have now stopped.

Sexual Effects

Some women notice a change in their sexual response after a hysterectomy. Because the uterus has been removed, uterine contractions that may have been felt during orgasm will no longer occur.

Some women feel more sexual pleasure after hysterectomy. This may be because they no longer have to worry about getting pregnant. It also may be because they no longer have the discomfort or heavy bleeding caused by the problem leading to hysterectomy.

Some women wish to have a supracervical hysterectomy because they think it will have less of an impact on their sexual response compared with a total hysterectomy. Whereas sexual response is different for every woman, research comparing women who have had total hysterectomies with those who have had supracervical hysterectomies has shown that there is no difference in sexual response and orgasms in women who have had the two types of surgery.

Finally…

Hysterectomy is just one way to treat uterine problems. It is major surgery and carries some risks. For some conditions, other treatment options are available. For others, hysterectomy is the best choice. Your health care provider can help you weigh the options and make a decision.

Glossary

Adhesions: Scarring that binds together the surfaces of tissues.

Antibiotic: A drug that is used to treat infection.

Cervix: The opening of the uterus at the top of the vagina.

Cesarean Delivery: Delivery of a baby through incisions made in the mother’s abdomen and uterus.

Deep Vein Thrombosis (DVT): A condition in which a blood clot forms in a deep vein, usually in the leg.

Electrocardiography (ECG): A procedure in which the heartbeat is monitored and the results recorded as a graph.

Endometriosis: A condition in which tissue similar to that normally lining the uterus is found outside of the uterus, usually in the ovaries, fallopian tubes, and other pelvic structures.

Estrogen: A female hormone produced in the ovaries.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Fibroids: Benign (noncancerous) growths that form in the muscle of the uterus.

General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery.

Hormones: Substances produced by the body to control the functions of various organs.

Hysterectomy: Removal of the uterus.

Laparoscope: A slender, light-transmitting instrument that is used to view abdominal and pelvic organs or perform surgery.

Menopause: The time in a woman’s life when the ovaries have stopped functioning; defined as the absence of menstrual periods for 1 year.

Osteoporosis: A condition in which the bones become so fragile that they break more easily.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Pelvic Exam: A manual examination of a woman’s reproductive organs.

Regional Anesthesia: The use of drugs to block sensation in certain areas of the body.

Uterine Prolapse: A condition in which the uterus drops down into the vagina.

Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy.

Vagina: A tube-like structure surrounded by muscles leading from the uterus to the outside of the body.