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Definition

Hysterectomy is the surgical term for removal of the uterus. This procedure results in the inability to become pregnant (called sterility). It may be done through the abdomen or the vagina.

Hysterectomy is a common surgery in the US. About 600,000 are done each year.

Depending on the condition, there are alternatives to hysterectomy. Other options may include nonsurgical approaches and less invasive procedures, such as endometrial ablation.

Parts of the Body Involved

• Partial or subtotal hysterectomy—Removal of the uterus (without removing the cervix)
• Total, complete, or simple hysterectomy—Removal of the uterus and cervix (the opening of the uterus leading to the vagina)
• Radical hysterectomy—Removal of the uterus, ovaries, fallopian tubes, upper part of the vagina, and the pelvic lymph nodes
• Salpingo-oophorectomy—Removal of the ovaries and fallopian tubes (may be combined with any of the above procedures)

Reasons for Procedure

Cancer

A hysterectomy is performed in almost all cases of uterine cancer that have not spread beyond the uterus. Cancers affecting the pelvic organs account for only about 10% of all hysterectomies. These include:

• Endometrial cancer
• Uterine sarcoma
• Cervical cancer
• Ovarian cancer
• Cancer of the fallopian tubes

Other kinds of treatment (eg, radiation or hormonal therapy) may be used as well.

Other Reasons

While controversial, this procedure may be done to treat uterine conditions when other treatments have not worked. These conditions include:

• Uterine fibroids (myomas)—common, benign (noncancerous) tumors that grow in the muscle of the uterus.
  • Leading cause for hysterectomies
  • Can cause no symptoms and may not need treatment, usually shrink after menopause
  • Sometimes cause heavy bleeding and pain
  • Other treatments are available, which are important if you want to have children
• Endometriosis—a benign condition in which endometrial tissue (the inside lining of the uterus) begins to grow on the outside of the uterus and on nearby organs (ie, ovaries, fallopian tubes, and other organs)
  • Second leading cause (usually done when other treatments have failed)
  • Most common in women in their 30s and 40s who have never been pregnant
  • May cause painful periods, abnormal vaginal bleeding, and sometimes infertility
  • Usually not a problem after menopause
  • May be treated with hormones and medicines that lower their levels of estrogen
  • Surgery may be done to remove patches of endometrial tissue
• Uterine prolapse—a benign condition in which the uterus moves from its usual place down into the vagina
  • Due to weak and stretched pelvic ligaments and tissues
  • Can affect other organs (eg, bladder)
  • May be caused by childbirth, obesity , and loss of estrogen after menopause
  • Treatment includes estrogen therapy, Kegel exercise to strengthen pelvic floor muscles, or use of a pessary (plastic ring inserted into the vagina to help support the uterus)
  • In severe cases, surgery is done
• Other reasons: chronic pelvic pain, heavy bleeding during or between periods, and chronic pelvic inflammatory disease (PID)

Explore your options and ask many questions before having to a hysterectomy.

Salpingo-Oophorectomy

In many cases, when a hysterectomy is done, the doctor also does a salpingo-oophorectomy. This involves removing the ovaries and fallopian tubes. Ask your doctor why you need this done. If you have cancer or are at high risk, for example, removing the ovaries may be necessary.

If you are having this surgery because of fibroids and you are premenopausal, get all the information that you need before making a decision. Removing your ovaries will cause menopause to happen right away. Also, if you are postmenopausal, your ovaries still produce small amounts of the hormone androgen.

Risk Factors for Complications During the Procedure

• Obesity
• Smoking
• Iron-deficiency anemia
• Heart or lung disease
• Diabetes
• Previous pelvic surgery or serious infection
• Use of prescription and nonprescription drugs during the past month

What to Expect

Prior to Procedure

Your doctor will likely do the following:

• Blood and urine tests
• X-ray of abdomen and kidneys
• Pelvic ultrasound—a test that uses sound waves to visualize the inside of the body
• Dilation and curettage (D&C)—surgical removal of tissue from the lining of the uterus

In the days leading up to the procedure:

• Arrange for a ride home and for help at home.
• Take enemas to clean your intestinal track.
• The night before, eat a light meal and do not eat or drink anything after midnight.
• If instructed, take antibiotics.

Anesthesia

General or local anesthesia

Description of the Procedure

Your abdominal and pelvic areas will be shaved. IV fluids and medications, a bladder catheter, and a blood transfusion (rarely) may be required. Other organs and tissues may also be removed or repaired.

There are three different methods:

Abdominal Hysterectomy

A cut is made in the lower abdomen to expose the tissue and blood vessels that surround the uterus and cervix. The tissue is cut, and the blood vessels are tied off to remove the uterus. The area is closed with stitches that dissolve. The uterus is removed from the top of the vagina. This area is then closed to prevent infection and to keep the intestines from dropping down.

	Abdominal Hysterectomy
	© 2008 Nucleus Medical Art, Inc.

Vaginal Hysterectomy

The vagina is stretched and kept open by special instruments. No outside incisions are needed. The doctor does make an internal incision at the top of the vagina around the cervix. The uterus and cervix are cut free, and the connecting blood vessels are tied off. The uterus and cervix are removed through the vagina. This area is then closed to prevent infection and to keep the intestines from dropping down.

	Vaginal Hysterectomy
	© 2008 Nucleus Medical Art, Inc.

Laparoscopically-Assisted Vaginal Hysterectomy (LAVH)

A small cut is made near the navel to insert a laparoscope. This small device allows the doctor see the pelvic organs. The abdomen is inflated with carbon dioxide to better view the organs to give more room. Other small cuts are made in the abdomen. Through these cuts, instruments are inserted. A cut is also made where the uterus joins the vagina. The bladder and rectum are gently pushed off the uterus, which is removed through the cut in the vagina. The vagina is then closed to prevent infection and to keep the intestines from dropping down. The areas are then stitched.

With each procedure, a vaginal "packing" is placed in the vagina. This will be removed after 1-2 days.

After Procedure

The tissue is sent to a lab to be analyzed. In the recovery room, you will have IV fluids and medications.

How Long Will It Take?

1-3 hours

Will It Hurt?

Anesthesia prevents pain during surgery. Expect some pain, pelvic fullness, bloating, and vaginal bleeding or discharge during the first few days. You'll be given pain medication.

Possible Complications

• Reactions to anesthesia
• Pain
• Infection
• Bleeding
• Fatigue
• Injured pelvic organs (bowel and/or bladder)
• Urinary incontinence (problems controlling your urine)
• Loss of ovarian function and early menopause
• Depression
• Sexual dysfunction

Average Hospital Stay

• Abdominal hysterectomy: 3-5 days
• Vaginal hysterectomy: 1-2 days

Postoperative Care

Recovery from abdominal hysterectomy usually takes 6-8 weeks. Recovery time will be quicker for the other procedures. On the morning after surgery, you will probably have the catheter and IV removed.

While recovering, your doctor may ask you to:

• On the first night, sit up in bed and walk a short distance.
• Keep the incision area clean and dry.
• Slowly increase your activities. Begin with light chores, short walks, and some driving. Depending on your job, you may be able to return to work.
• During the first two weeks, rest and avoid lifting.
• Take showers instead of baths.
• To promote healing, eat a diet rich in fruits and vegetables. Ask your doctor if you need to take iron.
• Try to avoid constipation. Eat high-fiber foods, drink water, and use stool softeners if needed.
• Wait six weeks before taking a bath and resuming sexual activity.
• Ask your doctor when you can douche and use tampons.
• Also ask about Kegel exercises.
• If you still have a cervix, get a Pap smear on a regular basis.

Outcome

Physical

Removing the uterus ends abnormal bleeding, reduces pelvic pressure, and removes fibroids. Some other conditions, such as cancer, may continue or return.

You will no longer have monthly periods and can no longer get pregnant. Birth control is not needed. If you still have ovaries, the eggs will dissolve in your abdomen.

If the ovaries are removed, menopause happens right away. Your doctor may have you take estrogen replacement therapy.

Emotional

Some women have strong reactions, including depression, in response to the loss of their uterus. Talk to your doctor about your feelings.

Sexual

Some women notice a change in their sexual response. Because the uterus has been removed, uterine contractions you may have felt during orgasm will no longer occur. If the ovaries have been removed, vaginal dryness may be a problem. This can be relieved with estrogen.

Some women have an increase in sexual enjoyment. This may be because they no longer feel pain from the condition and they no longer have to worry about pregnancy.

Call Your Doctor If Any of the Following Occurs

• Fever
• Dizziness or fainting
• Nausea and vomiting
• Short of breath
• Heavy bleeding
• Leakage from the incision or the incision opens up
• Pain when you urinate
• Swelling, redness, or pain in your leg

RESOURCES:

National Uterine Fibroids Foundation
http://www.nuff.org/

Women's Health.gov
http://www.4woman.gov/

CANADIAN RESOURCES

The Society of Obstetricians and Gynaecologists of Canada
http://www.sogc.org/index_e.asp/

Women's Health Matters
http://www.womenshealthmatters.ca/index.cfm/

References:

American College of Obstetricians and Gynecologists website. Available at: http://www.acog.org . Accessed October 14, 2005.

American Medical Association website. Available at: http://www.ama-assn.org/ . Accessed October 14, 2005.

Bren L. Alternatives to hysterectomy: new technologies, more options. US Food and Drug Administration website. Available at: http://www.fda.gov/FDAC/features/2001/601_tech.html . Accessed February 20, 2008.

Hysterectomy. Women's Health.gov website. Available at: http://www.4woman.gov/faq/hysterectomy.htm. Updated July 2006. Accessed October 14, 2005.

Women's reproductive health: hysterectomy. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/reproductivehealth/WomensRH/Hysterectomy.htm .Updated January 2008. Accessed February 20, 2008.

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