Hysterectomy

Description
Hysterectomy is the surgical removal of the uterus (the female reproductive organ that houses the embryo and fetus during pregnancy). For women in the United States, hysterectomy is one of the most common major surgeries.

Types of hysterectomy
There are different types of hysterectomies.
Total hysterectomy (also called complete hysterectomy): The entire uterus (including the cervix) is removed, but the ovaries (the glands that produce female sex hormones and eggs for reproduction) and fallopian tubes (two tubes located on each side of the uterus) remain.

Total hysterectomy with bilateral salpingo-oophorectomy: The entire uterus is removed, along with the ovaries and fallopian tubes. This type of hysterectomy causes a surgical menopause.

Subtotal hysterectomy (also called supracervical hysterectomy): The body of the uterus is removed, but the stump of the cervix (the neck of the uterus) remains. Some women prefer to keep the cervix because it may play a role in sexual functioning.

Radical hysterectomy: The uterus, surrounding lymph nodes and supporting structures of the uterus are removed. This type of hysterectomy is often done to treat gynecological cancer.

Purpose/indications
Hysterectomy is done to relieve symptoms and treat various clinical conditions, including:
cancerous tumors or growths in the cervix, uterus, fallopian tubes or ovaries
uterine fibroids or other noncancerous tumors that cause symptoms
endometriosis (when endometrial tissue, the tissue that lines the uterus, grows outside the uterus)
severe or excessive uterine bleeding or bleeding that doesn't respond to conservative care
hemorrhaging (heavy bleeding) after childbirth
chronic pelvic pain
chronic or severe pelvic infection
problems associated with pelvic floor relaxation (for example, cystocele, when the bladder protrudes into the vagina; rectocele, when the rectum protrudes into the vagina; or urinary incontinence)

Patient preparation
Before surgery, you may need blood and urine tests and X-rays. The specific tests you'll need depend on your clinical condition, age and the requirements of the surgical facility. Discuss any concerns you may have about the operation with your doctor or anesthesiologist.
Your doctor may recommend avoiding aspirin and nonsteroidal anti-inflammatory medications during the week before surgery. Do not eat or drink anything after midnight on the night before the procedure. You will probably be given an enema, and your doctor may also suggest wearing compression stockings to improve circulation and prevent blood clots in your legs from developing.


Procedure
A hysterectomy can be done through the vagina or an incision in the abdomen. The surgeon's recommendation for a vaginal or abdominal hysterectomy may depend on various factors, including the type of hysterectomy to be done, your previous surgical history and the reason for the procedure.
Abdominal hysterectomy: With an abdominal hysterectomy, the uterus and possibly the ovaries and fallopian tubes are removed through an incision in the abdomen.

Advantages: The surgeon can thoroughly explore the abdominal and pelvic cavities.

Disadvantages: You will have a 4- to 6-inch abdominal scar. Compared to a vaginal hysterectomy, you'll have a longer hospital stay, more abdominal pain and a slower recovery.
Vaginal hysterectomy: With a vaginal hysterectomy, the uterus is removed through the vagina.

Advantages: You'll have no incision or visible scar and only mild to moderate abdominal pain. Compared to an abdominal hysterectomy, you're likely to have a shorter hospital stay and a quicker recovery.

Disadvantages: The surgeon has a limited surgical field, which decreases the ability to see the abdominal cavity. Certain women may not have enough room in their vaginal areas for this surgery (such as women who have not had sex or have never delivered a child), making them unsuitable candidates for this type of hysterectomy.
Laparoscopically assisted vaginal hysterectomy: This type of procedure is done with a laparoscope (a thin tube equipped with a camera lens and light used to see the inside of a hollow organ or cavity). The laparoscope and other small instruments are passed through small incisions in the abdomen. Then, the surgeon detaches the uterus and sometimes the ovaries and/or fallopian tubes, and removes them through the vagina. This combination technique allows the surgeon to treat conditions that once required an abdominal hysterectomy.

Advantages: Laparoscopically assisted vaginal hysterectomy can be done in an outpatient setting, although most women need at least an overnight stay in the hospital. You're likely to have little abdominal pain and only three to four tiny marks on your skin. Like the traditional vaginal hysterectomy, you'll have no incision, fewer surgical complications, a shorter hospital stay and a quicker recovery.

Disadvantages: Laparoscopically assisted vaginal hysterectomy is a slower procedure. Gas used to expand your abdominal cavity during surgery may irritate your shoulder for a few days. Not all surgeons are trained or experienced in this technique, and some studies have shown a higher rate of complications for laparoscopically assisted hysterectomies than other types of hysterectomies. Certain women may not have enough room in their vaginal areas for this surgery (such as women who have not had sex or have never delivered a child), making them unsuitable candidates for this type of hysterectomy.

Postprocedure care
Before you're sent home after a hysterectomy, your doctor will make sure you're able to urinate; have appropriate bowel function; walk, eat and drink comfortably; and manage your pain. You'll be given information on any prescribed medications and when to schedule a follow-up appointment.
At home, avoid driving, heavy lifting and prolonged sitting for several weeks after surgery. Follow your doctor's instructions for resuming household and work activities (often within one to two weeks for a laparoscopically assisted vaginal hysterectomy, two to four weeks for a vaginal hysterectomy, and four to six weeks for an abdominal hysterectomy). You will also need to avoid sexual activity, douching, wearing tampons, and perhaps other activities until healing is complete, which may be up to six weeks.

After a hysterectomy, regular gynecologic exams continue to be important. Discuss with your doctor the optimal timing for routine screening exams. After a total hysterectomy, some women can stop having Pap smears to screen for cervical cancer. Women who have a history of cervical cancer or a precervical cancer condition should continue having pap smears, however, even if the cervix has been removed.


Benefits
Hysterectomy can relieve symptoms and strengthen pelvic structures. Many women enjoy an improved quality of life after a hysterectomy, including an improvement in sexual functioning.

Risks
Discuss all risks with your doctor before surgery. Depending on the type of hysterectomy, general risks may include:
infection
hemorrhage
pain
injury to the bowel, rectum, bladder or urinary structures
pulmonary embolism (blocking of a blood vessel in the lung by a blood clot, air bubble, fat deposit or other foreign substance)
There are additional risks whenever general anesthesia is used. Rarely, complications of general anesthesia or a hysterectomy may be fatal.

Remember, if both your ovaries are removed during the hysterectomy, you'll experience surgical menopause. This causes a sudden drop in your body's hormone levels, rather than the slow decline you would experience with natural menopause. This sudden loss of hormones usually causes intense menopausal symptoms. If your ovaries are left in place, your periods will stop, but you will not experience any other adverse menopausal symptoms at the time of the hysterectomy. You'll probably experience menopause two to three years earlier than you would have gone through natural menopause. Estrogen replacement therapy may need to be used to prevent the menopause symptoms immediately after surgery. Discuss the advantages and disadvantages of estrogen replacement therapy with your doctor.


Considerations
Successful relief of your symptoms will vary depending on the reason for the hysterectomy. The type of surgery you have will also impact the length of your recovery. Remember, a hysterectomy causes permanent sterility.
Tell your doctor about your feelings toward surgery, whether they are positive or negative. Discuss any concerns you may have about changes in body image, psychologically adjusting to life without a uterus, or not being able to bear children.

You may also want to raise the following questions with your doctor before surgery.

What other treatment options, either surgical or nonsurgical, are available?
What are the potential risks of surgery?
Will I have to stay in the hospital? If so, how long?
What type of anesthesia will be used?
Should I donate my own blood before surgery?
What sexual adjustments may there be after surgery?
If my ovaries are to be removed, what are the risks and benefits of hormone replacement therapy? How long will I need to take hormone replacements?
What types of physical and screening exams will I need in the future, such as Pap smears (used to detect cervical cancer)?
You may want to consider getting a second opinion from one or more other doctors before deciding on surgery.


Senior-specific information
Growing older is not a risk factor for hysterectomy. In fact, more than half of all hysterectomies are done on women under age 49. For older women, hysterectomies are often done to treat cancerous conditions or problems with the muscles that support the uterus.