Hysterectomy is the second most common major operation performed in the Western world after cesarean section. About 30% of women over 50 in the US have had a hysterectomy. There is a lot of unreasonable fear surrounding this procedure. Some of these fears come from reports from other women who have had a hysterectomy.
These reports depend on their own expectations and preconceptions. When it is performed by an experienced gynecologist and for the right reasons, a hysterectomy can significantly improve your quality of life and even save it!
Reasons for having a hysterectomy
- Fibroids – this is the most common reason for having a hysterectomy. It may be the only way to treat very large or multiple fibroids.
- To control uterine bleeding – when it is very heavy, prolonged, irregular and does not respond to non-surgical treatment. In the absence of a tumor, ovarian cyst, infection, pregnancy or endometriosis, this is known as dysfunctional uterine bleeding (DUB). It is often caused by hormone imbalance.
- Endometriosis – when it is widespread and painful.
- To treat descent (prolapse) of the uterus – Hysterectomy is recommended when the symptoms are very severe and Kegel exercises or vaginal estrogen have been unable to provide relief.
- To treat widespread and uncontrollable pelvic infection.
- Ectopic pregnancy – e.g. in cervical pregnancy or pregnancy outside the uterus where the placenta is attached to the uterus and cannot be removed.
- To remove cancer in the vagina, cervix, uterus, fallopian tubes or ovaries.
- To treat some life-threatening conditions affecting organs close to the uterus where treatment is difficult without removing the uterus e.g. cancer of the rectum or bladder.
Types of Hysterectomy
- Abdominal hysterectomy – this is carried out by making a cut (incision) in the abdomen and removing the uterus. This method is best for extensive painful endometriosis, very large uterine fibroids and cancer. It allows the surgeon to have a better look at the uterus and other pelvic organs. Abdominal hysterectomy recovery time is longer than for the other two types so a longer hospital stay is usual. It also has more complications during and after surgery.
- Vaginal hysterectomy – the uterus is removed through the vagina. It is ideal for cases of uterine prolapse and for removal of a moderate-sized uterus. This usually has fewer complications than the other two methods.
- Laparoscopic hysterectomy – here the uterus is removed with a laparoscope. This allows smaller incisions to be made.
Hysterectomies can also be divided into different types based on what tissues and the amount of these tissues that are removed:
- Subtotal hysterectomy – here only a part of the uterus is removed. This type of hysterectomy is usually done if you want your cervix left behind, or where total removal would cause injury to nearby organs like the rectum orbladder.
- Total abdominal hysterectomy (TAH) – here the whole of the uterus is removed completely.
- Total abdominal hysterectomy + bilateral salpingo-oophorectomy (BSO) – here the whole uterus is removed along with both ovaries.
Should normal ovaries be removed during a hysterectomy performed for conditions that are non-cancerous?
Generally, bilateral salpingo-oophorectomy is recommended for postmenopausal women. By this time, the ovaries have stopped functioning and it removes the risk of ovarian cancer.
However, removal in premenopausal women has been more controversial. Ovaries of premenopausal women are still producing sex hormones. Their removal at this time leads to surgical menopause. Note that even if the ovaries are conserved during hysterectomy their function gradually diminish due to reduction of blood flow afterwards. So you will tend to experience menopause several years earlier than you would without a hysterectomy.
On the other hand, if you have a strong family history of breast cancer, your risk of developing breast cancer will be reduced by 50% if both ovaries are removed.
Before your doctor gets to the stage of recommending a hysterectomy for you, usually he/she will have done the following:
- Taken a complete medical history from you including types of symptoms, their duration and severity.
- Done a thorough physical examination which may include a vaginal exam.
- Done some tests to confirm his/her diagnosis.
Your doctor should tell you clearly and in simple language:
- Why he/she is recommending the operation.
- The risks, benefits and side effects
- How long the operation will last
- Recovery time after a hysterectomy and when you can get back to your normal activities
- Whether or not your ovaries will be left behind and why
- Whether you will need hormone replacement
- Which type of hysterectomy is suitable for your condition
- Effects on your sex life
- Any feasible alternatives to hysterectomy
Make sure your partner, a close friend or family member is involved in the discussion. They should ask questions and clear their own doubts. Ultimately, it is your decision. Never go through with a hysterectomy until you are satisfied that you have enough facts to make an informed decision.
If your doctor is impatient with, or cannot answer your questions convincingly, then you’ve got the wrong surgeon. Try and get a second opinion.
A hysterectomy done for the right reasons by a good surgeon can dramatically improve your quality of life. Think of it positively as a the solution for your troublesome symptoms. It doesn’t make you less of a woman, it doesn’t make you less attractive. You’re still exactly the same woman except that you don’t have a uterus anymore.
Hysterectomy side effects include
- excessive bleeding
- damage to nearby organs e.g. bladder, gut
- pulmonary embolism
- vaginal dryness especially if your ovaries have been removed
You are more likely to develop side effects of a hysterectomy:
- if you are obese
- if you are having a hysterectomy because of cancer
- if you have any medical condition e.g. diabetes
- the older you are, the more likely you are to develop complications.
Death resulting from side effects of a hysterectomy are rare in most good centers in the US, about 1-2 per thousand surgeries, and none in some cases. Complications may occur in about 25% of women undergoing vaginal hysterectomy and 50% of women undergoing abdominal hysterectomy.
Some hysterectomy side effects are minor while others are life threatening.
There has been a lot of concern about decreased sex drive and difficulty in achieving orgasms even when the ovaries are intact. Studies have shown no difference in sexual or bladder function after a simple hysterectomy for non-cancerous disease.
Traditional hysterectomy involves a large abdominal incision to locate the uterus and remove it or all of its parts. Depending on the need and severity of the condition, the ovaries and cervix may or may not be removed. Hysterectomy is a procedure that should serve as a last option when the patient has not responded to other treatment protocols.
With today’s advancements in medicine, a less invasive form of hysterectomy, called laparoscopic hysterectomy is now another option for surgery. This type of hysterectomy is done by creating 4-5 small abdominal incisions where tubes are inserted, guided by a lighted tube called laparoscope which serves as the camera for viewing the uterus from outside the body. Surgical tools and instruments are inserted through the openings, then the uterus is cut into pieces and removed through the tubes. The operation is performed under general anesthesia with an endotracheal tube in place.
Laparoscopic Hysterectomy Pros and Cons
A number of advantages have been found with laparoscopic hysterectomy over traditional abdominal hysterectomy:
- Less invasive than abdominal hysterectomy
- Faster healing and recovery time
- Shorter hospital stay
- Minimal pain and blood loss
- Best suited in cases where the cervix may be left intact
- Leaves smaller abdominal scars
On the other hand, there are drawbacks associated with a laparoscopic hysterectomy:
- Because the procedure is quite recent, it can be challenging to find an experienced surgeon
- Can be very costly compared to abdominal hysterectomy
- May not be an advisable method in removing a very large uterus
- Patients with cancer or bad pap smear histories are not good candidates for this type of hysterectomy
- The procedure is longer to perform than abdominal hysterectomy
- Risk for injury when done by an unskilled surgeon
Removing the uterus is a very tough decision to make, especially for a woman in her childbearing years. It may affect femininity, sexual function, and cause emotional disturbances. Before consenting for a hysterectomy, you should explore all possible alternatives with your gynecologist, and seek second opinion if needed. It is also vital to understand the extent of the uterine removal, as to whether the cervix, ovaries, and other parts should be removed as well. As with any other types of surgeries, you should find a highly competent surgeon to perform the task to avoid possible complications. In addition, although laparoscopic hysterectomy is something to consider as an alternative, you should realize that this procedure is not right for everyone. Ask your doctor for advice if you are a candidate for this type of operation.
Hysterectomy or uterine artery embolization?
Most women have heard of hysterectomy, being removal of the uterus, for treating uterine fibroids but many may not be familiar with uterine artery embolization (UAE). This is a procedure where arteries leading to the fibroids are blocked so that the fibroids effectively starve and shrink. This procedure can be used on its own to treat fibroids but can also be used to shrink very large fibroids before carrying out a hysterectomy.
UAE has advantages and disadvantages compared to conventional hysterectomy.
Advantages of uterine artery embolization
- it has fewer complications
- it takes less time to recover from the procedure compared to hysterectomy
Disadvantages of uterine artery embolization
- it was less effective at curing symptoms associated with fibroids
- women were more likely to require further treatment for their symptoms, including a hysterectomy in some cases
In spite of these disadvantages, women were more likely to recommend UAE to their friends than a hysterectomy. UAE will definitely be popular among working women considering the shorter recovery time compared to hysterectomy.