Hysterectomy

Hysterectomy, showing removal

Of the uterus, but not the ovaries

Definition

Hysterectomy is the surgical removal of the uterus, resulting in sterility, or the inability to become pregnant. It may be done through the abdomen or the vagina.

Hysterectomy is the second most common major surgery among women in the United States. (The most common major surgery that women have is cesarean section delivery.) Each year, more than 600,000 hysterectomies are done. About one-third of women in the United States have had a hysterectomy by age 60.

Parts of the Body Involved

Partial or Subtotal Hysterctomy--Removal of the uterus

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 (metastasized). Cancers affecting the pelvic organs account for only about ten percent of all hysterectomies, and include:

Endometrial cancer

Uterine sarcoma cervical cancer of the ovaries Cancer of the Fallopian tubes Depending on the type and extent of the cancer, other kinds of treatment such as radiation or hormonal therapy may be used as well.

Other Reasons

Although controversial, a hysterectomy may also be done to treat these conditions of the uterus when they do not respond to other methods of treatment:

Uterine fibroids (myomas)--common, benign (noncancerous) tumors that grow in the muscle of the uterus.

More hysterectomies are done because of fibroids than any other problem of the uterus.

Fibroids often cause no symptoms and need no treatment, and they usually shrink after menopause. But sometimes fibroids cause heavy bleeding or pain.

There are alternatives to hysterectomy to treat fibroids, which may be especially important for younger women who hope 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 (i.e., ovaries, fallopian tubes, and other organs).

Endometriosis is the second leading reason for hysterectomies. It is most common in women in their thirties and forties, especially in women who have never been pregnant.

This condition may cause painful menstrual periods, abnormal vaginal bleeding, and sometimes loss of fertility (ability to get pregnant). Endometriosis is usually not a problem for women after menopause.

Women with endometriosis are often treated with hormones and medicines that lower their levels of estrogen. Surgery to remove the patches of endometrial tissue causing the symptoms may be done using a laparoscope or through a larger cut in the abdomen (laparotomy). A hysterectomy is generally not done unless other treatment has failed and symptoms are severe.

Uterine prolapse--a benign condition in which the uterus moves from its usual place down into the vagina.

Uterine prolapse is due to weak and stretched pelvic ligaments and tissues. Other organs such as the bladder can also be affected.

Childbirth, obesity, and loss of estrogen after menopause may contribute to this problem. Uterine prolapse accounts for about 16 percent of hysterectomies.

Treatment may include estrogen therapy, exercises to strengthen pelvic floor muscles, or use of a pessary, a plastic ring inserted into the vagina to help support the uterus. In more severe cases, surgery can restore the sagging organs to their normal location and repair the supporting tissues. Sometimes a hysterectomy may be done if the prolapse is causing severe problems.

Other reasons why hysterectomies are done include chronic pelvic pain, heavy bleeding during or between periods, and chronic pelvic inflammatory disease.

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 some prescription and nonprescription drugs; inform your doctor of any drugs, medications, or supplements you are using or have used in the last 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 to diagnose or treat gynecologic or obstetric conditions

In the days leading up to the procedure: Arrange for a ride to and from the procedure Arrange for help at home after returning from the hospital In order to clean out your intestinal track, you'll take one or more enemas The night before, eat a light meal and do not eat or drink anything after midnight Antibiotics may be given to prevent infection Your abdominal and/or pelvic areas will be shaved

During Procedure - IV fluids and medications, a bladder catheter, and in rare cases, a blood transfusion may be required. Depending on the reason for the surgery, other organs and tissues may be removed and/or repaired.

Anesthesia - General or local, depending on the kind of procedure

Description of the Procedure - There are three different methods:

Abdominal hysterectomy: A cut is made in the lower abdomen to expose the tissues and blood vessels that surround the uterus and cervix. These tissues are cut and the blood vessels are tied off to remove the uterus. Stitches are placed in these deep structures, which will eventually dissolve and do not need to be removed. The uterus is removed from the top of the vagina and the vagina is closed to prevent infection and to keep the intestines from dropping downward.

Vaginal hysterectomy: The vagina is stretched and kept open by special instruments; no external incision is made. The doctor does, however, make an internal incision at the top of the vagina around the cervix. The uterus and cervix are cut free from their supporting ligaments and surrounding tissue, and connecting blood vessels are tied off. The uterus and cervix are removed through the vagina, which is then closed to prevent infection and to keep the intestines from dropping downward.

Laparoscopically assisted vaginal hysterectomy (LAVH): A laparoscope is inserted through a small cut near the navel. This small, telescope-like device, about the width of a pencil, with a light on one end and a magnifying lens on the other, helps the doctor see the pelvic organs. The abdomen is inflated with a harmless gas (carbon dioxide) to improve your doctor's visibility and room to work. Images from the laparoscope are viewed on a special monitor.

Other small (1/4 to 1/2 inch wide) cuts are made in the abdomen, through which the doctor inserts instruments to help move organs and remove the uterus. 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 made in the vagina. The vagina is closed to prevent infection and to keep the intestines from dropping downward. The cuts are all closed with stitches, which will likely leave small scars.

With each procedure, a vaginal "packing" dressing is placed in the vagina. This will be removed after a day or two.

After Procedure

All removed tissue is sent to a lab to be analyzed. IV fluids and medications will be continued in the

Recovery room

How Long Will It Take?

1-3 hours

Will It Hurt?

Anesthesia prevents pain during the procedure. Expect some pain, pelvic fullness, bloating, and vaginal bleeding or discharge during the first few days after surgery. You'll be given pain medication to help relieve this discomfort.

Possible Complications:

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

Average Hospital Stay:1-5 days

Postoperative Care:

Most patients go home the third day following an abdominal hysterectomy and by the first or second day after a vaginal hysterectomy. Complete recovery from abdominal hysterectomy usually takes six to eight weeks because the incision is typically 5 inches long. During your recovery, you can expect a gradual increase in activities. Avoid all lifting during the first two weeks of your recovery period and get plenty of rest. In the weeks following the surgical procedure, you can begin to do light chores, some driving, and even return to work, provided your occupation does not involve too much physical activity. Around the sixth week following the operation, you can take tub baths and resume sexual activity. Women who have had vaginal hysterectomies generally recover more quickly.

The first night after the surgery, you may be asked to sit up in bed and walk a short distance.

The next morning, if there is no evidence of complications and you are able to drink fluids on your own, the catheter in your bladder and IV will be removed. To promote healing, eat a balanced diet rich in fresh fruits and vegetables. Depending on how much blood loss occurred during surgery, you may require a daily iron supplement. Try to avoid constipation. Eat high-fiber foods, drink plenty of water, and if necessary, use stool softeners. Shower instead of taking a bath for at least the first 2 weeks after your surgery. Keep your incision sites clean and dry. Do not douche or put anything in your vagina, such as a tampon, until your doctor tells you otherwise. Return to your normal activities gradually; most normal activities, including sex, can be resumed in about six weeks. Take daily walks as tolerated. Avoid heavy lifting for four to six weeks. If you have a subtotal hysterectomy, and therefore still have your cervix, you will still need pap smears on a regular basis to check for cervical abnormalities. Ask your practitioner when and how to perform Kegel exercises. These exercises can strengthen the muscles of the pelvic floor and prevent/improve urinary incontinence, as well as enhance sexual pleasure.

Outcome

Physical

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

After a hysterectomy, you will no longer have monthly periods and you can no longer get pregnant; birth control is not necessary. If your ovaries have been left in place, though, you will still produce hormones and eggs, but they will dissolve in your abdomen.

If the ovaries are removed (oophorectomy), your body's main source of estrogen and other sex hormones is gone. If you were not already postmenopausal, this sends your body into an instant menopause and you will experience typical menopausal symptoms, such as hot flashes. Hormone replacement therapy is usually recommended.

Emotional

Some women have strong emotional reactions, including depression, in response to the loss of their uterus.

Sexual

Some women notice a change in their sexual response after a hysterectomy. 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, but is usually relieved with the use of estrogen.

Some women report an increase in their sexual enjoyment, possibly because they are relieved of the pain from the condition that prompted this procedure, or no longer need to worry about an unintended pregnancy. Considerations before Having a Hysterectomy Talk to your health care provider about your options. Ask about other treatments that are available for your condition. Consider getting a second opinion from another health care provider. Ask about possible complications of surgery and/or medical treatments for your condition. Keep in mind that every woman is different and every situation is different. A good treatment choice for one woman may not be the best choice for another. Work with your health care provider to choose the treatment that is best for you.

Call Your Doctor If Any of the Following Occurs:

Develop a fever.

Become dizzy and faint.

Experience nausea and vomiting.

Become short of breath.

Have heavy bleeding.

Have leakage from the incision or the incision opens up.

Have pain when you urinate.

Have swelling, redness, or pain in your leg.

Have questions about the procedure or its result.

SOURCES:

American College of Obstetrics and Gynecologists

American Medical Association

The National Women's Health Information Center http://www.4woman.gov/faq/hysterectomy.htm

Medem Medical Library http://www.medem.com