Hysterectomy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Hysterectomy is the surgical removal of all or part of the uterus. In a total hysterectomy, the uterus and cervix are removed. In some cases, the fallopian tubes and ovaries are removed along with the uterus, which is a hysterectomy with bilateral salpingo-oophorectomy. In a subtotal hysterectomy, only the uterus is removed. In a radical hysterectomy, the uterus, cervix, ovaries, oviducts, lymph nodes, and lymph channels are removed. The type of hysterectomy performed depends on the reason for the procedure. In all cases, menstruation permanently stops and a woman loses the ability to bear children.

Purpose

The most frequent reason for hysterectomy in American women is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus that can cause pelvic, low back pain, and heavy or lengthy menstrual periods. They occur in 30–40% of women over age 40, and are three times more likely to be present in African-American women than in Caucasian women. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman’s normal activities.

Treatment of endometriosis is the reason for 20% of hysterectomies. The endometrium is the lining of the uterus. Endometriosis occurs when the cells from the endometrium begin growing outside the uterus. The outlying endometrial cells respond to the hormones that control the menstrual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding tissue, leading to pain and scarring.

Twenty percent of hysterectomies are done because of heavy or abnormal vaginal bleeding that cannot be linked to any specific cause and cannot be controlled by other means. Another 20% are performed to treat prolapsed uterus, pelvic inflammatory disease, or endometrial hyperplasia, a potentially pre-cancerous condition.

About 10% of hysterectomies are performed to treat cancer of the cervix, ovaries, or uterus. Women with cancer in one or more of these organs almost always have the organ(s) removed as part of their cancer treatment.

Demographics

Hysterectomy is the second most common operation performed on women in the United States. About 556,000 of these surgeries are done annually. By age 60, approximately one out of every three American women will have had a hysterectomy. It is estimated that 30% of hysterectomies are unnecessary.

The frequency with which hysterectomies are performed in the United States has been questioned in recent years. It has been suggested that a large number of hysterectomies are performed unnecessarily. The United States has the highest rate of hysterectomies of any country in the world. Also, the frequency of this surgery varies across different regions of the United States. Rates are highest in the South and Midwest, and are higher for African-American women. In recent years, although the number of hysterectomies performed has declined, the number of hysterectomies performed on younger women aged 30s and 40s is increasing, and 55% of all hysterectomies are performed on women ages 35–49.

Description

A hysterectomy is classified according to what structures are removed during the procedure and what method is used to remove them.

Total hysterectomy

A total hysterectomy, sometimes called a simple hysterectomy, removes the entire uterus and the cervix.

KEY TERMS

Cervix— The lower part of the uterus extending into the vagina.

Fallopian tubes— Slender tubes that carry eggs (ova) from the ovaries to the uterus.

Lymph nodes— Small, compact structures lying along the channels that carry lymph, a yellowish fluid. Lymph nodes produce white blood cells (lymphocytes), which are important in forming antibodies that fight disease.

Pap smear— The common term for the Papanicolaou test, a simple smear method of examining stained cells to detect cancer of the cervix.

Prolapsed uterus— A uterus that has slipped out of place, sometimes protruding down through the vagina.

The ovaries are not removed and continue to secrete hormones. Total hysterectomies are usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy.

In addition to a total hysterectomy, a procedure called a bilateral salpingo-oophorectomy is sometimes performed. This surgery removes the ovaries and the fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.

Subtotal hysterectomy

If the reason for the hysterectomy is to remove uterine fibroids, treat abnormal bleeding, or relieve pelvic pain, it may be possible to remove only the uterus and leave the cervix. This procedure is called a subtotal hysterectomy (or partial hysterectomy), and removes the least amount of tissue. The opening to the cervix is left in place. Some women believe that leaving the cervix intact aids in their achieving sexual satisfaction. This procedure, which used to be rare, is now performed more frequently.

Subtotal hysterectomy is easier to perform than a total hysterectomy, but leaves a woman at risk for cervical cancer. She will still need to get yearly Pap smears.

Radical hysterectomy

Radical hysterectomies are performed on women with cervical cancer or endometrial cancer that has spread to the cervix. A radical hysterectomy removes the uterus, cervix, above part of the vagina, ovaries, fallopian tubes, lymph nodes, lymph channels, and tissue in the pelvic cavity that surrounds the cervix. This type of hysterectomy removes the most tissue and requires the longest hospital stay and a longer recovery period.

Methods of hysterectomy

There are two ways that hysterectomies can be performed. The choice of method depends on the type of hysterectomy, the doctor’s experience, and the reason for the hysterectomy.

ABDOMINAL HYSTERECTOMY. About 75% of hysterectomies performed in the United States are abdominal hysterectomies. The surgeon makes a 4-6 incision either horizontally across the pubic hair line from hip bone to hip bone or vertically from navel to pubic bone. Horizontal incisions leave a less noticeable scar, but vertical incisions give the surgeon a better view of the abdominal cavity. The blood vessels, fallopian tubes, and ligaments are cut away from the uterus, which is lifted out.

Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.

The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons tend to have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy, and the recovery period is longer.

VAGINAL HYSTERECTOMY. With a vaginal hysterectomy, the surgeon makes an incision near the top of the vagina. The surgeon then reaches through this incision to cut and tie off the ligaments, blood vessels, and fallopian tubes. Once the uterus is cut free, it is removed through the vagina. The operation takes one to two hours. The hospital stay is usually one to three days, and the return to normal activities takes about four weeks.

The advantages of this procedure are that it leaves no visible scar and is less painful. The disadvantage is that it is more difficult for the surgeon to see the uterus and surrounding tissue. This makes complications more common. Large fibroids cannot be removed using this technique. It is very difficult to remove the ovaries during a vaginal hysterectomy, so this approach may not be possible if the ovaries are involved.

Vaginal hysterectomy can also be performed using a laparoscopic technique. With this surgery, a tube containing a tiny camera is inserted through an incision in the navel. This allows the surgeon to see the uterus on a video monitor. The surgeon then inserts two slender instruments through small incisions in the abdomen and uses them to cut and tie off the blood vessels, fallopian tubes, and ligaments. When the uterus is detached, it is removed though a small incision at the top of the vagina.

This technique, called laparoscopic-assisted vaginal hysterectomy, allows surgeons to perform a vaginal hysterectomy that might otherwise be too difficult. The hospital stay is usually only one day. Recovery time is about two weeks. The disadvantage is that this operation is relatively new and requires great skill by the surgeon.

Any vaginal hysterectomy may have to be converted to an abdominal hysterectomy during surgery if complications develop.

Diagnosis/Preparation

Before surgery the doctor will order blood and urine tests. The woman may also meet with the anesthesiologist to evaluate any special conditions that might affect the administration of anesthesia. On the evening before the operation, the woman should eat a light dinner and then have nothing to eat or drink after midnight.

Aftercare

After surgery, a woman will feel some degree of discomfort; this is generally greatest in abdominal hysterectomies because of the incision. Hospital stays vary from about two days (laparoscopic-assisted vaginal hysterectomy) to five or six days (abdominal hysterectomy with bilateral salpingo-oophorectomy). During the hospital stay, the doctor will probably order more blood tests.

Return to normal activities such as driving and working takes anywhere from two to eight weeks, again depending on the type of surgery. Some women have emotional changes following a hysterectomy. Women who have had their ovaries removed will probably start hormone replacement therapy.

Risks

Hysterectomy is a relatively safe operation, although like all major surgery it carries risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, damage to other organs such as the bladder, and post-surgery infection.

Other complications sometimes reported after a hysterectomy include changes in sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other symptoms of menopause can occur if the ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for heart disease and osteoporosis (a condition that causes bones to be brittle). Women with a history of psychological and emotional problems before the hysterectomy are likely to experience psychological difficulties after the operation.

As in all major surgery, the health of the patient affects the risk of the operation. Women who have chronic heart or lung diseases, diabetes, or iron-deficiency anemia may not be good candidates for this operation. Heavy smoking, obesity, use of steroid drugs, and use of illicit drugs add to the surgical risk.

Normal results

Although there is some concern that hysterectomies may be performed unnecessarily, there are many conditions for which the operation improves a an’s quality of life. In the Maine Woman’s Health Study, 71% of women who had hysterectomies to correct moderate or severe painful symptoms reported feeling better mentally, physically, and sexually after the operation.

Morbidity and mortality rates

The rate of complications differs by the type of hysterectomy performed. Abdominal hysterectomy is associated with a higher rate of complications (9.3%), while the overall complication rate for vaginal hysterectomy is 5.3%, and 3.6% for laparoscopic vaginal hysterectomy. The risk of death from hysterectomy is about one in every 1,000 women. The rates of some of the more commonly reported complications are:

• excessive bleeding (hemorrhaging): 1.8-3.4%
• fever or infection: 0.8-4.0%
• accidental injury to another organ or structure: 1.5-1.8%

Alternatives

Women for whom a hysterectomy is recommended should discuss possible alternatives with their doctor and consider getting a second opinion, since this is major surgery with life-changing implications. Whether an alternative is appropriate for any

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Hysterectomies are usually performed under the strict conditions of a hospital operating room. The procedure is generally performed by a gynecologist, a medical doctor who has specialized in the areas of women’s general health, pregnancy, labor and childbirth, prenatal testing, and genetics.

individual woman is a decision she and her doctor should make together. Some alternative procedures to hysterectomy include:

• Embolization. During uterine artery embolization, interventional radiologists put a catheter into the artery that leads to the uterus and inject polyvinyl alcohol particles right where the artery leads to the blood vessels that nourish the fibroids. By killing off those blood vessels, the fibroids have no more blood supply, and they die off. Severe cramping and pain after the procedure is common, but serious complications are less than 5% and the procedure may protect fertility.
• Myomectomy. A myomectomy is a surgery used to remove fibroids, thus avoiding a hysterectomy. Hysteroscopic myomectomy, in which a surgical hysteroscope (telescope) is inserted into the uterus through the vagina, can be done on an outpatient basis. If there are large fibroids, however, an abdominal incision is required. Patients typically are hospitalized for two to three days after the procedure and require up to six weeks recovery. Laparoscopic myomectomies are also being done more often. They only require three small incisions in the abdomen, and have much shorter hospitalization and recovery times. Once the fibroids have been removed, the surgeon must repair the wall of the uterus to eliminate future bleeding or infection.
• Endometrial ablation. In this surgical procedure, recommended for women with small fibroids, the entire lining of the uterus is removed. After undergoing endometrial ablation, patients are no longer fertile. The uterine cavity is filled with fluid and a hysteroscope is inserted to provide a clear view of the uterus. Then, the lining of the uterus is destroyed using a laser beam or electric voltage. The procedure is typically done under anesthesia, although women can go home the same day as the surgery. Another newer procedure involves using a balloon, which is filled with superheated liquid and inflated until it fills

QUESTIONS TO ASK THE DOCTOR

• Why is a hysterectomy recommended for my particular condition?
• What type of hysterectomy will be performed?
• What alternatives to hysterectomy are available to me?
• Will I have to start hormone replacement therapy?

• the uterus. The liquid kills the lining, and after eight minutes the balloon is removed.
• Endometrial resection. The uterine lining is destroyed during this procedure using an electrosurgical wire loop (similar to endometrial ablation).

Resources

BOOKS

Katz, VL, et al. Comprehensive Gynecology. 5th ed. St. Louis: Mosby, 2007.

Khatri, VP and JA Asensio. Operative Surgery Manual.1st ed. Philadelphia: Saunders, 2003.

Townsend, CM, et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Kovac, S. Robert. “Hysterectomy Outcomes in Patients with Similar Indications.” Obstetrics & Gynecology 95, no. 6 (June 2000): 787–93.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org.

American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org.

National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. http://www.nci.nih.gov.

OTHER

Bachmann, Gloria. “Hysterectomy.” eMedicine. May 3, 2002 [cited March 13, 2003]. http://www.emedicine.com/med/topic3315.htm.

Bren, Linda. “Alternatives to Hysterectomy: New Technologies, More Options.” Food and Drug Administration. October 29, 2001 [cited March 13, 2003]. http://www.fda.gov/fdac/features/2001/601_tech.html.

Debra Gordon

Stephanie Dionne Sherk