Hysterectomy

Uterine fibroids are the most common reason for hysterectomy — surgical removal of the uterus.

Hysterectomy is the only permanent solution for fibroids. A hysterectomy is major surgery, so you should be aware that you'll be unable to work for several weeks after the surgery, and you'll need someone at home to help you out. After a hysterectomy, you can no longer become pregnant.

If feasible, a vaginal hysterectomy is preferred because it's easier to recover from. The operation requires general anesthesia, lasts one to three hours and usually involves a hospital stay of two to five days. Full recovery can take four to six weeks, potentially causing disruption for you, your family and your workplace.

Most women who undergo hysterectomy for benign conditions such as fibroids find that their symptoms ease and their quality of life is better. However, a few obtain no pain relief or develop new problems such as hot flashes, weight gain, depression, anxiety and disinterest in sex.

Hysterectomy is relatively safe and effective, but it carries a small risk of complications, including bleeding, infection, and injury to intestines, bladder or ureters. The risk of death is rare — fewer than one in 1,000 women dies during the procedure. If you choose hysterectomy, you face the additional decision of whether to have your ovaries removed.

Your surgeon may use one of several surgical approaches — abdominal, vaginal, a combination of the two (laparoscopically assisted vaginal hysterectomy) or total laparoscopic hysterectomy. In each procedure, your surgeon seals off the blood vessels that supply your uterus and cuts the connective tissue (ligaments) that support it in the pelvis.

Surgical approaches to hysterectomy

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Vertical and Pfannenstiel incisions

Abdominal hysterectomy. In abdominal hysterectomy, the surgeon cuts through skin and connective tissue in your lower abdomen to reach your uterus. This approach usually has the most uncomfortable and lengthy recovery because of the deep abdominal incision.

The surgeon uses one of two abdominal incisions for the hysterectomy. A vertical incision starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. A horizontal bikini-line incision (Pfannenstiel incision) lies about an inch above your pubic bone.

Because the Pfannenstiel incision follows your skin's natural lines, it usually results in a thinner scar than does a vertical incision. However, it gives your surgeon less access to the pelvis, which may be important if your uterus is very large or highly distorted. The vertical incision can result in a thicker scar and a greater risk that abdominal tissues will eventually bulge through the incision site (herniate), requiring surgical repair. However, it provides the surgeon with greater access to your pelvis and may result in less blood loss.

Vaginal hysterectomy. In vaginal hysterectomy, the surgeon reaches your uterus by making a circular vaginal incision around the cervix. Traditionally, many doctors believed that a uterus larger than that of a 12-week pregnancy was too large for a vaginal hysterectomy. Doctors also advised women who had never been pregnant or who had borne children only by Caesarean section to have an abdominal hysterectomy. But evidence now suggests that vaginal hysterectomy can be successful in many of these women. Some surgeons are experts in techniques that allow removal of a larger uterus through the vagina.

To decrease the size of your uterus and to make vaginal hysterectomy feasible, your doctor may recommend that you take a medication called a gonadotropin-releasing hormone (Gn-RH) agonist before surgery. This is a synthetic version of the hormone released from the brain that triggers ovarian production of estrogen and progesterone. When given as therapy, the Gn-RH agonist instead blocks the production of estrogen and progesterone, causing fibroids to shrink. Also, menstruation stops, allowing you to rebuild iron stores if you have iron deficiency anemia.

Some women object to taking a Gn-RH agonist because it causes symptoms of menopause, including hot flashes, night sweats and vaginal dryness. However, these symptoms end when you stop taking the medication.

Laparoscopically assisted vaginal hysterectomy. A disadvantage of vaginal hysterectomy is that your surgeon can't see the organs surrounding your uterus. One way to avoid this limitation and a large abdominal incision is to have a laparoscopically assisted vaginal hysterectomy. In this procedure, a surgeon makes small incisions in your lower abdomen, expands your abdominal cavity with gas, and places a lighted tube (laparoscope) inside to provide the surgical team with detailed images of the outside of your uterus, ovaries and neighboring pelvic organs. Your surgeon uses specially crafted instruments to partially detach the uterus. Then he or she moves to the vagina to finish the operation.

Laparoscopic hysterectomy. In this newer variation, the procedure is performed entirely with the laparoscope and no vaginal incision is made. Your surgeon separates the uterus and fibroids into small pieces and removes them through small abdominal incisions made to accommodate the laparoscope and surgical instruments. Often, the cervix is left in place with this approach to hysterectomy (supracervical hysterectomy).

Types of hysterectomy

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Types of hysterectomy surgery

• Partial (subtotal). Removes the uterus but leaves the cervix in place. This addresses concerns that removing the cervix can cause problems with bladder, bowel and sexual function. It can also be an easier operation. However, a partial hysterectomy requires that you continue to have Pap tests to screen for cervical cancer.
• Total. Removes the uterus and cervix.
• Total with removal of ovaries and fallopian tubes (bilateral salpingo-oophorectomy). Removes the uterus, cervix, ovaries and fallopian tubes. This triggers menopause if it hasn't already occurred.

A factor to consider: Removal of ovaries

In more than half the hysterectomies in the United States, surgeons remove the ovaries (oophorectomy) to prevent ovarian cancer. Ovarian cancer is a major cause of death among American women. Removal of the ovaries is optional if you have a hysterectomy for uterine fibroids.

The ovaries produce not only the female hormones estrogen and progesterone, but also testosterone, the so-called male hormone. After menopause, ovarian production of estrogen and progesterone drops sharply. If you haven't yet reached menopause and you decide to have your ovaries removed, you'll have to decide whether to take medication to replace the estrogen produced by your ovaries.

Lack of estrogen can lead to porous bones (osteoporosis) and symptoms of menopause, such as hot flashes and mood swings, and the younger you are, the more severe your symptoms may be. Some women opt to take synthetic estrogen (hormone therapy) to ease menopausal symptoms. However, hormone therapy is controversial because it may increase your risk of heart disease, stroke and breast cancer. Talk with your doctor to determine if the benefits of estrogen replacement outweigh the risks for you. See the "Related links" section of this guide for more information about hormone therapy.

Testosterone helps maintain muscle and bone and may contribute to sexual desire and well-being. After menopause your ovaries, along with your adrenal glands, still secrete some testosterone. Women usually don't need testosterone replacement therapy after removal of their ovaries.

Doctors don't agree on possible benefits of removing healthy ovaries at hysterectomy. Many argue that the risk of ovarian cancer doesn't justify the loss of ovarian hormones in young women unless there's another disease present that depends on ovarian function. Doctors may advise women who are close to menopause to have their ovaries removed at the time of hysterectomy. In this case, the risk of ovarian cancer may be greater than the benefits a woman would receive from a few more months of ovarian function.

Discuss with your doctor the benefits of removing your ovaries. Consider whether you have any risk factors for ovarian cancer, which include:

• A family history of ovarian or breast cancer
• Presence of the BRCA1 or BRCA2 cancer genes
• Age
• Never having borne children
• A history of infertility
• Obesity in early childhood

What to expect

A hysterectomy requires that you arrive at the hospital on the day of surgery and stay for a few days afterward.

How do you prepare?
To make sure that your stomach is empty, refrain from eating and drinking for about eight hours before your surgery. If you're on medications, ask your doctor if you should stop taking them before or after surgery. Leave valuables at home; remove any nail polish.

When you arrive at the hospital, staff members help you prepare for surgery. You need to remove eyeglasses or contact lenses, hairpins or hair ornaments, and dentures. Nurses may give you an enema or laxative and may require that you douche.

To prepare for surgery, you change into a hospital cap and gown and put on special stockings to prevent blood clots in your legs. A nurse may clean and possibly shave your abdomen and genital area. Before going to the operating room, you may receive an injection of pain medication.

How is it done?
In the operating room, members of the surgical staff attach strips of tape connected to wires to your torso and arms to monitor your heart rate and rhythm. A device (pulse oximeter) is placed on one of your fingers to track the oxygen level in your blood.

A nurse inserts a needle — attached to a slender tube — into a vein in your arm (intravenous, or IV) to give you fluids, anesthetics, antibiotics or pain medication. A thin tube placed in your urethra (urinary catheter) keeps your bladder empty.

This surgery requires general anesthesia, which means you're given drugs that make you lose consciousness. You receive anesthesia drugs (anesthetics) intravenously or through a mask. They act as hypnotics, painkillers and muscle relaxants.

A machine (ventilator) ensures that you receive enough oxygen while getting the correct dose of anesthetic. The ventilator has a tube that goes through your mouth and into your windpipe (trachea).

After the procedure
In the recovery room, staff members monitor your condition. After the effects of anesthesia fade, staff members return you to your hospital room for continued observation.

To control pain, your doctor may give you an opioid (morphine and related drugs), nonsteroidal anti-inflammatory drugs (NSAIDs) or both. Many hospitals offer patient-controlled analgesia (PCA), a system that delivers a dose of pain medication to your bloodstream through a vein when you press a button. To help monitor and treat your pain, you may be asked to rate your pain on a scale of 1 to 10.

Usually by the next day, oral medications replace IV medications. You may receive IV fluids until you're able to drink, and you may not be able to eat solid foods right away. Medical staff members urge you to walk around as soon as you're able, because walking reduces the risk of many postoperative complications.

At discharge from the hospital, your doctor prescribes oral pain medication, tells you how to care for your incision, and discusses restrictions on your diet and activities. You may have to avoid certain activities, such as driving, lifting heavy objects, climbing stairs or exercising vigorously until you recover. Also, your doctor may advise that you not use tampons or have sexual intercourse for up to six weeks. You can expect some vaginal drainage for up to six weeks as well.

Common concerns about hysterectomy

You may have additional concerns about hysterectomy, including long-term complications. Discuss any concerns you have directly with your doctor.

Incontinence. Some women worry that hysterectomy leads to urinary incontinence — leakage of urine. Because the same muscles and ligaments support both your bladder and uterus, removal of your uterus runs the risk of damaging muscles or nerves of the urinary tract. However, most women don't develop incontinence after hysterectomy. Much of the surgical repair work done with the removal of the uterus can prevent this damage and is usually successful.

Incontinence is a common problem with advancing age for women who have an intact uterus. Studies to evaluate a possible link between hysterectomy and incontinence have produced conflicting results, suggesting there is no clear relationship. Also, many other conditions are linked to incontinence, including childbirth, genetics and hormonal changes after menopause. Discuss any concerns with your doctor.

Sexual function. You may also have concerns about the impact of a hysterectomy on your sex life. Sexual interest and response aren't completely understood, but the reduction in testosterone and the absence of the uterus and ovaries after hysterectomy likely play roles. Blood vessels of the uterus fill during arousal and then rapidly drain after orgasm. Uterine, vaginal and urethral muscles contract during orgasm. After hysterectomy uterine contractions disappear, although contractions still occur in the lower genital tract. Women might report a difference in orgasm but don't necessarily find it less pleasurable. Some women actually find sex to be more enjoyable and less painful after hysterectomy surgery.

Pros and cons

A hysterectomy removes the uterus and fibroids, and usually relieves your symptoms. But it isn't the best solution for everyone. Your preferences and concerns play a large role in determining the best choice for you. Before deciding whether to undergo a hysterectomy, consider these points: