Hysterectomy

Uterine fibroids: Uterine fibroids are the single most common indication for hysterectomy.

A hysterectomy is a surgical procedure whereby the uterus (womb) is removed. This surgery for women is the most common non-obstetrical surgical procedure in the United States.

Approximately 300 out of every 100,000 women will undergo a hysterectomy.

A hysterectomy is performed for the treatment of uterine cancer or very severe pre-cancers (called dysplasia, carcinoma in situ, or CIN III or microinvasive carcinoma of the cervix). A hysterectomy for endometrial cancer (uterine lining cancer) is the removal of the cancer from the body. Hysterectomy is the foundation of treatment for uterine cancer.

The most common reason hysterectomy is performed is for uterine fibroids.

Other common reasons are:

• Abnormal uterine bleeding (vaginal bleeding),
• Cervical dysplasia (pre-cancerous conditions of the cervix),
• Endometriosis
• Urerine prolapse (including pelvic relaxation).

Only 10% of hysterectomies are performed for cancer. This article will primarily focus on the use of hysterectomy for non-cancerous, non-emergency reasons, which can involve even more challenging decisions for women and their doctors.

The most common reason for a hysterecotmy are uterine fibroids (also known as uterine leiomyomata). Uterine fibroids are benign (non-cancerous) growths of the uterus, the cause of which is unknown. Although the majority of them don't cause or turn into uterine cancer

Uterine fibroids can cause medical problems. Reasons for a hysterectomy in women with uterine fibroids are:

• Excessive size (usually greater than the size of a two-month pregnancy).
• Pressure or pain.
• Bleeding severe enough to cause anemia.

Pelvic relaxation is another condition that can require treatment with a hysterectomy. In this condition, a woman experiences a loosening of the support muscles and tissues in the pelvic floor area. Mild relaxation can cause first degree prolapse

There are three types of prolapse:

1. First degree prolapse: Mild relaxation can cause, in which the cervix (the uterine opening) is about halfway down into the vagina.
2. Second degree prolapse: In second degree prolapse the cervix or leading edge of the uterus has moved to the vaginal opening.
3. Third degree prolapse: In third degree prolapse, the cervix and uterus protrude past the vaginal opening.

Second and third degree uterine prolapse must be treated with hysterectomy.

Vaginal wall weakness

A cystocele, rectocele, or urethrocele can lead to symptoms of, for example:

• Urinary incontinence (unintentional loss of urine)
• Pelvic heaviness
• Impaired sexual performance.

Urine loss tends to be aggravated by:

• Sneezing
• Coughing
• Jumping
• Laughing

Risk factors for pelvic relaxation:The most common risk factor for pelvic relaxation is childbearing; although, there may be other causes. Avoiding birth and having a caesarean section (C-section) doesn't necessarily eliminate the risk of developing pelvic relaxation.

A woman must have a pelvic examination, Pap smear, and a diagnosis prior to proceeding with a hysterectomy.

• Prior to having a hysterectomy for pelvic pain, women might undergo more limited (less extensive) exploratory surgery procedures (such as laparoscopy) to rule out other causes of pain.
• Prior to having a hysterectomy for abnormal uterine bleeding, women require some type of sampling of the lining of the uterus (biopsy of the endometrium) to rule out cancer or pre-cancer of the uterus. This procedure is called endometrial sampling.
• Also, pelvic ultrasounds and/or pelvic computerized tomography (CT) tests can be done to confirm a diagnosis. In a woman with pelvic pain or bleeding, a trial of medication treatment is often given before a hysterectomy is considered.

Therefore, a premenopausal (still having regular menstrual periods) woman whose uterine fibroids are causing bleeding but no pain is generally first offered medical therapy with hormones. Non-hormonal treatments are also available, such as tranexamic acid and more moderate surgical procedures, such as ablations (removal of the lining of the uterus). If she still has significant bleeding that causes major impairment to her daily life, or the bleeding continues to cause anemia (low red blood cell count due to blood loss), and she has no abnormality on endometrial sampling, she may be considered for a hysterectomy.

A postmenopausal woman (whose menstrual periods have ceased permanently) who has no abnormalities in the samples of her uterus (endometrial sampling) and still has persistent abnormal bleeding after trying hormone therapy, may be considered for a hysterectomy. Several dose adjustments or different types of hormones may be required to decide on the optimal medical treatment for an individual woman.

• In the past the most common hysterectomy was done by an incision (cut) through the abdomen (abdominal hysterectomy).
• Now most surgeries can utilize laparoscopic assisted or vaginal hysterectomies (performed through the vagina rather than through the abdomen) for quicker and easier recovery.
• The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges tend to be higher.
• The procedures seem to take comparable lengths of time (about two hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.

What are the types of hysterectomies?

There are now a variety of surgical techniques for performing hysterectomies. The ideal surgical procedure for each woman depends on her particular medical condition. Below, the different types of hysterectomy are discussed with general guidelines about which technique is considered for which type of medical situation. However, the final decision must be made after an individualized discussion between the woman and physician who best understands her individual situation.

Remember, as a general rule, before any type of hysterectomy, women should have the following tests in order to select the optimal procedure:

1. Complete pelvic exam including manually examining the ovaries and uterus.
2. Up-to-date Pap smear.
3. Pelvic ultrasound may be appropriate, depending on what the physician finds on examination.
4. A decision regarding whether or not to remove the ovaries at the time of hysterectomy.
5. A complete blood count and an attempt to correct anemia if possible.

7 Types of hysterectomy

• Total abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopy-assisted vaginal hysterectomy
• Supracervical hysterectomy
• Laparoscopic supracervical hysterectomy
• Radical hysterectomy
• Oophorectomy and salpingo-oophorectomy

The total abdominal hysterectomy is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar on the abdomen may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated.

• Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy.
• Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after attempts at non-surgical treatments.
• Clearly a woman cannot bear children after this procedure, so it is not generally performed on women who desire childbearing unless there is a serious condition, such as cancer.
• Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.

During this procedure, the uterus is removed through the vagina. A vaginal hysterectomy is appropriate for conditions such as uterine prolapse, endometrial hyperplasia, or cervical dysplasia.

• These are conditions in which the uterus is not too large, and in which the whole abdomen does not require examination using a more extensive surgical procedure. The woman will need to have her legs raised up in a stirrup device throughout the procedure.
• Women who have not had children may not have a large enough vaginal canal for this type of procedure.
• If a woman has too large a uterus, cannot have her legs raised in the stirrup device for prolonged periods, or has other reasons why the whole upper abdomen must be further examined, the doctor will usually recommend an abdominal hysterectomy.

Laparoscopy-assisted vaginal hysterectomy (LAVH) is similar to the vaginal hysterectomy procedure described above, but it adds the use of a laparoscope. A laparoscope is a very thin viewing tube used to visualize structures within the abdomen. Certain women would be best served by having laparoscopy used during vaginal hysterectomy because it allows the upper abdomen to be carefully inspected during surgery. Examples of uses of the laparoscope would be for early endometrial cancer (to verify lack of spread of cancer), or if oophorectomy (removal of the ovaries) is planned. Just as with simple vaginal hysterectomy without a laparoscope, the uterus must not be excessively large. The physician will also review the medical situation to be sure there are no special risks prohibiting use of the procedure, such as prior surgery that could have increased the risk for abnormal scarring (adhesions). If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular abdominal hysterectomy might be considered.

A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a "stump." The cervix is the area that forms the very bottom of the uterus, and sits at the very end (top) of the vaginal canal (see illustration above). The procedure probably does not totally rule out the possibility of developing cancer in this remnant "stump." Women who have had abnormal Pap smears or cervical cancer clearly are not appropriate candidates for this procedure. Other women may be able to have the procedure if there is no reason to have the cervix removed. In some cases the cervix is actually better left in place, such as some cases of severe endometriosis. It is a simpler procedure and requires less time to perform. It may give some added support of the vagina, decreasing the risk for the development of protrusion of the vaginal contents through the vaginal opening (vaginal prolapse).

The laparoscopic supra cervical hysterectomy procedure is performed like the LAVH procedure, but the uterus is separated from the cervix, and the uterine tissue is removed through the laparoscopic incision. Recovery is generally faster than with other types of hysterectomy. Cervical preservation is less likely to result in menses (menstruation) as the inner lining of the cervix is usually cauterized.

The radical hysterectomy procedure involves more extensive surgery than a total abdominal hysterectomy because it also includes removing tissues surrounding the uterus and removal of the upper vagina. Radical hysterectomy is most commonly performed for early cervical cancer. There are more complications with radical hysterectomy compared to abdominal hysterectomy. These include injury to the bowels and urinary system.

Oophorectomy is the surgical removal of the ovary(s), while oophorectomy and salpingo-oophorectomy (removal of the ovaries or Fallopian tubes)is the removal of the ovary and its adjacent Fallopian tube. These two procedures are performed for ovarian cancer, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Occasionally, women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventive (prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast. Current recommendations are that the fallopian tubes should be removed during hysterectomy even if the ovaries are preserved. This is done to decrease the lifetime risk of ovarian cancer, which can arise from the fallopian tubes in up to 25% of case.

Complications of a hysterectomy include

• infection,
• pain, and
• bleeding in the surgical area.

An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.

A hysterectomy for conditions other than cancer generally are not considered until after other less invasive treatments are unsuccessful.

• Newer procedures, for example, uterine artery embolization (UAE) or surgical removal of a portion of the uterus (myomectomy), are being used to treat excessive uterine bleeding.
• Endometrial ablation and newer medications are alternatives.

Any woman with a history of abnormal Pap smears should have Pap smears for the remainder of her life. This is because of the low, but real, chance that cervical cancer can recur at the surgical site where the cervix was removed.

In addition, women with a history of abnormal Pap smears, other women who require continued. Pap smears are women with supracervical hysterectomy, where the cervix was left in place. In this situation, in contrast to the woman who has had hysterectomy for reasons of cervical cancer, the woman who has had supracervical hysterectomy will be able to follow the same screening guidelines as for other women who have not had surgery. For example, the physician may stop doing Pap smears at age 65 if the woman has been well-screened and has always had normal Pap smears.

Women who do not need to continue having Pap smears are those who have had vaginal hysterectomy or abdominal hysterectomy for benign (not cancer) reasons, such as uterine fibroids. If they have had normal Pap smears prior to the procedure, they need not continue to have Pap smears after their surgery.