Hysterectomy

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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

1. Fibroids – this is the most common reason for having a hysterectomy. It may be the only way to treat very large or multiple fibroids.
2. 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.
3. Endometriosis – when it is widespread and painful.
4. 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.
5. To treat widespread and uncontrollable pelvic infection.
6. Ectopic pregnancy – e.g. in cervical pregnancy or pregnancy outside the uterus where the placenta is attached to the uterus and cannot be removed.
7. To remove cancer in the vagina, cervix, uterus, fallopian tubes or ovaries.
8. 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

1. 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.
2. 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.
3. 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:

1. 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.
2. Total abdominal hysterectomy (TAH) – here the whole of the uterus is removed completely.
3. 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.

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