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8 October, 2008

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Hysterectomy - surgical procedures

Hysterectomy is the surgical removal of a woman's uterus. It may also involve the removal of the fallopian tubes and ovaries. Once a hysterectomy is performed, a woman can no longer have children or menstrual periods. Hysterectomy is used to treat a number of conditions, such as excessive menstrual bleeding and cancer. In Australia, around 30,000 women undergo this operation every year.

Conditions that may require hysterectomy
A hysterectomy may be performed to correct various gynaecological problems including:

Heavy, irregular or abnormal menstrual bleeding
Fibroids
Endometriosis
Uterine prolapse
Cancer of the uterus, ovary or cervix
Pelvic inflammatory disease.

Medical issues to consider
Apart from cancer, many of the gynaecological conditions assisted by hysterectomy may also be successfully treated using other methods. If, after discussion of all options with your doctor, you choose to have a hysterectomy, there are several things that your doctor should discuss with you before the operation. These include:

Your medical history (as some pre-existing conditions may influence decisions on surgery and anaesthetics).
The pros and cons of abdominal surgery versus vaginal surgery.
Your support options after surgery.
Your feelings about the surgery.

You will have a range of tests, including a complete blood count test to check for problems such as anaemia.

Operation procedure
You will have an intravenous drip inserted into a vein in your hand or arm, and will be given a general anaesthetic. The operation may be performed via a lower abdominal incision (cut) or through the vagina.

Abdominal hysterectomy
For an abdominal hysterectomy, a cut is usually made horizontally along your pubic hairline (and your pubic hair will be shaved around the incision). For most women, this results in a small scar. Some patients may need a vertical incision in the lower abdomen.

Vaginal hysterectomy
A vaginal hysterectomy is performed through an incision (cut) at the top of the vagina. This may or may not involve the use of a laparoscope. A laparoscope is a slender instrument used in 'keyhole' surgery. During a laparoscopic assisted vaginal hysterectomy, surgery is performed via three or four small incisions in the abdomen. It is completed through the vagina.

Vaginal hysterectomy is a preferred option for many women as it avoids the need for a long abdominal cut. An abdominal procedure is generally recommended when large fibroids or cancer is present.

Types of hysterectomy
There are four variations of hysterectomy, including:

Total hysterectomy - the entire uterus and cervix is removed, but the ovaries are retained.
Subtotal (partial) hysterectomy - the uterus is removed, but the cervix may be retained. While removal of the cervix is generally advised because it is a potential cancer site in the body, some women consider that it serves a purpose during penetrative sex. If the cervix is kept, regular Pap smears are necessary.
Hysterectomy and bilateral salpingo-oopherectomy - the uterus, fallopian tubes and ovaries are removed. This operation is performed if cancer of the ovaries or the uterus has been diagnosed. It may also be performed for severe infection or endometriosis.
Radical hysterectomy - the most extensive version of the operation. It involves the removal of the uterus, fallopian tubes, ovaries, upper part of the vagina, and associated pelvic ligaments and lymph nodes. This may be performed if cancer of the cervix, ovaries or uterus is present.

Immediately after the operation
After the operation, you can expect:

There will be some soreness around the operation site - your doctor will prescribe pain-killing medication for you.
You may experience 'wind' pain for a few days.
Depending on the procedure and your condition, the intravenous tube in your arm will be removed sometime during the first few days.
The catheter (drainage tube) in your bladder is usually removed within 24 hours of surgery, unless the bladder was traumatised during the procedure.
As soon as possible, you will be encouraged to get out of bed and go for short walks around the ward.
Depending on the type of surgery, you can expect a hospital stay of between two and seven days.
Recovery is generally faster after vaginal surgery than abdominal surgery.

Following surgery, it is important to start pelvic floor and abdominal exercises as soon as possible. These exercises strengthen the muscles in the pelvis and help maintain normal bladder function and vaginal muscle tone. Your doctor or physiotherapist will let you know how soon you can start these particular exercises.

Side effects and possible complications
Some of the side effects and possible complications of hysterectomy include:

Nausea and vomiting.
Infection.
Internal haemorrhage.
Build-up of blood beneath the stitches.
Internal scar tissue.
Allergic reaction to the anaesthetic.
Blood clots.
Vaginal vault prolapse.
Feelings of grief and loss.
Injury to the bowel, bladder or ureters (tubes that carry urine from the kidneys to the bladder) - this is rare.
Fistula (abnormal hole between internal structures, such as the bowel and vagina). This is also rare.

Taking care of yourself at home
Be guided by your doctor, but general suggestions for the six week post-operative period include:

Rest - try to rest as much as possible for at least two weeks. You should avoid driving during this time.
Exercise - continue with the exercises you were shown in hospital. After two weeks of rest, you should aim to go for a 10 minute walk each day, unless advised otherwise by your doctor.
Standing - avoid standing for more than a few minutes at a time in the early post-operative period. You can increase standing time as recovery progresses.
Lifting - avoid heavy lifting and stretching.
Constipation - to avoid constipation, drink plenty of fluids and eat fresh fruits and vegetables. You may wish to take stool softeners for the first few days.
Medications - if you have been prescribed antibiotics, make sure you take the full course, even if you feel well.
Sex - it is advised that you avoid penetrative sex until after the post-operative check (at about six weeks) to ensure the vagina is fully healed. If vaginal dryness is a problem, it may be helpful to use a water based lubricant.

Long term outlook
After hysterectomy, you will no longer need contraception or have menstrual periods. If your ovaries were removed, you will experience sudden menopause. You may want to discuss short term hormone replacement therapy (HRT) or other options with your doctor. Hysterectomy can be effective for gynaecological complaints like fibroids and endometriosis, but some conditions (such as cancer) may recur. You will need to have regular check-ups to make sure you are cancer free. You may need to have a regular vault smear. This test is similar to a Pap smear but it takes cells from the vaginal walls instead of the cervix.

Other forms of treatment
Many of the various gynaecological conditions cured by hysterectomy can often be successfully treated using other methods, including:

Fibroids - options include surgery to remove the fibroids (myomectomy), drugs to temporarily block the action of sex hormones and shrink the growths, or else the fibroids can be frozen, cauterised or removed by laser (myolysis).
Heavy bleeding - options include taking the contraceptive pill to regulate the periods, other hormonal drug therapies, surgical removal of the endometrium, or the insertion of an intrauterine device (IUD) that releases small amounts of synthesised sex hormone into the uterus.
Uterine prolapse - options include pelvic floor exercises, the insertion of a ring-shaped pessary into the vagina to prop up the uterus, or surgical repair.
Endometriosis - options include hormonal drugs, surgical removal of the endometrium, or the insertion of an intrauterine device (IUD) that releases small amounts of synthesised sex hormone into the uterus.

Where to get help

Your doctor
Gynaecologist
Women's health or community health service
Family planning clinic

Things to remember

Hysterectomy is the surgical removal of the uterus.
A hysterectomy may be performed to correct various gynaecological problems including abnormal menstrual bleeding, fibroids, endometriosis, and cancer of the uterus, ovary or cervix.
The operation may be performed via an abdominal incision or through the vagina.
Apart from cancer, many of the various gynaecological conditions cured by hysterectomy can often be successfully treated using other methods