Hysterectomy is the surgical removal of the womb (body of uterus and cervix). The operation may be with or without the removal of the ovaries.
The uterus is a muscular organ of the female body, shaped like an upside-down pear. The lining of the uterus (the endometrium), thickens and after ovulation is ready to receive a fertilised ovum (egg). If the ovum is unfertilised, the lining comes away as bleeding. This is known as menstruation (period). If the ovum is fertilised, the developing baby is nurtured inside the uterus throughout the nine months of pregnancy.
Once a woman has had a hysterectomy, she will no longer have menstrual periods and cannot have a child. She no longer needs to use contraception.
Hysterectomy is used to treat a number of conditions, such as excessive menstrual bleeding. Every year in Australia, around 30,000 women have a hysterectomy. Some people are concerned that more hysterectomies are performed than are necessary.
Reasons for a hysterectomy
The conditions that may be treated by hysterectomy include:
- fibroids – non-malignant (non-cancerous) growths inside the muscular walls of the uterus
- heavy or irregular menstrual periods – however, new techniques now used include endometrial ablation (which is surgical destruction of the uterus lining) or use of a levonorgestrel-releasing inter-uterine device (IUD)
- severe period pain (dysmenorrhoea) – due to adenomyosis or severe recurrent endometriosis
- cancer of the cervix, uterus or ovaries
- endometriosis – a condition in which cells from the lining of the uterus grow in other areas of the body, especially around the ovaries and peritoneum (lining inside the abdomen) in the pelvis
- adenomyosis – a condition where endometrial cells grow in the muscle of the uterus
- prolapse – the uterus falls into the vagina because of loose ligaments or damage to the pelvic floor muscles
- pelvic inflammatory disease (PID), caused by bacterial infection, often sexually transmitted infections (STIs).
Hysterectomy for women of childbearing age
Once a woman has had a hysterectomy of any kind, she cannot become pregnant. If the ovaries of a premenopausal woman are removed, she has had a surgical menopause. This means she will have a drop in production of the sex hormones oestrogen, progesterone and testosterone. Vaginal dryness, hot flushes, sweating and other symptoms of natural menopause may occur.
Women who undergo bilateral oophorectomy (removal of both ovaries) usually take hormone replacement therapy (HRT) – also known as oestrogen replacement therapy (ERT), as usually only oestrogens are required to maintain their hormone levels.
Other roles of the uterus and ovaries
Once a woman’s childbearing years are finished, hysterectomy may seem a logical treatment choice. This is because pregnancy is often considered to be the only function of the uterus.
However, the uterus has a number of other important functions, including:
- Sexuality – the uterus rhythmically contracts during orgasm, contributing to sensations of pleasure.
- Hormone production by the ovaries – the ovaries definitely play a major role in maintaining the female hormonal system. Their removal results in menopausal symptoms and therefore, unless diseased, a woman’s ovaries should not be removed during hysterectomy. Within 24 hours, oestrogen levels have fallen by 50 per cent.
- Self-image – the uterus is of great psychological importance to some women for many reasons, including fertility, femininity, sexuality and body image.
Treatments other than hysterectomy
Except if a woman has cancer, doctors recommend that hysterectomy should be a procedure of last resort, when all other treatment options have failed. Since the introduction of the levonorgestrel-releasing IUD and endometrial ablation, hysterectomy rates have reduced.
There are other treatments for the conditions that may prompt a hysterectomy. For example, while 50 to 70 per cent of women have fibroids, most are small, do not lead to symptoms and do not require treatment. For those that do require treatment, choice depends on the size and position, as well as the symptoms caused by fibroids.
This treatment may include:
- myomectomy – removal of fibroids by surgery, either as:
- open myomectomy via laparotomy
- laparoscopic myomectomy (keyhole)
- hysteroscopic resection of a submucosal fibroid (removal from inside the uterus – a procedure performed through the vagina into the uterus)
- uterine artery embolisation – placing small beads or oils into the uterine artery to block blood supply to the fibroid via a catheter that is inserted in the artery in the groin under radiological control
- MRI-directed ultrasound – where ultrasound is beamed to the fibroid, which heats it up and causes destruction of it.
Heavy bleeding is another condition that may prompt a hysterectomy. This may be due to fibroids, adenomyosis, cancers, bleeding disorders, other medical conditions and also unknown causes.
Alternative treatment to a hysterectomy for heavy bleeding may include:
- hormone therapies – such as progestins (progesterone-like medications), LNG-releasing IUDs, etonogestral-releasing implants and Depot Provera
- COCP – combined oral contraceptive pill
- surgery – endometrial ablation.
Alternative treatment to a hysterectomy for a uterine prolapse depends on the degree of prolapse, but may include:
- pelvic floor exercises
- the insertion of a pessary into the vagina to prop up the uterus
- surgical repair without hysterectomy.
For endometriosis, options may include hormonal therapies, surgical removal of areas of endometriosis, or a combination of both.
Types of hysterectomy
The five types of hysterectomy are:
- total hysterectomy – where the body of the uterus and cervix are removed
- subtotal (partial) hysterectomy – where the uterus is removed, but the cervix is left in place. While removal of the cervix is generally advised because it is a potential cancer site, some women feel that it serves a purpose during penetrative sex. If the cervix is kept, regular pap tests are necessary
- hysterectomy and bilateral salpingo-oophorectomy – where the uterus, fallopian tubes and ovaries are removed. This operation is performed if the woman has cancer of the ovaries or the uterus, or for chronic pain due to recurrent pelvic infection or recurrent endometriosis
- radical hysterectomy – which is 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 is performed if the woman has cancer of the cervix, ovaries or uterus
- hysterectomy with prophylactic bilateral salpingectomy – some doctors recommend removing the fallopian tubes at the time of hysterectomy due to research suggesting that early ‘ovarian’ cancers originate in the tubes.
Before choosing a hysterectomy
If, after talking about all the options with your doctor, you choose to have a hysterectomy, your doctor should discuss several things 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 (open or laparoscopic) surgery versus vaginal surgery
- your support options after surgery
- your feelings about the surgery.
You will have a range of tests before your hysterectomy, including a complete blood-count test to check for problems such as anaemia (deficiency in red blood cells, haemoglobin, or in total blood volume).
The operation may be performed via an incision (cut) in your lower abdomen (abdominal hysterectomy), three to four small incisions in your abdomen (laparoscopic hysterectomy), or through your vagina (vaginal hysterectomy).
For an abdominal hysterectomy, the surgeon usually makes a horizontal cut along your pubic hairline (your pubic hair will have been shaved around the incision). For most women, this leaves a small scar. Some women may need a vertical midline incision in the lower abdomen, especially if the hysterectomy is for a large uterine fibroid.
For a laparoscopic hysterectomy, the surgeon inserts a telescope (laparoscope) to see your pelvic organs through a small incision in your navel, and makes another three or four small incisions through which other instruments are used. Carbon dioxide gas is used to distend (inflate) your abdomen, like a balloon, so all of your organs can be clearly seen.
The surgeon then removes a woman’s uterus, with or without fallopian tubes and ovaries, through the vagina. If the top of her vagina is sutured (stitched) through keyhole incisions, the operation is called a total laparoscopic hysterectomy. If the gynaecologist stitches the top of the vagina through the vagina, it is called a laparoscopically assisted vaginal hysterectomy.
A vaginal hysterectomy is performed through an incision at the top of the vagina. Many women prefer a vaginal hysterectomy, as you do not need a long abdominal cut. However, an abdominal hysterectomy is generally recommended when a woman has large fibroids or cancer.
After a hysterectomy
Immediately after a hysterectomy operation, you can expect to:
- wake up in the recovery room
- feel some soreness around the operation site – you will be given pain-relieving medication to enable you to maintain some mobility
- experience wind pain for a few days
- have the intravenous (IV) tube removed from your arm sometime during the first few days, depending on the procedure and your condition
- have the catheter (drainage tube) removed from your bladder within 24 hours of surgery, unless your bladder was traumatised during surgery
- be encouraged to get out of bed and go for short walks around the hospital ward as soon as possible, therefore adequate pain relief is very important
- stay in hospital for two to seven days, depending on the type of surgery
- have a faster recovery after vaginal surgery than open abdominal surgery, although with good pain relief, recovery may be the same for all forms of the surgery.
It is important to start pelvic floor and abdominal exercises within the first few weeks after surgery. These exercises strengthen the muscles in your 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.
Complications after a hysterectomy
The possible complications of a hysterectomy include:
- nausea and vomiting – post-anaesthetic or medication induced – for the first one to three days
- internal haemorrhage (internal bleeding)
- build-up of blood beneath the stitches (haematoma)
- internal scar tissue
- allergic reaction to the anaesthetic
- blood clots
- difficulties with urination
- injury to the bowel, bladder or ureters (tubes that carry urine from the kidneys to the bladder) – rare
- fistula (abnormal hole between internal structures, such as the bowel and vagina) – rare
- vaginal vault prolapse (when the upper vaginal wall loses its shape and sags or bulges)
- decreased sexual desire – not necessarily the case, as you may have a positive response due to the treatment of symptoms
- constant pelvic pain – rare and post-operatively usually shows improvement
- feelings of grief and loss – if not counselled appropriately before the hysterectomy.
Self-care after hysterectomy
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. Always rest lying down.
- Exercise – continue with the exercises you were shown in hospital. You should aim to go for a 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 your 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.
- Medication – 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 vaginal sex until after the post-operative check (about four to six weeks after the operation) to make sure the vagina is fully healed. If vaginal dryness is a problem, it may be helpful to use a water-based lubricant, or sweet almond oil or olive oil.
Long-term outlook after hysterectomy
After hysterectomy, you will no longer need contraception or have menstrual periods. If your ovaries were removed, you will experience menopause, with symptoms starting within a few days of your surgery.
If you were still having periods before your hysterectomy, your doctor should discuss oestrogen replacement therapy (ERT) or other options with you. How long you might need ERT will depend on your age.
Hysterectomy can be effective for gynaecological conditions like fibroids, endometriosis and adenomyosis, but some conditions may recur, such as cancer (depending on the stage of the cancer). You will need to have regular check-ups to make sure you are cancer free. You may need to have a regular vault smear test – similar to a pap test, but involving cells from the top of your vagina instead of the cervix.
Where to get help
- Your doctor
- Local women’s health centre
- Community health centre
- Family planning clinic
Things to remember
- Hysterectomy is the surgical removal of the womb (uterus), with or without the cervix.
- Hysterectomy is used to treat a number of conditions, including heavy or painful periods, fibroids and prolapse.
- The operation may be performed through the abdomen or the vagina.
- Apart from cancer, many gynaecological conditions can often be successfully treated using other methods, so hysterectomy is recommended if other methods fail.