Hysterectomy
Encyclopedia
A hysterectomy is the surgical
removal of the uterus
, usually performed by a gynecologist
. Hysterectomy may be total (removing the body, fundus
, and cervix
of the uterus; often called "complete") or partial (removal of the uterine body while leaving the cervix intact; also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States
alone, of which over 90% were performed for benign conditions. Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons.
Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended when other treatment options are not available. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases.
Oophorectomy
(removal of ovaries) is frequently done together with hysterectomy to decrease the risk of ovarian cancer
. However, recent studies have shown that prophylactic oophorectomy without an urgent medical indication decreases a woman's long-term survival rates substantially and has other serious adverse effects, particularly in terms of inducing early-onset-osteoporosis
through removal of the major sources of female hormonal production. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy.
, the number of hysterectomies between 2008 and 2009 was almost 47,000. The national rate in for the same timeline was 338 per 100,000 population, down from 484 per 100,000 in 1997. The reasons for hysterectomies differed depending on whether the woman was living in an urban or rural location. Urban women opted for hysterectomies due to uterine fibroids
and rural women had hysterectomies mostly for menstrual disorder
s.
, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60. There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.
Occasionally, women will express a desire to undergo an elective hysterectomy—that is, a hysterectomy for reasons other than the resolution of reproductive system conditions or illnesses. Some of the conditions under which a woman may request to have a hysterectomy (or have one requested for her if the woman is incapable of making the request) for non-illness reasons include:
Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings:
In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer
since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smear
s to check for cervical dysplasia or cancer
.
) techniques were developed.
Most hysterectomies in the United States are done via laparotomy
(abdominal incision, not to be confused with laparoscopy
). A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis
as possible, similar to the incision made for a caesarean section
. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. Historically, the biggest problem with this technique were infections, but infection rates are well-controlled and not a major concern in modern medical practice. An open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. Before the refinement of the vaginal and laparoscopic vaginal techniques it was also the only possibility to achieve subtotal hysterectomy, meanwhile any of the techniques can be used for subtotal hysterectomy.
Vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected or surgical exploration is required.
With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries then the vaginal procedure. LAVH begins with laparoscopy
and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix must be removed with the uterus. Total laparoscopic hysterectomy (TLH) is more advanced than a LAVH and does not require a double-setup, laparoscopic and vaginal.
The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports.
Total laparoscopic hysterectomy (TLH) is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions
Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similar to the total laparoscopic surgery but the uterus is amputated between the cervix and fundus.
"Robotic hysterectomy" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision.
Vaginal hysterectomy was shown to be superior to LAVH and some types of laparoscopic surgery (sufficient data was not available for all types of laparoscopic surgery), causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. It is however not possible or very difficult to perform some more complicated surgeries using this technique.
A recent Cochrane review
recommends vaginal hysterectomy over other variants where possible. Laparoscopic surgery offers certain advantages when vaginal surgery is not possible but has also the disadvantage of significantly longer time required for the surgery.
In direct comparison of abdominal (laparotomic) and laparoscopic techniques laparoscopic surgery causes longer operation time and substantially higher rate of major complications while offering much quicker healing.
Vaginal hysterectomy is the only available option that is feasible without total anaesthesia or in outpatient settings (although so far recommended only in exceptional cases).
Time required for completion of surgery in the eVAL trial is reported as following:
Large multifibroid uteri and subtotal hysterectomies did previously require abdominal incision but
with the use of in situ morcellation they can be sometimes also performed using laparoscopic or vaginal techniques. Even impacted fibroid uteri with severe adhesions, oblitered cul-de-sac and no motion whatsoever on pelvic exam can be removed laparoscopically by experienced laparoscopic surgeons. An advanced laparoscopist can replace the majority of inpatient total abdominal hysterectomies performed for benign indications with outpatient total laparoscopic hysterectomy.
Non-robotic laparoscopic hysterectomy has a higher likelihood a requiring a large incision and conversion to open technique than robotic hysterectomy. In addition blood loss and duration of hospital stay were lower when using robotic technique when compared to non-robotic laparoscopic hysterectomy.
The other techniques are not long enough in use to allow a general assessment, it appears that laparoscopic subtotal hysterectomy(LSH) is a promising technique.
The Maine Women Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence
due to uterine prolapse
, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness. Somewhat surprisingly, ovarian cancer risk after hysterectomy appears to be substantially lowered even when the ovaries are preserved.
certain risks and side effects.
The mortality rate is several times higher when performed in patients that are pregnant, have cancer or other complications.
Long term effect on all case mortality is relatively small. Women under the age of 45 years have a significantly increased long term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy.
Approximately 35% of women after hysterectomy undergo another related surgery within 2 years.
Ureteral injury is not uncommon and can range from 2.2% to 3% depending on whether the modality is abdominal, laparoscopic, or vaginal. The injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage.
Time for full recovery is very long and independent on the procedure that was used. Depending on the definition of "full recovery" 6 to 12 months have been reported. Serious limitations in everyday activities are expected for a minimum of 4 months.
The average onset age of menopause
in those who underwent hysterectomy is 3.7 years earlier than average even when the ovaries are preserved. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% women, some of them even require hormone replacement treatment. Surprisingly, a similar and only slightly weaker effect has been also observed for endometrial ablation
which is often considered as an alternative to hysterectomy.
Substantial number of women develop benign ovarian cysts after hysterectomy.
When only the uterus is removed there is a three times greater risk of cardiovascular disease
. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis
(decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.
Hysterectomies have also been linked with higher rates of heart disease and weakened bones. Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone
levels as compared to those left intact. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while increased testosterone
levels in women are associated with a greater sense of sexual desire.
Oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders.
are well known adverse effects that develop with high frequency a very long time after the surgery. Typically, those complications develop 10–20 years after the surgery. For this reason exact numbers are not known, and risk factors are poorly understood. It is also unknown if the choice of surgical technique has any effect. It has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. One long term study found a 2.4 fold increased risk for surgery to correct urinary stress incontinence following hysterectomy
The risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor. Overall incidence is approximately doubled after hysterectomy.
. Hormonal effects or injury of the ureter were considered as possible explanations.
Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy
due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.
and should be considered before any surgery.
Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation
which is an outpatient procedure in which the lining of the uterus is destroyed with heat, mechanically or by radio frequency ablation. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. It is not effective for patients with very thick uterine lining or uterine fibroids.
." A myomectomy may be performed through an open incision, laparoscopically or through the vagina (hysterescopy).
Uterine artery embolization
is a minimally invasive procedure for treatment of uterine fibroids. Under local anesthesia a catheter is introduced into the femoral artery at the groin and advanced under radiographic control into the uterine arterty. A mass of microspheres or polyvinyl alcohol
(PVA) material (an embolus) is injected into the uterine arteries in order to block the flow of blood through those vessels. The restriction in blood supply usually results in in significant reduction of fibroids and improvement of heavy bleeding tendency. The 2006 Cochrane review comparing hysterectomy and UAE did not find any major advantage for either procedure. The subsequently finished HOPEFUL study found substantially fewer serious adverse effects for UAE with lesser overall cost and comparable satisfaction. In this study 86% UAE treated women and 70% hysterectomy treated women recommend their treatment to a friend.
Uterine fibroids can be treated also with a non-invasive procedure called Magnetic Resonance guided Focused Ultrasound (MRgFUS). This procedure involves no cutting or general anesthesia and the uterus remains intact.
for trans men. Some in the FTM community prefer to have this operation along with hormone replacement therapy
in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer
and hormonally induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience
portion of their transition. Just as many, however, prefer to wait until they have full "bottom surgery
" (removal of female sexual organs and construction of male-appearing external anatomy) to avoid undergoing multiple separate operations.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
removal of the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
, usually performed by a gynecologist
Gynaecology
Gynaecology or gynecology is the medical practice dealing with the health of the female reproductive system . Literally, outside medicine, it means "the science of women"...
. Hysterectomy may be total (removing the body, fundus
Fundus (uterus)
The fundus of the uterus is the top portion, opposite from the cervix.Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates...
, and cervix
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
of the uterus; often called "complete") or partial (removal of the uterine body while leaving the cervix intact; also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
alone, of which over 90% were performed for benign conditions. Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons.
Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended when other treatment options are not available. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases.
Oophorectomy
Oophorectomy
Oophorectomy is the surgical removal of an ovary or ovaries. The surgery is also called ovariectomy, but this term has been traditionally used in basic science research describing the surgical removal of ovaries in laboratory animals...
(removal of ovaries) is frequently done together with hysterectomy to decrease the risk of ovarian cancer
Ovarian cancer
Ovarian cancer is a cancerous growth arising from the ovary. Symptoms are frequently very subtle early on and may include: bloating, pelvic pain, difficulty eating and frequent urination, and are easily confused with other illnesses....
. However, recent studies have shown that prophylactic oophorectomy without an urgent medical indication decreases a woman's long-term survival rates substantially and has other serious adverse effects, particularly in terms of inducing early-onset-osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
through removal of the major sources of female hormonal production. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy.
Canada
In CanadaCanada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
, the number of hysterectomies between 2008 and 2009 was almost 47,000. The national rate in for the same timeline was 338 per 100,000 population, down from 484 per 100,000 in 1997. The reasons for hysterectomies differed depending on whether the woman was living in an urban or rural location. Urban women opted for hysterectomies due to uterine fibroids
Uterine fibroids
A uterine fibroid is a benign tumor that originates from the smooth muscle layer and the accompanying connective tissue of the uterus.Fibroids are the most common benign tumors in...
and rural women had hysterectomies mostly for menstrual disorder
Menstrual disorder
-Disorders of ovulation:Infrequent or irregular ovulation -Disorders of ovulation:Infrequent or irregular ovulation -Disorders of ovulation:Infrequent or irregular ovulation (usually defined as cycles of ≥36 days or -Disorders of ovulation:Infrequent or irregular ovulation (usually defined as...
s.
United States
According to the National Center for Health StatisticsNational Center for Health Statistics
National Center for Health Statistics is a division of the United States federal agency the Centers for Disease Control and Prevention . As such, NCHS is under the United States Department of Health and Human Services...
, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60. There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.
United Kingdom
In the UK, one in 5 women are likely to have a hysterectomy by the age of 60, and ovaries are removed in about 20% of hysterectomies.Indications
Hysterectomy is a major surgical procedure that has risks and benefits, and affects a woman's hormonal balance and overall health for the rest of her life. Because of this, hysterectomy is normally recommended as a last resort to remedy certain intractable uterine/reproductive system conditions. Such conditions include, but are not limited to:- Certain types of reproductive system cancers (uterineUterine cancerThe term uterine cancer may refer to any of several different types of cancer which occur in the uterus, namely:*Uterine sarcomas: sarcomas of the myometrium, or muscular layer of the uterus, are most commonly leiomyosarcomas.*Endometrial cancer:...
, cervicalCervical cancerCervical cancer is malignant neoplasm of the cervix uteri or cervical area. One of the most common symptoms is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer is in its advanced stages...
, ovarianOvarian cancerOvarian cancer is a cancerous growth arising from the ovary. Symptoms are frequently very subtle early on and may include: bloating, pelvic pain, difficulty eating and frequent urination, and are easily confused with other illnesses....
, endometriumEndometrium-Function:The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a...
) or tumors, including uterine fibroidsUterine fibroidsA uterine fibroid is a benign tumor that originates from the smooth muscle layer and the accompanying connective tissue of the uterus.Fibroids are the most common benign tumors in...
that do not respond to more conservative treatment options. - Severe and intractable endometriosisEndometriosisEndometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
(growth of the uterine lining outside the uterine cavity) and/or adenomyosisAdenomyosisAdenomyosis is a medical condition characterized by the presence of ectopic glandular tissue found in muscle. The term adenomyosis is derived from the terms adeno- , myo- , and -osis...
(a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature), after pharmaceutical or other surgical options have been exhausted. - Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted.
- Postpartum to remove either a severe case of placenta praeviaPlacenta praeviaPlacenta praevia is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage...
(a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical haemorrhage. - Several forms of vaginal prolapseVaginal prolapseFemale genital prolapse is characterized by a portion of the vaginal canal protruding from the opening of the vagina...
.
Occasionally, women will express a desire to undergo an elective hysterectomy—that is, a hysterectomy for reasons other than the resolution of reproductive system conditions or illnesses. Some of the conditions under which a woman may request to have a hysterectomy (or have one requested for her if the woman is incapable of making the request) for non-illness reasons include:
- Prophylaxis against certain reproductive system cancers, especially if there is a strong family history of reproductive system cancers (especially breast cancerBreast cancerBreast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
in conjunction with BRCA1 or BRCA2 mutationBRCA mutationA BRCA mutation is a mutation in either of the genes BRCA1 and BRCA2. Harmful mutations in these genes produce a hereditary breast-ovarian cancer syndrome in affected families...
), or as part of recovery from such cancers. - Part of overall gender transition for transmen.
- Severe developmental disabilities, though this treatment is controversial at best, and specific cases of sterilization due to developmental disabilities have been found by state-level Supreme Courts to violate the patient's constitutional and common law rights.
Types of hysterectomy
Hysterectomy, in the literal sense of the word, means merely removal of the uterus. However other organs such as ovaries, fallopian tubes and the cervix are very frequently removed as part of the surgery.- Radical hysterectomy : complete removal of the uterus, cervix, upper vagina, and parametriumParametriumIn women, the supravaginal portion of the cervix is separated in front from the bladder by fibrous tissue, the parametrium , which extends also on to its sides and laterally between the layers of the broad ligaments....
. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situation. - Total hysterectomy : Complete removal of the uterus and cervix.
- Subtotal hysterectomy : removal of the uterus, leaving the cervix in situ.
Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings:
- There was no difference in the rates of incontinence, constipation or measures of sexual function.
- Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates.
- Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy.
- There was no difference in the rates of other complications, recovery from surgery, or readmission rates.
In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer
Cervical cancer
Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. One of the most common symptoms is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer is in its advanced stages...
since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smear
Pap smear
The Papanicolaou test is a screening test used in to detect pre-cancerous and cancerous processes in the endocervical canal of the female reproductive system. Changes can be treated, thus preventing cervical cancer...
s to check for cervical dysplasia or cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
.
Technique
Hysterectomy can be performed in different ways. The oldest known technique is abdominal incision. Subsequently the vaginal (performing the hysterectomy through the vaginal canal) and later laparoscopic vaginal (with additional instruments inserted through a small hole, frequently close to the navelNavel
The navel is a scar on the abdomen caused when the umbilical cord is removed from a newborn baby...
) techniques were developed.
Most hysterectomies in the United States are done via laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
(abdominal incision, not to be confused with laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
). A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis
Pelvis
In human anatomy, the pelvis is the lower part of the trunk, between the abdomen and the lower limbs .The pelvis includes several structures:...
as possible, similar to the incision made for a caesarean section
Caesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. Historically, the biggest problem with this technique were infections, but infection rates are well-controlled and not a major concern in modern medical practice. An open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. Before the refinement of the vaginal and laparoscopic vaginal techniques it was also the only possibility to achieve subtotal hysterectomy, meanwhile any of the techniques can be used for subtotal hysterectomy.
Vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected or surgical exploration is required.
With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries then the vaginal procedure. LAVH begins with laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix must be removed with the uterus. Total laparoscopic hysterectomy (TLH) is more advanced than a LAVH and does not require a double-setup, laparoscopic and vaginal.
The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports.
Total laparoscopic hysterectomy (TLH) is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions
Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similar to the total laparoscopic surgery but the uterus is amputated between the cervix and fundus.
"Robotic hysterectomy" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision.
Comparison of techniques
The abdominal technique is very often applied in difficult circumstances or when complications are expected. Given these circumstances the complication rate and time required for surgery compares very favorably with other techniques, however time required for healing is much longer.Vaginal hysterectomy was shown to be superior to LAVH and some types of laparoscopic surgery (sufficient data was not available for all types of laparoscopic surgery), causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. It is however not possible or very difficult to perform some more complicated surgeries using this technique.
A recent Cochrane review
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
recommends vaginal hysterectomy over other variants where possible. Laparoscopic surgery offers certain advantages when vaginal surgery is not possible but has also the disadvantage of significantly longer time required for the surgery.
In direct comparison of abdominal (laparotomic) and laparoscopic techniques laparoscopic surgery causes longer operation time and substantially higher rate of major complications while offering much quicker healing.
Vaginal hysterectomy is the only available option that is feasible without total anaesthesia or in outpatient settings (although so far recommended only in exceptional cases).
Time required for completion of surgery in the eVAL trial is reported as following:
- abdominal 55.2 minutes average, range 19-155
- vaginal 46.6 minutes average, range 14-168
- laproscopic (all variants) 82.5 minutes average, range 10-325 (combined data from both trial arms)
Large multifibroid uteri and subtotal hysterectomies did previously require abdominal incision but
with the use of in situ morcellation they can be sometimes also performed using laparoscopic or vaginal techniques. Even impacted fibroid uteri with severe adhesions, oblitered cul-de-sac and no motion whatsoever on pelvic exam can be removed laparoscopically by experienced laparoscopic surgeons. An advanced laparoscopist can replace the majority of inpatient total abdominal hysterectomies performed for benign indications with outpatient total laparoscopic hysterectomy.
Non-robotic laparoscopic hysterectomy has a higher likelihood a requiring a large incision and conversion to open technique than robotic hysterectomy. In addition blood loss and duration of hospital stay were lower when using robotic technique when compared to non-robotic laparoscopic hysterectomy.
The other techniques are not long enough in use to allow a general assessment, it appears that laparoscopic subtotal hysterectomy(LSH) is a promising technique.
Benefits
Hysterectomy is usually performed for serious conditions and is highly effective in curing those conditions.The Maine Women Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
due to uterine prolapse
Uterine prolapse
Uterine prolapse is a form of female genital prolapse Uterine prolapse is a form of female genital prolapse Uterine prolapse is a form of female genital prolapse (also called pelvic organ prolapse or prolapse of the uterus (womb).Treatment is surgical, and the options include hysterectomy or a...
, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness. Somewhat surprisingly, ovarian cancer risk after hysterectomy appears to be substantially lowered even when the ovaries are preserved.
Risks and side effects
Hysterectomy has like any other surgerySurgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
certain risks and side effects.
Mortality and surgical risks
Short term mortality (within 40 days of surgery) is usually reported in the range of 1-6 cases per 1000 when performed for benign causes. Risks for surgical complications are presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity.The mortality rate is several times higher when performed in patients that are pregnant, have cancer or other complications.
Long term effect on all case mortality is relatively small. Women under the age of 45 years have a significantly increased long term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy.
Approximately 35% of women after hysterectomy undergo another related surgery within 2 years.
Ureteral injury is not uncommon and can range from 2.2% to 3% depending on whether the modality is abdominal, laparoscopic, or vaginal. The injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage.
Convalescence
Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for vaginal or laparoscopically assisted vaginal procedures.Time for full recovery is very long and independent on the procedure that was used. Depending on the definition of "full recovery" 6 to 12 months have been reported. Serious limitations in everyday activities are expected for a minimum of 4 months.
Unintended oophorectomy and premature ovarian failure
Removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovariesparing.The average onset age of menopause
Menopause
Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
in those who underwent hysterectomy is 3.7 years earlier than average even when the ovaries are preserved. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% women, some of them even require hormone replacement treatment. Surprisingly, a similar and only slightly weaker effect has been also observed for endometrial ablation
Endometrial ablation
Endometrial ablation is a medical procedure that is used to remove or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. ...
which is often considered as an alternative to hysterectomy.
Substantial number of women develop benign ovarian cysts after hysterectomy.
Premature menopause and its effects
Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce hormones even after the cessation of menstrual periods.When only the uterus is removed there is a three times greater risk of cardiovascular disease
Cardiovascular disease
Heart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...
. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
(decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.
Hysterectomies have also been linked with higher rates of heart disease and weakened bones. Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone
Testosterone
Testosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
levels as compared to those left intact. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while increased testosterone
Testosterone
Testosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
levels in women are associated with a greater sense of sexual desire.
Oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders.
Urinary incontinence and vaginal prolapse
Urinary incontinence and vaginal prolapseVaginal prolapse
Female genital prolapse is characterized by a portion of the vaginal canal protruding from the opening of the vagina...
are well known adverse effects that develop with high frequency a very long time after the surgery. Typically, those complications develop 10–20 years after the surgery. For this reason exact numbers are not known, and risk factors are poorly understood. It is also unknown if the choice of surgical technique has any effect. It has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. One long term study found a 2.4 fold increased risk for surgery to correct urinary stress incontinence following hysterectomy
The risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor. Overall incidence is approximately doubled after hysterectomy.
Effects on social life and sexuality
Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.Other rare problems
Hysterectomy may cause an increased risk of the relatively rare renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases...
. Hormonal effects or injury of the ureter were considered as possible explanations.
Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.
Alternatives
Depending on the indication there are alternatives to hysterectomy :Heavy bleeding
Levonorgestrel intrauterine devices are highly effective at controlling dysfunctional uterine bleeding or menorrhagiaMenorrhagia
Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus...
and should be considered before any surgery.
Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation
Endometrial ablation
Endometrial ablation is a medical procedure that is used to remove or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. ...
which is an outpatient procedure in which the lining of the uterus is destroyed with heat, mechanically or by radio frequency ablation. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. It is not effective for patients with very thick uterine lining or uterine fibroids.
Uterine fibroids
Uterine fibroids may be removed and the uterus reconstructed in a procedure called "myomectomyMyomectomy
Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.-Indications:...
." A myomectomy may be performed through an open incision, laparoscopically or through the vagina (hysterescopy).
Uterine artery embolization
Uterine artery embolization
Uterine artery embolization is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body...
is a minimally invasive procedure for treatment of uterine fibroids. Under local anesthesia a catheter is introduced into the femoral artery at the groin and advanced under radiographic control into the uterine arterty. A mass of microspheres or polyvinyl alcohol
Polyvinyl alcohol
Polyvinyl alcohol is a water-soluble synthetic polymer .-Properties:...
(PVA) material (an embolus) is injected into the uterine arteries in order to block the flow of blood through those vessels. The restriction in blood supply usually results in in significant reduction of fibroids and improvement of heavy bleeding tendency. The 2006 Cochrane review comparing hysterectomy and UAE did not find any major advantage for either procedure. The subsequently finished HOPEFUL study found substantially fewer serious adverse effects for UAE with lesser overall cost and comparable satisfaction. In this study 86% UAE treated women and 70% hysterectomy treated women recommend their treatment to a friend.
Uterine fibroids can be treated also with a non-invasive procedure called Magnetic Resonance guided Focused Ultrasound (MRgFUS). This procedure involves no cutting or general anesthesia and the uterus remains intact.
As part of transitioning from female-to-male
Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of sex reassignment surgerySex reassignment surgery
Sex reassignment surgery is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble...
for trans men. Some in the FTM community prefer to have this operation along with hormone replacement therapy
Hormone replacement therapy (female-to-male)
Hormone replacement therapy for transgender gender variant and transsexual introduces hormones associate with the gender that the patient identifies with...
in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer
Uterine cancer
The term uterine cancer may refer to any of several different types of cancer which occur in the uterus, namely:*Uterine sarcomas: sarcomas of the myometrium, or muscular layer of the uterus, are most commonly leiomyosarcomas.*Endometrial cancer:...
and hormonally induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience
Real life experience
Real-life experience is a process where transsexual and transgender people live full-time in their preferred gender identity for a period of time, in order to demonstrate that they can function as a member of said gender...
portion of their transition. Just as many, however, prefer to wait until they have full "bottom surgery
Sex reassignment surgery female-to-male
Sex reassignment surgery from female to male includes a variety of surgical procedures for transsexual men that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning....
" (removal of female sexual organs and construction of male-appearing external anatomy) to avoid undergoing multiple separate operations.
See also
- Hysterectomy Educational Resources and Services (HERS) FoundationHysterectomy Educational Resources and Services (HERS) FoundationThe Hysterectomy Educational Resources & Services Foundation is an independent non-profit international women’s health educational advocacy organization . The stated mission of the organization is to give women a greater voice within the healthcare system by education and advocacy programs...
- Michael Neary
- Ornella SizziOrnella SizziOrnella Sizzi is a noted Italian surgeon renowned as a pioneer in the field of minimally invasive surgery. Dr. Sizzi has multiple publications in laparoscopic hysterectomy, and other aspects of minimally invasive surgery. Dr. Sizzi is a member of The Society of Elite Laparoscopic Surgeons. She...
External links
Laparoscopic Hysterectomy 1- laparoscopic hysterectomy
- Female Anatomy: Functions of the Female Organs (Hysterectomy Support Groups)
- MedlineMEDLINEMEDLINE is a bibliographic database of life sciences and biomedical information. It includes bibliographic information for articles from academic journals covering medicine, nursing, pharmacy, dentistry, veterinary medicine, and health care...
article on Hysterectomy