What is a hysterectomy?
A hysterectomy is the removal of the uterus (womb). It can be a total hysterectomy/complete hysterectomy (removal of uterus and cervix), a subtotal hysterectomy/partial hysterectomy/supracervical hysterectomy (cervix is left behind) or a radical hysterectomy (removal of a safety margin for severe endometriosis or gynaecological cancer).
Ovary removal or preservation?
Removal of ovaries: At a hysterectomy the ovaries (responsible for the production of the hormones oestrogen and progesterone) can be removed at the time of hysterectomy without additional effort. It does not complicate the hysterectomy or prolong the operation time. Removing the ovaries can be achieved laparoscopically. It also has no impact on the cost of your operation.
Removing the ovaries will make a woman menopausal if she is not menopausal as yet. In postmenopausal women, removing the ovaries does not change the hormonal situation. Typically, I recommend removal of the ovaries in women who have a high risk of ovarian cancer (BRCA1/2, Lynch, history of breast cancer) and/or in postmenopausal women.
Preservation of ovaries: Alternatively, the ovaries can be preserved, which maintains the production of the hormones oestrogen and progesterone. If at least one ovary can be preserved the hysterectomy should not or only minimally interfere with the onset of menopause. Preserving ovaries is useful and recommended in young women who are not at increased risk of ovarian cancer.
Why a hysterectomy?
A hysterectomy may be recommended for a number of reasons. Benign conditions include conditions that lead to severe pelvic pain and bleeding, such as uterine fibroids, adenomyosis/endometriosis, benign pelvic masses, uterine prolapse, pelvic inflammation and cancer. In Australia, approximately 30,000 women will have a hysterectomy every year.
Alternatives to a hysterectomy
- Uterine artery embolisation: The rationale is that reduction of blood flow to the uterus will result in infarction of parts of the uterus and subsequent shrinkage. A catheter is advanced through the femoral artery towards the uterine artery and alcohol or gelatin particles, glue or coils are injected to occlude the large vessels feeding the uterus. I recommend uterine artery embolisation for treatment of vascular malformations (arteriovenous malformations), pelvic congestion syndrome, and tumour-related bleeding when surgery is not possible. For the treatment of uterine fibroids or adenomyosis, no data from randomised trials are available to support uterine artery embolisation. Multiple cases of acute pelvic pain requiring emergency hysterectomy have been reported under those circumstances.
- A Bakri balloon catheter is invaluable for the management of postpartum haemorrhage (acute bleeding after giving birth) to avoid a postpartum hysterectomy. In case of severe haemorrhage, it gets inserted into the uterine cavity and then the balloon is inflated. The balloon will stay for one to two days and will then be removed under controlled conditions.
- Endometrial ablation is effective for conditions that exclusively involve the endometrium (inner lining of the uterus). The main indication for endometrial ablation is functional (hormonal) uterine bleeding. Its success rate is around 40%. It is contraindicated for women with known or suspected cancer or precancerous changes, women who wish to retain fertility, acute pelvic infection and in postmenopausal women.
- Hormonal treatment/levonorgestrel-IUD is an attractive alternative to hysterectomy to treat heavy menstrual bleeding and also used for contraception. A levonorgestrel IUD (Mirena) is a small coil that is coated with a Progestin hormone that is very slowly released into the uterine cavity. More recently, our group published successful treatment of patients with endometrial cancer and pre-cancer with Mirena. Mirena is unlikely to be effective in all conditions that involve the myometrium (fibroids, adenomyosis). Prior to an insertion of a Mirena an endometrial sampling (endometrial biopsy, Pipelle) or a hysteroscopy and a curettage (D&C) needs to be performed to exclude cancer.
- Pelvic floor exercise and pessaries: In patients with mild pelvic organ prolapse or elderly patients with significant medical co-morbidities an operation can be avoided by pelvic floor exercise and pessaries.
Types of Hysterectomy
In QLD more than 6,200 hysterectomies are performed every year and the vast majority are required for benign conditions (uterine fibroids, adenomyosis/endometriosis or to prevent cancer (BRCA gene mutation, Lynch syndrome). Hysterectomy is highly effective to treat those conditions.
Typically, it removes the uterus and the cervix (total hysterectomy). The ovaries can be removed if the patient is menopausal or the patient is at high risk for developing ovarian cancer (BRCA gene mutation). Otherwise the ovaries should be preserved to prevent artificial instant menopause and its consequences (osteoporosis).
Comparison of surgical techniques
Abdominal hysterectomy: A large number of hysterectomies are performed through an abdominal incision (“open”). This incision can be transverse (like a caesarean section) or through a midline incision. The recovery time for an open hysterectomy is 4 to 6 weeks and sometimes longer due to the need for a long incision to heal. An open hysterectomy is preferred for ovarian cancer surgery. Generally, an open hysterectomy is out dated for women requiring surgery for benign conditions and should not be performed in those circumstances. In particular, big women should avoid open surgery if not absolutely necessary.
Vaginal hysterectomy: Many hysterectomies are performed vaginally and have clear advantages over an open surgical approach, such as fewer complications, shorter hospital stay, quicker recovery and shorter healing time. While almost all gynaecologists are familiar with vaginal hysterectomy, some hysterectomies are too risky to be performed vaginally. Previous surgery (caesarean sections) or a narrow vagina (no vaginal birth) often makes this approach impossible. In those circumstances, a Total Laparoscopic Hysterectomy should be considered. Vaginal hysterectomy is still the surgical approach of choice in women who have their hysterectomy primarily for pelvic floor repair.
Total laparoscopic hysterectomy (TLH) is an operation that is done through keyhole incisions. It is suitable for almost all patients, even those with previous surgery, or obese and super-obese patients.
TLH is well established in Australia and safely practiced by experienced gynaecologists for at least 15 years. It uses a “keyhole” approach: CO2 gas is used to expand the abdominal cavity. Then three or four tiny incisions (5 mm) are made and a high-resolution camera plus thin instruments will be inserted into the abdominal cavity. The camera takes live images and the surgeon can operate by looking at the screen.
There are three main advantages of TLH compared to abdominal hysterectomy:
- Quicker recovery and less pain: Typically, patients who have a TLH are active after 1 to 2 weeks (work, home duties), compared to 4 to 6 weeks after an “open” procedure. Patients who have an abdominal hysterectomy require ten times more painkillers than patients who had a TLH. Patients who have a vaginal hysterectomy require twice the amount of painkillers compared to patients who have a TLH.
- Fewer surgical complications: The risk of surgical complications is reduced to 30% to 50% compared to an “open” hysterectomy.
- Cost effective: TLH has slightly higher costs of surgery. However these costs are offset by shorter hospital stay (1 to 2 days with TLH; 5 to 7 days with open hysterectomy).
Risks and surgical complications of Hysterectomy:
Any surgery carries risks. However, the overall rate of severe surgical complications is at least 30% higher in patients who have an Abdominal “Open” Hysterectomy compared to a Laparoscopic Hysterectomy.
- The risk of cardiac, cerebrovascular or anaesthetic complications (less than 1%), a risk of pelvic organ injury during surgery (1.5%) and a risk of deep vein thrombosis (1%). These risks are similar across all three surgical techniques. Vaginal discharge following hysterectomy is normal for up to 6 weeks. I recommend to abstain from sexual intercourse during that time to minimise the risk of infection.
- Patients who have constipation tendencies might require laxatives after any surgery because the painkillers we need to use can constipate.
- Patients considering a TLH have a 2% risk that the operation needs to be converted to an open procedure due to unforseen problems (bleeding, adhesions and distorted anatomy, etc).
- The risk of injury to bladder, ureter or bowel, blood vessels and nerves is approximately 1.5% and similar across all surgical techniques.
- Removal of ovaries in young women (oophorectomy) will result in menopause and is not recommended for young (premenopausal) patients with benign conditions.
- A risk of deep vein thrombosis (blood clot in calf) or pulmonary embolus (blood clot in lung) is low (less than 1%) and this risk is comparable across surgical techniques.
- The risk of postsurgical complications is 30% less with laparoscopic than with open (abdominal) hysterectomy. The risk of infection is much higher with open surgery than with TLH. Especially in obese and super-obese women (BMI>40) that risk can be as high as 50%. In contrast, that risk is much lower with TLH.
- Patients who require a radical hysterectomy (cancer, endometriosis) have a risk of bladder dysfunction for up to several weeks.
- Patients who have a TLH often experience “shoulder pain” for up to one day after surgery. The CO2 gas that we use in surgery can irritate some nerves that run along the spine and radiate upwards into the shoulder blade.
Hysterectomy techniques (1,2):
|Hospital stay||5-7 days||2-3 days||1-2 days|
|Surgical complications (postoperative)||18%||??||12%|
|Recovery from surgery||4-6 weeks||2-3 weeks||1-2 weeks|
|Duration of surgery||+25 mins|
(1) Janda et al., Lancet Oncol. 2010; 11: 772-80;
(2) Obermair et al., European Journal of Cancer 2012; 48: 1147– 1153.
Recovery from hysterectomy
Hysterectomy recovery time: You need to stay in hospital for one or two days if you have a laparoscopic hysterectomy. For open (abdominal) hysterectomy the hospital stay is longer. I recommend that you take it easy for the next couple of weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths for the next 6 weeks and other factors that could disrupt wound healing or facilitate an infection. The DO'S and DONT'S post hysterectomy are described here. Recovery from hysterectomy is difficult to predict. All going well, a patient should be able to go back to work and do normal housework after two weeks.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
Follow-up: After surgery, all patients with uterine cancer (except those with very low risk of recurrence) should be seen regularly for follow-up for 5 years. These examinations will always include pelvic examinations. I will discuss with my patients if any other tests (PAP smears, medical imaging, blood tests) are required. After five years, the risk of a recurrence becomes very low. Should you experience any bleeding or pain, please do not wait but contact my office straight away.
Pain after hysterectomy: All patients receive strong painkillers during and after surgery. All patients will receive pain killers upon leaving the hospital. It is critical that all patients continue the pain medication beyond discharge from hospital for approximately 10 days. Otherwise pain will catch up and you will worry.
Exercise after hysterectomy: Whenever possible we will mobilise patients on the day or the day after a hysterectomy with the help of experienced physiotherapy staff. At discharge, I recommend to "take it easy" for a week. Gentle exercise is possible as is light home duties. Competitive training should be avoided for a few weeks.
Hysterectomy is not recommended for the following reasons:
Reasons not to have a hysterectomy are birth control or to get rid of (normal) monthly periods. There are far less invasive procedures available to gynaecologists to achieve birth control and the same outcome.
I would also be hesitant to offer a hysterectomy for mood swings, bloating, headache, or menopause symptoms because these symptoms are mainly endocrine symptoms and as we all know the uterus does not produce hormones. These symptoms relate to the ovaries and a patient's hormonal function rather than the uterus. Removing the uterus will not address the symptoms, which will then persist or recur.
We also need to be careful with hysterectomy for Cervical Intraepithelial Neoplasia (CIN) without informing women that they will require meticulous follow up including vaginal vault cytology every year after surgery.
Unfortunately some hysterectomies are performed for abnormal uterine bleeding without prior curettage. The chances of finding a uterine malignancy “unexpectedly” are between 10% and 20%. If a hysterectomy is offered for abdominal uterine bleeding it is critical to sample the endometrium for cancer first and only then offer a hysterectomy.
For information about what to do and what not to do after a hysterectomy please read the speedy recovery fact sheet.