Hysterectomy

What is a hysterectomy?

A hysterectomy is a surgery that removes a woman’s uterus, sometimes with or without the cervix. Many people think that a hysterectomy means removal of the ovaries too. This is not usually the case, particularly if you are premenopausal. Having your uterus removed means that you will no longer menstruate every month.

Hysterectomies are done for many reasons, but the most common include:

• Uterine fibroids that cause heavy bleeding, painful periods, bulk symptoms, or pain with intercourse
• Dysfunctional bleeding – irregular bleeding not improved with medicines
• Endometriosis/Adenomoysis (endometriosis of the uterus)
• Heavy monthly bleeding
• Chronic pelvic pain
• Cancers of the uterine, cervix, ovary or fallopian tube
• Prolapse symptoms
• Infection - such as chronic PID

A hysterectomy may be done in either thru the vagina, abdominally or laparoscopically. The type of hysterectomy is dependent on many factors including:

• Number of previous children and how they were delivered – vaginal versus cesarean section
• Size of the uterus
• Size of the patient
• Presence of cervical dysplasia such as a current abnormal pap smear showing active HPV infection
• History of previous pelvic surgeries/history of adhesions
• Comfort of your surgeon with different surgical methods (you should ask!)

With the advancement of technology, laparoscopic hysterectomies are becoming feasible for most patients, even those with large uteri. A laparoscopic hysterectomy is done entirely laparoscopically with no large incisions, typically just three small laparoscopic sites. The uterus is removed at the level of the cervix and is then morcellated (chopped up) into many small pieces that are removed via the small incisions. It avoids the use of a large incision and speeds healing and recovery by staying minimally invasive.

This procedure is called a laparoscopic supracervical hysterectomy or LSH. The ovaries may or may not be removed at the same time, depending on your discussion with your surgeon. Leaving the cervix in place is safe to do as long as you have no evidence of current cervical abnormality (a previous history of an abnormal pap is not necessarily a contraindication to laparoscopic hysterectomy). Having the procedure done laproscopically decreases healing time, allows sooner intercourse, and typically is done as an outpatient. Other benefits include: lower rates of infection, likely decreased blood loss, no “bikini” scar on your abdomen, and no healing in the vagina.

An abdominal hysterectomy (TAH) is done through the abdominal wall and involves an incision either across the bikini area or up and down on your abdominal wall. It is typically still the surgery used for women who are known to have significant abdominal adhesions that obscure visualization, some cancers of the reproductive tract, or very large uterine fibroids. Drawbacks of TAH are: longer recovery time, increased infection rate, risk of hernia at incision site, and adhesion formation.

A vaginally hysterectomy (TVH) is traditionally used for women that have small enough uteri to pass thru the vagina. Also, most women having a vaginal hysterectomy have had one or less cesarean sections. Having a vaginal hysterectomy involves removing both the uterus and cervix. Ovaries may be left or removed at the same time as a TVH. Sometimes a vaginal hysterectomy is combined with a laparoscopy, typically to help facilitate removal of the ovaries. This is called a LAVH – laparoscopically-assisted vaginal hysterectomy. Risks of LAVH/TVH include infection, bleeding, and damage to the bladder or ureters, but less likely than with a TAH.

Having a hysterectomy is a big decision, and one you should thoroughly discuss with your family and surgeon. However, technology is changing rapidly and allowing patients to regain function more quickly and get back to their lives sooner. Make sure you do some research and come ready to discuss treatment options with your health care provider.

Hysterectomy Issues to Discuss:

1. Which is the right approach for me? TAH, TVH, LAVH, LSH
2. How long will I need to recover and/or take off work?
3. What are my restrictions exactly? Driving, exercising, etc.
4. When can I engage in sexual relations again?
5. Do I need my ovaries removed?
6. Do I need my cervix removed?
7. What about any incontinence? Some incontinence procedures can be combined with hysterectomy
8. Discuss any strong family history of breast, colon, ovarian, or uterine cancers with your doctor prior to hysterectomy
9. Will this affect my libido? Removal of the ovaries prior to menopause can affect libido, make sure you discuss this with your surgeon prior to surgery. Many women want their ovaries removed to help reduce their risk of subsequent ovarian cancer. It is not a simple yes or no answer!