What is a hysterectomy?
The term “hysterectomy” comes from the Greek hystera, meaning “uterus,” and ektome, meaning “to cut out.” While hysterectomy refers to the removal of the uterus and, most commonly, the attached Fallopian tubes, there are several types of hysterectomies. Total hysterectomy, contrary to popular belief, does not mean that the ovaries are removed with the uterus. Rather, the term indicates the removal of the uterus and cervix. Subtotal, or partial, hysterectomy is the excision of the uterus above the cervix; the cervix is left in place. Either one or both ovaries may be removed with the uterus (unilateral oophorectomy or bilateral oophorectomy). Salpingo-oophorectomy refers to the removal of one of the Fallopian tubes along with the accompanying ovary, while bilateral salpingo-oophorectomy refers to the removal of both Fallopian tubes and ovaries.
Indications for hysterectomy can be divided into noncancerous and cancerous conditions. Within the noncancerous category, the most common indication for hysterectomy is symptomatic fibroids. Many women have fibroids, and the majority of fibroids do not cause symptoms and can be left alone. Symptomatic fibroids are those which are large enough to cause pressure symptoms in the pelvis, compress the bladder or rectum, or cause pain or discomfort during intercourse. Another type of symptomatic fibroids are those which cause excessively heavy menstrual bleeding and, when severe, anemia.
A hysterectomy is indicated in these situations if the patient fails to respond to less conservative therapy for symptomatic fibroids. Examples of conservative therapy for heavy bleeding include high-dose estrogen or birth control pills. A hysterectomy is usually performed only when childbearing is no longer desired, since removal of the uterus precludes pregnancy. Prior to hysterectomy, large fibroids may be shrunk with a course of a hormone called gonadotropin-releasing hormone. Unfortunately, this treatment results in menopausal symptoms, including hot flushes and bone density depletion, and therefore cannot be used for prolonged periods of time. More recently, treatments such as uterine artery embolization, in which the arteries feeding the uterus are blocked off using foreign particles such as gel foam, have been tried as an alternative to hysterectomy, in an attempt to preserve the uterus and avoid major surgery.
Another indication for hysterectomy is in patients who have had recurrent fibroids after myomectomy. A myomectomy is the surgical removal of isolated fibroids, rather than removal of the uterus itself. The benefit is that the uterus can be preserved, although the downside is that fibroids may regrow. Hysterectomy is the definitive treatment for uterine fibroids.
Another noncancerous indication for hysterectomy is adenomyosis, a painful condition whereby the cells of the uterine lining are abnormally embedded in the uterine muscle. No good treatments exist for this condition besides hysterectomy. Another indication for hysterectomy occurs in cases of abnormal uterine bleeding in which the bleeding is refractory to management with nonsurgical treatments, such as birth control pills or procedures that ablate the uterine lining. Other less common indications for hysterectomy are uterine prolapse (in which the uterus descends into the vaginal canal, causing discomfort or urinary incontinence), chronic pelvic pain (refractory to more conservative management), and large infections of the uterus and pelvis that are unresponsive to antibiotics. Hysterectomy may also be performed as part of a cesarean section if the surgeon encounters uncontrollable bleeding after delivery of the infant.
Uterine cancer is a clear indication for hysterectomy. Often, the cancer causes abnormal uterine bleeding. Prior to hysterectomy, the cancer has usually been confirmed on biopsy of the uterine lining. If the cancer is small and localized to a small area of the uterus, then removal of the uterus alone may be curative. More often, however, uterine cancer may have spread more deeply into the uterine wall or even grown beyond the uterus. In these cases, hysterectomy may be accompanied by more extensive surgery that includes removing lymph nodes or other pelvic structures.
Most frequently, hysterectomy is accomplished through a 6- to 8-inch midline incision running either down from the navel or across the lower abdomen near or below the hairline (known as a “bikini incision”). This procedure is referred to as an abdominal hysterectomy. Vaginal hysterectomy is the removal of the uterus through the vaginal canal, rather than through a surgical opening in the abdomen. This procedure is most often performed to resolve prolapse (because the uterus has already descended into the vaginal canal) or when the uterus is not massively enlarged and can be pulled down and out through the vagina. If the hysterectomy is performed because of large fibroid tumors, then the abdominal approach is usually used. On rare occasions, a vaginal hysterectomy may be facilitated using laparoscopy. In these cases, laparoscopy enables visualization and manipulation of the uterus via small incisions in the abdomen to assist in removal of the uterus through the vaginal canal.
During the hysterectomy, the patient is almost always under general anesthesia. The patient lies on her back for abdominal hysterectomies. In vaginal hysterectomies, the patient’s legs are placed in stirrups and the knees are spread apart to enable the gynecologist to gain access to the vaginal canal. The actual removal of the uterus involves clamping, transecting, and suture ligating the blood vessels that feed the uterus and the tissues that anchor the uterus in the pelvic cavity. Care is taken by the surgeon to avoid the ureters, the tubes carrying urine from the kidney to the bladder. The ureters are very close to the lower part of the uterus and can be damaged easily. If the entire uterus is removed, then the top end of the vagina, called the cuff, is sutured closed. If the cervix is left in place, then the top of the cervix is sutured closed.
After the surgery, the patient receives narcotic pain medication and antibiotics to prevent infection and is monitored carefully to confirm that vital signs are stable and recovery is appropriate. Laboratory tests may be performed to ensure that the patient is not unusually anemic and that important organs such as the kidneys are functioning properly. Until a patient is able to walk, a catheter (a rubber tube attached to a collecting bag) will be used to pass urine. Patients may initially take liquids by mouth. When they can tolerate liquids, indicating no apparent injury to the bowels, patients may begin to take solid food. A patient may be hospitalized for two to four days after the hysterectomy, although hospital stays in general have been shortening in length. On the whole, patients who receive vaginal hysterectomies have shorter hospital stays than patients receiving abdominal hysterectomies, assuming that no complications arise. Patients can usually resume normal sexual functioning six weeks after the surgery.
Hysterectomy can be used to provide relief from pressure, pain, and bleeding from the uterus. It may also be curative in the early stages of uterine cancer and can increase survival in later stages. For women who are finished with childbearing and whose lifestyles or responsibilities do not allow them to try more conservative treatments, many of which require several months to take effect, hysterectomy can provide definitive relief from symptoms within the defined time period needed to undergo scheduled surgery. In cases of life-threatening uterine hemorrhage, hysterectomy can save a woman’s life.
The common complications of hysterectomy are those which are common to many major surgeries. One complication is excessive blood loss. The average blood loss during a hysterectomy is estimated at between 400 and 500 cubic centimeters (about a pint). When removal of the uterus is difficult, for instance because of the position of large fibroids, increased blood loss is likely to occur. When excessive blood loss is of concern, the patient’s blood levels may be checked during the procedure. A patient who is significantly anemic may receive blood transfusions to avoid poor oxygenation of the major organs and to increase blood volume, and hence avoid shock. The number of transfusions depends on the amount of blood estimated to be lost. If a blood vessel continues to bleed after the patient leaves the operating room, then the patient may need to return to the operating room to have the bleeding vessel identified and sutured.
Another common complication of hysterectomy is infection. Even when aseptic techniques are followed, an infection may develop several days after the surgery. This is particularly true in vaginal hysterectomies, where the surgeon works through the vaginal canal, considered a clean but contaminated field. For this reason, patients are given antibiotics immediately prior to surgery in order to prevent infection. A patient who shows signs of infection after the surgery may be placed on an extended course of antibiotics. The source of these infections can range from the vaginal cuff site to the peritoneum (the lining of the pelvic and abdominal cavity) and the urinary tract.
The third major complication that can occur with hysterectomy is inadvertent damage to internal organs. The urinary tract and the bowels are particularly at risk during hysterectomy because of their proximity to the uterus. The ureters can be occluded inadvertently by the misplacement of a suture. If discovered early, this damage can be repaired. If the problem is not recognized, however, then a damaged ureter can result in kidney malfunction. For this reason, kidney function is carefully followed after the hysterectomy through blood tests. Since the bladder sits on the bottom half of the uterus, it is a common organ that can be damaged during a hysterectomy. If the bladder is accidentally entered using the scalpel during surgery, then it can usually be repaired during the procedure. Postsurgery, the patient may need prolonged catheterization of the bladder to enhance bladder recovery. The large and small intestines are another common site of surgical injury. They can be accidentally cut or sutured. Sometimes, this problem is not detected until after the patient has left the operating room, and the problem becomes apparent when normal bowel function does not return in a timely fashion postoperatively. The patient may experience nausea, vomiting, and abdominal distension and discomfort and may not be able to pass gas from the rectum.
Another complication that can occur after surgery is the formation of blood clots, particularly in the leg veins, as a result of the patient’s immobility during and after surgery. These clots can be dangerous when they break off from their source and move into the lungs, a condition called pulmonary embolism. Large pulmonary emboli can be life-threatening. Pulmonary emboli can be prevented using warm compression stockings during and after surgery to promote blood flow. Early ambulation (walking) after surgery can also decrease the chances of developing leg vein clots and pulmonary emboli.
Long-term complications of hysterectomy also include scar formation in the pelvis, called adhesions, which can interfere with bowel function or cause pelvic pain. Some patients may experience the prolapse of the remaining pelvic organs (such as the bowels and bladder) into the space formerly occupied by the uterus. Procedures may be employed during the hysterectomy to anchor the vaginal cuff and close any spaces where prolapse might occur.
In rare cases, removal of the uterus can inadvertently decrease blood supply to any remaining ovaries, leading to ischemia and loss of ovarian function. In these cases, the patient may experience the symptoms of estrogen deficiency, also known as menopausal symptoms. They include hot flashes, vaginal dryness, and, when estrogen deficiency is prolonged, bone density loss. In women whose hysterectomies included removal of the ovaries, the hot flashes may become apparent a few days after surgery. In these cases, estrogen therapy or other medications may be of benefit.
The impact of a hysterectomy on a woman’s psychological state varies from woman to woman. In women who have been suffering a great deal from their symptoms, be it pressure and pain or abnormal bleeding, a hysterectomy can be a relief and enable them to return to their activities of daily living. Hysterectomy can improve sexual function in many cases. In other women, a hysterectomy can trigger a sense of loss and represent the end of the woman’s fertility, which is often associated with youth and vitality.
In ancient times, the complaints of women and the illnesses of the female organs were viewed as coming from an “unhappy uterus.” It was believed that the uterus had the primary purpose of childbearing and that, when the uterus was not occupied with this function, it might show its wrath by abnormal bleeding and pain. These beliefs prevailed for centuries; early medical history indicates that women’s gynecologic complaints were largely ignored. Moreover, no safe surgical procedures had been developed.
A noteworthy event in early American medical history was the operation attempted and documented by a frontier physician and surgeon, Ephraim McDowell. In 1809 in Danville, Kentucky, this daring young doctor carried out experimental surgery on a middle-aged woman to remove a huge ovarian tumor. Without the benefit of anesthesia and a sterile technique, he performed successful abdominal surgery on four out of five other patients.
Myomectomy, or removal of a fibroid tumor of the uterus, was the next procedure to be performed—first in France and later (about 1850) in Massachusetts by Washington Atlee. The first hysterectomy was successfully performed by Walter Burnham in the same decade, but he lost twelve of his next fifteen hysterectomy patients. In the text Operative Gynecology (1898), Howard A. Kelly of Baltimore describes one hundred hysterectomies that he performed in the late nineteenth century, all done because of pelvic infection. He lost only four patients, though convalescence for some survivors was prolonged.
Remarkable medical progress occurred in the nineteenth century in abdominal and vaginal surgical techniques. In the 1850s, Marion Sims of South Carolina was the first to perform vaginal surgery in the United States. He successfully repaired a vesicovaginal fistula, an abnormal opening between the bladder and the vagina through which urine escapes into the vagina. In the late nineteenth century, the “Manchester” operation for uterine prolapse was performed by A. Donald in Manchester, England. Prior to this procedure, uterine prolapse was treated with a pessary, a device inserted into the vagina to hold the uterus in place.
In the 1930s, N. Sproat Heany of Chicago devised the present-day technique of vaginal hysterectomy. Vaginal (as opposed to abdominal) hysterectomy, it was believed, resulted in a less complicated procedure with shorter convalescence and more cosmetically pleasing results for most patients. For some time, vaginal hysterectomy was viewed as superior to abdominal hysterectomy. In the 1970s, between 25 and 40 percent of all hysterectomies were accomplished vaginally, depending on the age of the woman at the time of surgery. In 1981, however, a landmark study published by the US Congress, weighing the costs, risks, and benefits of hysterectomy, stated that women undergoing vaginal hysterectomy are more likely to have postoperative fever and to receive antibiotic treatment. Moreover, vaginal hysterectomy patients may undergo further surgery at a rate as high as 5 to 10 percent.
By the late 1980s and early 1990s, the trend among many gynecologists had shifted away from hysterectomy to more conservative treatments, when possible. Physicians began to question whether hysterectomies were, in some or even in most cases, medically necessary. As more information became available to women regarding alternatives to hysterectomy (a major revenue-producing surgical procedure in the United States), many women became more apt to question their physicians when told that hysterectomy was the only possible solution to their gynecological problems.
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