Surgical Removal of the Uterus, or Womb

Hysterectomy is the surgical removal of the uterus, or womb. This article will explain:

  • Why you may need to have a hysterectomy
  • How hysterectomy is performed
  • What to expect before and after the operation

Remember, no two women undergoing a hysterectomy are alike. The reasons for and the outcome of any surgical procedure depend on your age, the severity of your problem, and your general health. This article is not intended to take the place of your surgeon’s professional opinion. Rather, it is intended to help you understand the basic elements of this surgical procedure. Read this information carefully. If you have questions after reading this material, discuss them openly and honestly with your surgeon.

Why Are Hysterectomies Performed?

Hysterectomy may be performed to treat a variety of gynecological (female reproductive system) problems. It is an elective procedure 90 percent of the time. Today most hysterectomies are done to treat benign (non-cancerous) fibroid tumors of the uterus. While not life-threatening, these growths cause pelvic pain, excessive bleeding or pain during sexual intercourse. Fibroid tumors are common and usually do not require surgery. Other forms of treatment, which preserve the uterus and childbearing capacity, are also available. You should discuss these options with your surgeon.

Endometriosis is a condition in which the tissue lining the uterus becomes displaced and grows in other parts of the abdomen, where it can cause pain. Endometriosis is the second most common reason for a woman to have a hysterectomy.

However, the practice of treating endometriosis by performing hysterectomy has been declining in the last decade because other treatments have evolved. You should discuss these other options with your surgeon first to see if another treatment for endometriosis may be effective for you.

Prolapse of the uterus is another reason why some women decide to undergo a hysterectomy. In this condition, the uterus descends or sags into the vagina due to stretching of the ligaments and fibrous tissue that usually hold it in place. Women with cancer of the uterus or cancer of the cervix require special types of treatment, which may include a simple or radical hysterectomy. These women should seek the counsel of a gynecologic oncologist.

Are All Hysterectomies the Same?

You may hear different names used to refer to this type of operation. That is because there are different types of hysterectomies. A total hysterectomy or panhysterectomy applies only to the removal of the uterus and cervix. When the ovaries and fallopian tubes on both sides of the uterus also are removed, the procedure is called a hysterectomy and bilateral salpingooophorectomy (“salpingo” is from the Greek word for “tube,” while “oophor” is from the Greek word for “bearing eggs,” that is, the ovaries). A radical hysterectomy is a much more extensive procedure and is only performed in special situations such as cancer of the uterus or cervix. It includes removal of the uterus, cervix and surrounding tissue, the upper vagina, and usually the pelvic lymph nodes. A surgeon with special training in gynecologic oncology performs this type of procedure.

Is Hysterectomy Mainly for Older Women?

You may be surprised to know that 42, a relatively young age, is the average age of women undergoing hysterectomy. More than three-fourths of all women who have a hysterectomy are between 20 and 49 years of age.

Is There Any Reason to Avoid or Delay Hysterectomy?

It is not sensible to have a hysterectomy in order to prevent cancer of the cervix or uterus. In this case, the risks of having a major operation outweigh any supposed cancer-protection benefits. Furthermore, hysterectomy is not considered to be the first choice for sterilization in most healthy women. Another procedure, tubal ligation, is a cheaper, easier and safer method for most women.

Hysterectomy may not be advisable if your problem has not been adequately diagnosed. For instance, if you have pelvic pain that is not specifically caused by the uterus, a hysterectomy may not relieve your pain. The pain may be due to problems in your digestive, urinary or skeletal systems. In these cases, your doctor will want to do the proper tests and X-rays to locate the exact source of your pain. In addition to the tests and X-rays indicated, a diagnostic laparoscopy may be helpful in selecting the appropriate treatment.

Similarly, most women with abnormal bleeding, especially menopausal or post-menopausal women, should have an endometrial biopsy (EMB) or a dilatation and curettage (D&C) procedure to rule out uterine cancer before undergoing a hysterectomy. Hysteroscopy (a surgical procedure in which a gynecologist uses a small lighted telescopic instrument to view the inside of the uterus) should not be performed until uterine cancer has been ruled out by D&C or EMB. If cancer is present within the uterus, the hysteroscope has the potential to push it out through the fallopian tubes into the abdominal cavity.

Finally, women who are obese, who have diabetes, high blood pressure, or some other chronic conditions, are at increased risk during any type of operation. For these women, hysterectomy should only be considered if reasonable alternatives have been exhausted.

If you have any questions about hysterectomy, ask your doctor. If it would make you feel more confident about your medical treatment, get a second opinion from another physician who is qualified to diagnose and treat your condition. Unless you have a severe pelvic infection or uncontrollable bleeding, you do not have to rush into having a hysterectomy. Even with a diagnosis of cancer, a short delay to seek another qualified opinion is usually safe and worthwhile.

How Do I Decide if I Should Have a Hysterectomy?

You will no longer be able to get pregnant after a hysterectomy. Thus, before you choose elective hysterectomy, you must consider both the severity of your problem and your desire to have children in the future.

Although this operation may improve your quality of life by relieving chronic symptoms, such as pain or bleeding, some women are willing to tolerate these conditions.

Ask yourself:

  • Do I want to become pregnant in the future?
  • How do I feel about not having a uterus?
  • What is my husband’s (or partner’s) attitude toward this operation?

Ask your surgeon:

  • What will happen if I don’t have a hysterectomy?
  • What are the risks of a hysterectomy in my particular case?
  • Is my condition likely to improve on its own, stay the same, or get worse?
  • Is a hysterectomy medically necessary or recommended to relieve my particular symptoms?

Before your operation, you will be asked to sign a document giving your “informed consent” to the operation. This form lets you know any risks or possible complications that can be caused by the surgical procedure. Some states have specific laws that pertain to hysterectomies. These laws require surgeons to explain the alternatives and the risks of the procedure and are intended to make sure you underastand the potential after-effects of the operation.

How Is Hysterectomy Performed?

The surgeon can remove the uterus through a surgical incision made either inside the vagina or in the abdomen. In both the vaginal and abdominal approaches, the surgeon detaches the uterus from the fallopian tubes and ovaries as well as from the upper vagina.

Abdominal Hysterectomy

When a hysterectomy is performed through an incision in the abdomen, it allows the surgeon to see the pelvic organs easily and gives him or her more operating space than is permitted in a vaginal hysterectomy.

Thus, for large pelvic tumors or suspected cancer, your surgeon may decide to do the procedure abdominally. Patients who have an abdominal hysterectomy require a longer hospital stay than those who have a vaginal hysterectomy. In addition, they may experience greater discomfort immediately following the operation, and will have a visible scar.

However, the surgeon often can make a less-noticeable horizontal incision, called a bikini-cut, that extends along the top of the pubic hairline.

Vaginal Hysterectomy

The vaginal approach to hysterectomy is ideal when the uterus is not enlarged or when the uterus has dropped as a result of the weakening of surrounding muscles. This approach is technically more difficult than the abdominal procedure because it offers the surgeon less operating space and less opportunity to view the pelvic organs. However, it may be preferred if a patient has a prolapsed uterus, if the patient is obese, or in some cases has early cervical or uterine cancer. A vaginal hysterectomy leaves no external scar.

A variation on vaginal hysterectomy is LAVH (laparoscopic-assisted vaginal hysterectomy). A laparoscope is a device the surgeon can use to examine the inside of the pelvis. LAVH is an alternative for women who have ovarian disease but previously had only one choice: an abdominal hysterectomy that leaves a long incision. With LAVH, much of the procedure is done through tiny incisions using a laparoscope. The rest of the procedure then can be finished vaginally.

Stages of Recovery

After the operation, you will likely remain in the recovery room for one to three hours. You may be given pain medication, and possibly antibiotics to prevent infection. You will probably be able to walk around your room the day after your operation, depending on the type of procedure you underwent. Most patients go home the third day following an abdominal hysterectomy and by the first or second day after a vaginal hysterectomy or LAVH.

Complete recovery from abdominal hysterectomy usually takes six to eight weeks because the incision is typically 5 inches long. During your recovery, you can expect a gradual increase in activities. Avoid all lifting during the first two weeks of your recovery period and get plenty of rest. In the weeks following the surgical procedure, you can begin to do light chores, some driving, and even return to work, provided your occupation does not involve too much physical activity.

Around the sixth week following the operation, you can take tub baths and resume sexual activity. Women who have had vaginal hysterectomies generally recover more quickly.

Risks or Complications?

Hysterectomy is regarded as one of the safest operations. Nevertheless, no operation is without risk. Severe complications and even death occasionally occur with this operation.

The uterus is located between the ureters (small tubes which transport urine from the kidneys to the bladder) on each side, the urinary bladder in front, and the rectum behind. All of these structures are subject to injury, especially if the operation is difficult, as can occur with large fibroids, endometriosis or cancer. Bleeding and infection also can occur, but most infections are now avoided by using antibiotics. Blood clots in the legs (DVT-deep vein thromboses) sometimes occur postoperatively and can break off and travel to the lungs causing a sometimes fatal pulmonary embolism (blood clot). These clots largely can be avoided in high-risk patients by using special stockings during the operation or by using blood thinners.


Long-Term Effects

After having a hysterectomy, you will no longer be able to get pregnant and will no longer have menstrual periods. If you were premenopausal (still menstruating) before the operation and have your fallopian tubes and ovaries removed, you will experience all of the symptoms of menopause as your body gets used to different hormone levels. These symptoms may include hot flashes and perhaps irritability and depression. If the symptoms are severe, your doctor may prescribe hormone replacement medication. Hysterectomy usually has no physical effect on your ability to experience sexual pleasure or orgasm.

Following hysterectomy, the ovaries will continue to function; however, the actual occurrence of menopause will be difficult to determine since the uterus has been removed and the patient will no longer have periods. As the age of menopause, approximately age 50, is approached, symptoms such as hot flashes may warrant testing to see if hormone replacement therapy is indicated. If you experience vaginal dryness, it can be remedied by using prescription hormone creams or pills or water-soluble lubricants that you can purchase at the pharmacy.

A sense of loss following the removal of any organ is normal and takes time for adjustment. While depression following hysterectomy does not happen to everyone, it is more common if the operation was done because of cancer or severe illness, rather than as an elective operation.

Additionally, if you are under age 40 or the operation interfered with your plans to have children, depression is more likely to occur. This depression can be temporary, depending on your general outlook on life and the availability of a good support group of family and friends. Most women experience an improvement of mood and increased sense of well-being following hysterectomy. For many, relief from fear of pregnancy results in heightened sexual enjoyment following the procedure.

Surgery by Surgeons

A fully trained surgeon is a physician who, after medical school, has gone through years of training in an accredited residency program to learn the specialized skills of a surgeon. One good sign of a surgeon’s competence is certification by a national surgical board approved by the American Board of Medical Specialties. All board-certified surgeons have satisfactorily completed an approved residency training program and have passed a rigorous specialty examination. The letters F.A.C.O.G. (Fellow of the American College of Obstetrics and Gynecology) or F.A.C.S. (Fellow of the American College of Surgeons) after a surgeon’s name are a further indication of a surgeon’s qualifications. Surgeons who become Fellows of the College have passed a comprehensive evaluation of their surgical and OB/GYN training and skills; they also have demonstrated their commitment to high standards of ethical conduct. This evaluation is conducted according to national standards that were established to ensure that patients receive the best possible surgical care.

Laparoscopically Assisted Vaginal Hysterectomy

To treat certain problems of the uterus, your doctor may suggest a procedure called laparoscopically assisted vaginal hysterectomy (LAVH). LAVH combines laparoscopy and hysterectomy. Laparoscopy is used to look into the abdomen at the reproductive organs. Hysterectomy is surgery to remove the uterus.

What Is LAVH?
LAVH is a special form of hysterectomy — removal of the uterus. The uterus is a reproductive organ in the lower abdomen.

The uterus can be removed in two ways. When it is removed through a cut (incision) in the abdomen, the procedure is called an abdominal hysterectomy. When it is removed through the vagina, it is called a vaginal hysterectomy.

LAVH involves the use of a small, telescope-like device called a laparoscope. The laparoscope is inserted into the abdomen through a small cut. It brings light into the abdomen so that your doctor can see inside.

The laparoscope also can be used before hysterectomy to look at the pelvic organs to help your doctor see what conditions are present.

Reasons for LAVH 
Hysterectomy may be offered as a treatment option for problems with the uterus.

Following are reasons to perform LAVH:

  • Adhesions
  • Endometriosis
  • Fibroids
  • Salpingo-oophorectomy. If the ovaries and fallopian tubes also are removed during hysterectomy, it is called salpingo-oophorectomy.

 

The Procedure 
Before LAVH, certain steps will be taken to prepare you for the procedure:

  • Your pelvic area and abdomen may be shaved.
  • You will be given an intravenous (IV) line.
  • You will be given anesthesia (pain relief). You will not be awake during the surgery.

In some cases, an abdominal hysterectomy may be required if an LAVH could not be done.

Benefits 
The main reason for LAVH is to allow the uterus to be removed safely through the vagina if a standard vaginal hysterectomy cannot be done.

Risks
There are some risks that may occur with any surgery. These may include:

  • Bleeding
  • Infection
  • Problems from the anesthesia
  • Blood clots in the veins or lungs
  • Death (rare)

LAVH can take longer than other types of hysterectomy. This means that you may need more anesthesia than you would with other forms of hysterectomy.

After Surgery 
Hysterectomy is major surgery, no matter how it is done. You will have some pain. You may need to stay in the hospital for a few days.

After you leave the hospital, you will need to rest and take care of yourself.

Make sure you know the warning signs of a problem. Contact your doctor if you have any of the following:

  • Fever or chills
  • Heavy bleeding or vaginal discharge
  • Severe pain
  • Redness or discharge from the abdominal cuts
  • Problem with urination or bowel movements
  • Shortness of breath or chest pain

 

Finally … 
If you have problems with your uterus, you and your doctor may decide that a hysterectomy is the best treatment. LAVH may be an option.

This excerpt from ACOG’s Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.

To ensure the information is current and accurate, ACOG titles are reviewed every 18 months.

Copyright © October 2000 The American College of Obstetricians and Gynecologists