Hysterectomy

Hysterectomy is the most common type of elective surgery for Australian women. The majority of hysterectomies are to treat conditions such as fibroids, heavy bleeding, endometriosis/adenomyosis and prolapse. The development of several new treatments for some of these conditions will hopefully see a reduction in the number of hysterectomies currently performed.

Before you decide

A hysterectomy is a procedure that rarely needs to be performed urgently, except in the case of cancer or uncontrolled bleeding after delivery of a baby. Therefore, a woman considering the procedure can take time to investigate all her options, including other possible treatments. Women advised to have a hysterectomy for a non-cancerous condition without firstly being offered more conservative treatments may benefit in obtaining a second opinion from another gynaecologist.

Deciding whether to have a hysterectomy can be a difficult and emotional process. By becoming informed about the procedure, women can confidently discuss available options, express their concerns and wishes with their gynaecologist, and make a decision that is right for them.

Other options for fibroids
Fibroids, also referred to as myomas or leiomyomas, are predominantly noncancerous growths of uterine muscle tissue. The most common symptom associated with fibroids is heavy bleeding. Available treatments depend upon the location and number of fibroids, the severity of symptoms, the woman's age and her childbearing plans. For women nearing menopause, simply waiting may be a viable option as the drop in oestrogen at the menopause may result in the fibroids shrinking sufficiently to alleviate the symptoms. Similarly, a temporary menopause can be induced with the synthetic hormones GnRH analogues which stop the ovaries from producing oestrogen. The Mirena intra-uterine system (IUS) may be suitable for some women (see heavy bleeding section).

Heat or laser can be used to reduce the size of some types of fibroids (myolosis). In addition, fibroids can be surgically removed (myomectomy). This procedure is generally reserved for women still wishing to have children. GnRH analogues can be used to shrink fibroids before surgery to make their removal easier.

A relatively new procedure in Australia, uterine fibroid embolisation (UFE) is now available in most major centres. It involves injecting particles into the blood vessels which in turn blocks the blood supply to the fibroid, causing it to shrink. The procedure's long term success rate, safety and effect on fertility are yet to be fully established.

Other options for heavy bleeding
A woman's menstrual periods are considered 'heavy' if they significantly interfere with her daily activities. Long periods (more than seven days), flooding and the passing of blood clots are all indications of heavy bleeding. Treatment for heavy bleeding will depend upon its cause but may include non-hormonal drugs (NSAIDs, tranexamic acid) and hormonal drugs (oral contraceptive pill).

The Mirena intra-uterine system (IUS) has been found to be very effective in reducing heavy bleeding. Mirena is similar to an IUD but also includes a reservoir that releases constant low dosages of progestogen directly into the uterus. It has been suggested that approximately 60% of women can avoid hysterectomy by using Mirena (1).

Other options include the removal of the endometrium by endometrial ablation. In the past, endometrial ablation was mostly performed using a roller-ball but today microwave, radio wave and balloon ablation provide further options.

Other options for uterine prolapse
A uterine prolapse occurs when weakened pelvic floor muscles, ligaments or vaginal walls cause the uterus to drop from its original position in the pelvic cavity, into the vagina. Often other pelvic organs like the bladder or bowel will also prolapse in conjunction with the dropping of the uterus. A mild prolapse can be helped with regular pelvic floor exercises, while a mild to moderate prolapse may be treated with the use of a ring pessary (ie. a silicon device fitted firmly into the vagina to physically support the uterus). Pessaries may be suitable for women who do not wish to have surgery or who are unsuitable candidates for surgery (eg. elderly women or women with other medical conditions that make surgery high risk). A number of surgical procedures are available which correct uterine prolapse without hysterectomy.

Other options for endometriosis/adenomyosis
Endometriosis is a condition in which endometrial tissue (the tissue that lines the uterus) grows in other parts of the body, usually in the pelvis. Adenomyosis occurs when the endometrial tissue grows into the muscle wall of the uterus. Treatment for endometriosis and adenomyosis includes a range of hormonal drugs, such as progestins, Danazol and GnRH analogues. Alternatively, the endometrial tissue can be surgically removed. For women experiencing heavy bleeding as the main symptom of adenomyosis, the Mirena intra-uterine system (IUS) may bring relief.

For further information on the treatment options described above contact our Health Information Line (see below for contact details).

When you decide

Sub-total or partial hysterectomy involves the removal of Fallopian tubes and the upper two-thirds of the uterus only, preserving the cervix. This procedure is not commonly performed in Australia.
Hysterectomy with ovarian conservation involves the removal of the Fallopian tubes, uterus and the cervix, while preserving the ovaries. Sometimes referred to as a total hysterectomy.
Hysterectomy with oophorectomy involves the removal of the Fallopian tubes, uterus and cervix, together with one or both sets of ovaries.
Radical or Wertheim's hysterectomy involves the removal of the Fallopian tubes, uterus, cervix, ovaries as well as nearby lymph nodes and the upper portion of the vagina. This type of hysterectomy is used in the treatment of some gynaecological cancer cases.

Risks/benefits of keeping your ovaries

Some gynaecologists recommend having the ovaries removed during a hysterectomy to prevent the possibility of developing ovarian cancer. For the pre-menopausal woman, the removal of the ovaries results in a reduction of the female hormones oestrogen and progesterone, bringing on an 'instant' menopause (referred to as a surgical menopause). The drop in hormone levels may cause menopausal-related symptoms such as hot flushes, night sweats and vaginal dryness and also increase the risk of heart disease and osteoporosis. In pre-menopausal women, ovaries are the main source of androgens, including testosterone. Testosterone is thought to play a role in sexual desire and response.

Although ovarian cancer is often deadly (it tends to be at an advanced stage when diagnosed), the actual risk of developing it is quite low at 1 in 104 (2). The reluctance of many women to take HRT long term, the side effects caused by ovary removal and the relatively low risk of ovarian cancer suggest that retaining healthy ovaries during a hysterectomy would be of benefit to many women's future health (3). Women who are at higher risk of ovarian cancer (eg. family history) should discuss the pros and cons of keeping their ovaries with their gynaecologist.

In some cases, premenopausal women who retain their ovaries during a hysterectomy experience the menopause up to two years earlier. This is most likely due to inadvertent damage to the local blood supply during surgery, or the formation of adhesions or scar tissue.

Abdominal, vaginal or laparoscopic

The actual hysterectomy operation can be performed in several different ways. The method chosen will depend on the surgeon's skills, expertise and preference, the reason for the hysterectomy and the woman's characteristics (eg. weight, previous pelvic surgery, if she has had children).

Abdominal
An abdominal hysterectomy is conducted when there is a need for extensive exploration (in the case of cancer), if the uterus is enlarged or if the woman has never had children or is obese. The presence of large fibroids, extensive adhesions or endometriosis are other examples where this procedure is often preferred. An abdominal hysterectomy can be performed in two ways, with a vertical incision or a bikini line cut.

A vertical incision generally involves a cut from the navel to the pubic hairline. The bikini line cut, as its name suggests, is done horizontally, directly above the pubic hairline. It leaves a less obvious scar and results in a shorter recovery time.

The advantages of an abdominal hysterectomy are lower incidence of damage to the urinary tract and blood vessels. It also allows the repair of a prolapse at the same time. The disadvantages are more pain, a lengthier hospital stay and longer recovery time.

Vaginal
A vaginal hysterectomy involves making an incision in the upper portion of the vagina and removing the uterus through the vagina. The advantages of this method are less pain, a shorter hospital stay and recovery time and the absence of a visible scar. A review of different surgical approaches to hysterectomy for non-cancerous conditions concluded that a vaginal hysterectomy should be performed in preference to an abdominal hysterectomy where possible (4).

Laparoscopic
The term is used to describe a hysterectomy in which any part of the operation is performed laparoscopically. Laparoscopic surgery involves making three or four small incisions in the abdomen. A laparoscope (an instrument that allows the interior of the abdomen to be viewed) is inserted through one of the incisions into the abdominal cavity. The surgeon is then able to view the pelvic organs on a video screen and insert surgical instruments through the other incisions.

Laparoscopic procedures have been promoted as being advantageous due to a shorter hospitalisation and recovery time than for an abdominal hysterectomy. However, the surgeon must be experienced in the procedure before these benefits can be seen. Disadvantages include a possible longer operating time (depends on how much of the operation is performed laparoscopically), higher costs and an increased risk of damage to the urinary tract. Women considering undergoing a laparoscopic hysterectomy are encouraged to enquire about the surgeon's training in this procedure and the number of procedures s/he has performed.

Tips for visiting the gynaecologist

• When visiting the gynaecologist to discuss the option of having a hysterectomy there are a number of questions to keep in mind.
  
  
• Are there any other suitable treatment options available besides a hysterectomy?
  
• What occurs in these treatments and what are the success rates/failure rates?
  
  
• What type of hysterectomy would be performed and which organs would be removed?
  
  
• What will the method of surgery be - abdominal, vaginal or laparoscopic?
  
  
• What is the surgeon's expertise in procedures such as vaginal or laparoscopic hysterectomy?
  
  
• What are the possible complications/side effects (including sexual function)?
  
  
• What is the length of recovery time (in hospital, before returning to work/normal activities)?
  
  
• Will hormone replacement therapy be recommended?

It may be useful to take along a friend/partner. This person can provide support and also take notes of what is said, providing a record of the consultation. Requesting written information on the procedure can also be helpful.

Risks and complications

The most common complications following hysterectomy are post-operative fever and infection. Other more serious problems that can occur include haemorrhage, the formation of a blood clot in the lungs, damage to surrounding organs during surgery and urinary complaints. There are also risks associated with the use of anaesthetics.

Following a hysterectomy, there is an increased risk of vaginal vault prolapse. A vaginal vault prolapse occurs when the top of the vagina drops down due to a reduction in support structures. Further surgery may be required to correct the problem. The risk of vaginal vault prolapse can be reduced at the time of hysterectomy by simple additions to the procedure.

Risks and complications depend upon the type of hysterectomy performed and the individual woman's health status (eg. smoking, obesity, other health conditions). Therefore, women should discuss their risk levels with their gynaecologist.

Recovery

Following surgery, women may feel nauseous, a side affect of the general anaesthetic, as well as some pain and discomfort in the abdominal region. Drugs to relieve both nausea and pain are provided. There may also be some vaginal discharge/bleeding which should reduce after a few days. Women are encouraged to get up and walk around on the first day following surgery. This exercise is important in avoiding constipation and gas and in decreasing the risk of developing blood clots and lung infections. Hospitalisation time varies according to the type of hysterectomy performed and whether any post-operative complications are experienced. Generally, hospitalisation for uncomplicated abdominal hysterectomy is 3-5 days and 2-3 days for vaginal or laparoscopic hysterectomy.

The overall time it takes for a woman to recover from a hysterectomy is, again, dependent on the type of hysterectomy performed and the individual person. Women who have an abdominal hysterectomy will generally require six to eight weeks before they can return to normal activities/work. Those who have a vaginal or laparoscopic hysterectomy can expect a shorter recovery time. Generally, women should avoid any heavy lifting, bending at the waist, pressure on the wound, active sports or sexual penetration during their recovery.

Usually, a post-operative check-up takes place approximately six weeks after the operation, to ensure that everything has healed properly. This visit provides an opportunity for a woman to discuss any concerns she may have and to ask what types of activities are now permitted.

Depression
There is actually little evidence to suggest a direct connection between having a hysterectomy and developing depression. In fact, many women's psychological symptoms improve due to relief from the gynaecological problem/s for which they were having a hysterectomy. Those at risk of developing depression following a hysterectomy are women with existing psychological problems, women who do not find symptom relief, women who develop serious post-surgery complications or side effects and women who have been rushed into the procedure without coming to terms with it.

Symptoms of depression may include: severe and prolonged feelings of sadness and hopelessness; diminished interest in activities; decrease in appetite, significant weight loss or gain; sleep disturbance; decreased libido; lack of energy; and thoughts of death or suicide. Women suffering from depression following their hysterectomy should consult either their general practitioner or a counsellor, and may find joining a support group to be helpful.

Surgical menopause and hormone replacement therapy (HRT)
Pre-menopausal women who have a hysterectomy with bi-lateral oophorectomy (both ovaries removed) will undergo a surgical menopause. Unlike the gradual changes usually experienced by women in natural menopause, these changes are more sudden and can be quite distressing. HRT is one treatment option often recommended by doctors as a way of alleviating menopausal symptoms like hot flushes and vaginal dryness.

HRT usually involves the administration of the hormones in the form of either pills, patches, sprays, gels or implants. Women who have had their uterus removed are usually only given oestrogen replacement as the progestogen component is prescribed to prevent the thickening of the uterus and associated uterine cancer.

Only limited data are available on the risks and benefits of using HRT in women who have experienced a surgical menopause. Women deciding on whether to take HRT following a hysterectomy with bi-lateral oophorectomy need to discuss the issue with their doctor.

For women not wishing to take HRT, there are a number of alternative options that may help alleviate menopausal symptoms. These include eating a diet rich in phytoestrogens and calcium, participating in regular exercise, practicing stress management strategies and trying natural and herbal remedies.

Sex after hysterectomy

Penetrative sex is not recommended until the top of the vagina has safely healed, approximately six to eight weeks after hysterectomy. During this time women may wish to focus on other activities such as the touching of outer genitals, hugs, kisses and massage. Healing times differ between individuals so women may wish to discuss this with their gynaecologist at the post-operative check-up.

Physiological changes
Many women do not experience any change in sexual activity following a hysterectomy. Women who were having a hysterectomy for conditions that may have interfered with their sex life (eg. made sex uncomfortable/painful, left them feeling unwell) may notice an increase in sexual desire/activity as a result. Not having to be concerned about unwanted pregnancy can also have a positive effect.

Pre-menopausal women who have their ovaries removed during a hysterectomy may experience vaginal dryness and thinness which can make penetrative intercourse uncomfortable. This can be alleviated by using a water-based lubricant (eg. K-Y jelly), a vaginal oestrogen cream or pessary or traditional HRT.

The uterus elevates during sexual excitement and contracts with orgasm. Therefore, women who were aware of these uterine sensations prior to having a hysterectomy may find a change in sexual sensations. Similarly, a small number of women gain sexual pleasure and orgasm from having the cervix repeatedly touched. The loss of cervical stimulation may result in a woman experiencing difficulty in reaching orgasm or finding that their orgasms are less intense. The loss of the cervix can also have an impact on vaginal lubrication.

Psychological changes
Changes in the way a woman feels about herself can also have an impact on sexual desire and satisfaction. Some women who have recently had a hysterectomy feel less feminine or less womanly. For pre-menopausal women, their menstrual cycle may have played an important part in their sense of femaleness and/or youthfulness. Women with partners may fear they will see them differently following a hysterectomy. Women experiencing problems with their sex life following a hysterectomy may find visiting a psychologist, counsellor or sex therapist helpful.

The need to have Pap smears after hysterectomy

Women who have not had their cervix completely removed at hysterectomy still need to have regular Pap smears. Some women who have a hysterectomy which includes removal of the cervix may also still need to have Pap smears:

• Women whose hysterectomy was performed because of cancer of the uterus, cervix, ovaries or Fallopian tubes, or abnormal cells were found at the time of surgery
  
• Women who do not know the exact reason for their hysterectomy
  
• Women whose previous Pap smear results were abnormal
• Women whose previous Pap smear results are not known
• Women taking medication which suppresses the immune system
• Women exposed to the drug Stilboestrol before they were born (this drug was prescribed for pregnant women in the 1950s and 1960s to prevent miscarriage).

It is recommended that these women consult their gynaecologist about the need and frequency of further Pap smears.

References

1. Hurskainen R & Paavonen J. Levonorgestrel-releasing intrauterine system in the treatment of heavy menstrual bleeding Curr Opin Obstet Gynecol 2004; 16:6:487-90
   
2. Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR) Cancer in Australia 2001 Canberra: AIHW 2004; 91
   
3. Speroff, T. et al. A risk-benefit analysis of elective bilateral oophorectomy: Effect of changes in compliance with estrogen therapy on outcome Am J Obstet Gynecol 1991;164:1:165-174
   
4. Johnson, N et al. Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database Syst Rev 2005;1:CD003677

Further help and information from Women's Health Queensland Wide

Health Information Line:
Our free statewide line is staffed by women's health nurses and midwives. They provide women with up to date information, support and referral to health practitioners and services. Women can contact the Health Information Line by phone or email via the 'Ask a Health Question' page on the website. All phone calls and emails are confidential.
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All our factsheets and booklets are available on our website. The website also features articles on women's health from our newsletter, student factsheets, upcoming events, library services and 'Ask a Health Question' page. A list of reputable links is also available where women can search for further information on health topics.
www.womhealth.org.au

Further reading

See our

• Genital prolapse factsheet
• Gynaecological health library booklist

This factsheet was originally published in November 1998. It was revised by Kirsten Braun and the Editorial Committee in July 2001, July 2003 and May 2005.

Last Modified: May 1, 2005