What is a hysterectomy?
This procedure involves removal of the uterus and cervix. It does not automatically imply removal of the ovaries (but this may be advised in certain situations). Removal of the uterus with conservation of the ovaries will stop any further menstrual bleeding but retain all normal hormonal function of the ovaries.
Why a hysterectomy?
Heavy painful periods, endometriosis, fibroids, cancer, strong family history of cancer, hormonal imbalance and prolapse are the most common reasons for this surgery.
Are there alternatives to hysterectomy?
Yes depending on what your problem is and how it affects you. There will always be a discussion about potential alternatives where appropriate to give you options. The Mirena progesterone secreting IUD is a popular alternative in treating heavy painful periods for some patients and this can be arranged.
Do the doctors always have to remove my ovaries?
No. Most premenopausal women having a hysterectomy done for benign reasons e.g. for heavy painful periods will retain their ovaries (and therefore their normal hormonal function) and as a result do not require hormone replacement. Patients with some cancers and other conditions may require removal of their ovaries at the time of surgery. This will be discussed in detail during your consultation preoperatively.
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, ovaries are removed in women who have a high risk of ovarian cancer (BRCA1/2, Lynch, history of breast cancer) and/or in postmenopausal women.
Types of Hysterectomy
- 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 week. An open hysterectomy is preferred for ovarian cancer surgery
- 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.
- 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.
How do doctors perform a laparoscopic hysterectomy?
The entire procedure is performed through 3-4 small cuts (all between half to one centimetre) via a high definition camera inserted through the belly button and specialised instruments.
What are the advantages?
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
- Fewer surgical complications: The risk of surgical complications is reduced 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 vs 5 days with open hysterectomy)
Can cancers be treated laparoscopically?
Yes, some cancers like the cancer of the lining of the womb
How long will I be in hospital?
The vast majority of patients are discharged after only 1-2 nights in hospital. Most patients are back functioning normally (and at work if so desired) by 2 weeks.
Will the laparoscopic operation be painful?
A certain amount of discomfort should be expected following any operation. During a laparoscopic operation, carbon dioxide will be used to inflate the abdomen giving the room to operate. This rises to dull to moderate pain, which usually lasts no more then 12-24 hours. Gas and/or fluid may irritate the diaphragm resulting in possible “shoulder tip pain” in some patients. Any discomfort usually passes in 24-48 hours. Most patients are taking simple analgesia only on discharge from hospital.
Will I have vaginal bleeding after the operation? (after any type of hysterectomy)
You will have no further periods ever again. You may experience a small amount of vaginal bleeding, spotting or discharge immediately after the operation but this usually only lasts a few days.
Do I have to have stitches removed? (after any type of hysterectomy)
All sutures are usually of a self-absorbing variety and do not require removal at all. You will be advised if this is not the case.
Risks and surgical complications of Hysterectomy
Any surgery carries risks.
- The risk of cardiac, cerebrovascular or anaesthetic complications (less than 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 risk that the operation needs to be converted to an open procedure due to unforeseen 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%
- 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
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.Please read the “Recovering Well from Hysterectomy booklet” Supplied by RCOG and can be found on my website in my resources section
- 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
- Exercise after hysterectomy –Whenever possible we will mobilise patients on the day or the day after a hysterectomy 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 with 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.