Hysterectomy

 

Introduction

A hysterectomy is a surgical procedure to remove the womb (uterus). After the operation you will no longer be able to get pregnant.

If you haven't already gone through the menopause, you will also no longer have periods, regardless of your age. The menopause is when a woman's monthly periods stop, usually at around the age of 52.

It is more common for women between the ages of 40 and 50 to have a hysterectomy.

Why do I need a hysterectomy?

Hysterectomies are carried out to treat conditions that affect the female reproductive system, including:

• Heavy periods (menorrhagia)
• Long-term pelvic pain
• Non-cancerous tumours (fibroids)
• Ovarian cancer, uterine cancer, cervical cancer or cancer of the fallopian tubes

A hysterectomy is a major operation with a long recovery time and is only considered after alternative, less invasive treatments have been tried.

Things to consider

If you have a hysterectomy, as well as having your womb removed you may have to decide whether to also have your cervix or ovaries removed .

Your decision will usually be based on your personal feelings, medical history and any recommendations your doctor may have.

You should be aware of the different types of hysterectomy and their implications.

Types of hysterectomy

There are a various types of hysterectomy. The type you have depends on why you need the operation and how much of your womb and surrounding reproductive system can safely be left in place.

The main types of hysterectomy are:

• Total hysterectomy: the womb and cervix (neck of the womb) are removed; this is the most commonly performed operation
• Subtotal hysterectomy: the main body of the womb is removed leaving the cervix in place
• Total hysterectomy with bilateral salpingo-oophorectomy: the womb, cervix, fallopian tubes (salpingectomy) and the ovaries (oophorectomy) are removed
• Radical hysterectomy: the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue

There are three ways to carry out a hysterectomy:

• Vaginal hysterectomy: where the womb is removed through a cut in the top of the vagina
• Abdominal hysterectomy: where the womb is removed through a cut in the lower abdomen
• Laparoscopic hysterectomy (keyhole surgery): where the womb is removed through several small cuts in the abdomen

Complications of a hysterectomy

There is a small risk of experiencing heavy bleeding, infection, damage to your bladder or bowel or a serious reaction to the general anaesthetic.

Recovering from a hysterectomy

A hysterectomy is a major operation. You can be in hospital for up to five days following surgery and it takes about six to eight weeks to fully recover.

Rest as much as possible during this time and don't lift anything heavy, such as bags of shopping. You need time for your abdominal muscles and tissues to heal.

Surgical menopause

If your ovaries are removed during a hysterectomy, you will go through the menopause immediately after the operation, regardless of your age. This is known as a surgical menopause.

If one or both of your ovaries are left intact, there's a chance you will experience the menopause within five years of having your operation.

If you experience a surgical menopause after having a hysterectomy, you should be offered hormone replacement therapy (HRT).

Why a hysterectomy is necessary 

A hysterectomy is a major operation for a woman that will only be recommended if other treatment options havebeen unsuccessful.

The most common reasons for having a hysterectomy include:

• Heavy periods (menorrhagia), due to fibroids for example
• Pelvic pain, due to endometriosis, unsuccessfully treated pelvic inflammatory disease (PID) or fibroids for example
• Prolapse of the uterus 
• Cancer of the womb, ovaries or cervix 

Heavy periods

Many women lose a large amount of blood during their monthly periods. They may also experience other symptoms, such as pain and stomach cramps.

For some women, the symptoms can have a significant impact on their quality of life. Sometimes, heavy periods can be caused by fibroids, but in many cases there is no obvious cause.

In some cases, removing the womb may be the only way of stopping persistent heavy menstural bleeding when:

• other treatments have proved ineffective
• the bleeding has a significant impact on quality of life and it is preferable for periods to stop
• the woman no longer wishes to have children

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a bacterial infection of the female reproductive system.

If detected early, the infection can Fbe treated with antibiotics. However, if it spreads, it can damage the womb and fallopian tubes, resulting in long-term pain.

A hysterectomy to remove the womb and fallopian tubes may be recommended if a woman has severe pain from PID and no longer wants children.

Endometriosis

Endometriosis is a condition where cells that line the womb are also found in other areas of the body and reproductive system, such as the ovaries, fallopian tubes, bladder and rectum.

If the cells that make up the lining of the womb become trapped in other areas of the body, it can cause the surrounding tissue to become inflamed and damaged. This can lead to pain, heavy and irregular periods and infertility (inability to conceive).

A hysterectomy may remove the areas of endometrial tissue causing the pain. However, it will usually only be considered if other, less invasive treatments have not worked and the woman decides not to have any more children.

Prolapse of the uterus

A prolapsed uterus happens when the tissues and ligaments that support the womb become weak, causing it to drop down from its normal position.

Symptoms can include back pain, a feeling that someting is coming down out of your vagina, leaking urine (urinary incontinence) and difficulty having sex. A prolapsed uterus can often occur as a result of childbirth.

A hysterectomy resolves the symptoms of a prolapse because it removes the entire womb. It may be recommended if the tissues and ligaments that support the womb are severely weakened and the woman does not want any more children.

Cancer

A hysterectomy may be recommended for the following cancers:

• cervical cancer
• ovarian cancer
• cancer of the fallopian tubes
• uterine cancer (cancer of the womb)

If the cancer has spread and reached an advanced stage, a hysterectomy may be the only viable treatment option.

Things to consider before having a hysterectomy

If you have a hysterectomy, as well as having your womb removed you may have to decide whether to have your cervix or ovaries removed.

These decisions are usually made based on your medical history, your doctor’s recommendations and your personal feelings. It is important that you are aware of the different types of hysterectomy and their implications.

Removal of the cervix (total or radical hysterectomy)

If you have cancer of the cervix (the neck of the womb), ovaries or womb, you may be advised to have your cervix removed to prevent the cancer spreading.

Even if you do not have cancer, removing the cervix means that there is no risk of developing cervical cancer in the future.

Many women are concerned that removing the cervix will lead to a loss in sexual function, but there is no evidence to support this.

Some women are reluctant to have their cervix removed because they want to retain as much of their reproductive system as possible. If you feel this way, ask Dr. B C Shah whether there are any risks associated with keeping your cervix.

If you have your cervix removed, you will no longer need to have cervical screening tests. If you do not have your cervix removed, you will need to continue having regular screening for cervical cancer (cervical smears).

Removal of the ovaries (salpingo-oophorectomy)

A woman's ovaries should only be removed if there is a significant risk of associated disease, such as ovarian cancer.

If you have a family history of ovarian or breast cancer, removing your ovaries (an oophorectomy) may be recommended to prevent cancer occurring in the future.

Dr. B C Shah will be able to discuss the pros and cons of removing your ovaries with you. If your ovaries are removed, your fallopian tubes will also be removed.

If you have already gone through the menopause, or you are close to it, removing your ovaries may be recommended regardless of the reason for having a hysterectomy. This is to protect against the possibility of ovarian cancer developing.

Some feel that it is best to leave healthy ovaries in place if the risk of ovarian cancer is small; for example, if there is no family history of the condition.

This is because the ovaries produce several female hormones that can help protect against conditions such as osteoporosis(weak and brittle bones). They also play a part in feelings of sexual desire and pleasure.

If you would prefer to keep your ovaries, make sure you have made this clear to Dr. B C Shah before your operation. You may still be asked to give consent (permission) for your ovaries to be removed if an abnormality is found during the operation.

Think carefully about this and discuss any fears or concerns  with Dr. B C Shah.

Surgical menopause

If you have a total or radical hysterectomy that removes your ovaries, you will experience the menopause immediately following your operation, regardless of your age. This is known as a surgical menopause.

If a hysterectomy leaves one or both of your ovaries intact, there is a chance that you will experience the menopause within five years of having the operation.

Although your hormone levels decrease after the menopause, your ovaries continue producing testosterone for up to 20 years. Testosterone is a hormone that plays an important part in stimulating sexual desire and sexual pleasure.

Your ovaries also continue to produce small amounts of the hormone, oestrogen, after the menopause. It is a lack of oestrogen that causes menopausal symptoms such as hot flushes, depression, vaginal dryness, insomnia (sleep problems), fatigue and night sweats.

Hormone replacement therapy (HRT)

After having your ovaries removed, you may be offered HRT. This replaces some of the hormones that your ovaries used to produce and relieves any menopausal symptoms you may have.

It is unlikely that the HRT you are offered will exactly match the hormones that your ovaries previously produced.

The amount of hormones a woman produces can vary greatly and you may need to try different doses and brands of HRT before you find one that feels suitable.

Not everyone is suitable for HRT. For example, it is not recommended for women who have had a hormone-dependent type of breast cancer or liver disease. It's important to let Dr. B C Shah know about any such conditions that you've had.

If you are able to have HRT and both of your ovaries have been removed, it's important that you continue with the treatment until you reach the normal age for the menopause (52 is the average age).

How a hysterectomy is performed

There are different types of hysterectomy. The operation you have will depend on the reason for the surgery and how much of your womb and reproductive system can safely be left in place.

The main types of hysterectomy are described below.

Total hysterectomy

During a total hysterectomy, your womb and cervix (neck of the womb) is removed.

A total hysterectomy is usually the preferred option over a subtotal hysterectomy because removing the cervix means that there is no risk of you developing cervical cancer at a later date.

Subtotal hysterectomy

A subtotal hysterectomy involves removing the main body of the womb and leaving the cervix in place.

This procedure is not performed very often. If the cervix is left in place, there is still a risk of cervical cancer developing and regular cervical screening will still be required.

Some women want to keep as much of their reproductive system as possible, including their cervix. If you feel this way, talk to Dr. B C Shah about any risks associated with keeping your cervix.

Total hysterectomy with bilateral salpingo-oophorectomy

A total hysterectomy with bilateral salpingo-oophorectomy is a hysterectomy that also involves removing the fallopian tubes (salpingectomy) and ovaries (oophorectomy).

It is recommended that the ovaries should only be removed if there is a significant risk of further problems – for example, if there is a family history of ovarian cancer.

Dr. B C Shah will be able to discuss the pros and cons of removing your ovaries with you.

Radical hysterectomy

A radical hysterectomy is usually carried out to remove and treat cancer when other treatments such as chemotherapy and radiotherapy aren't suitable or haven't worked.

During the procedure, the body of your womb and cervix will be removed, along with your fallopian tubes, part of your vagina, ovaries, lymph glands and fatty tissue.

Performing a hysterectomy

There are three ways that a hysterectomy can be performed. They are:

• Vaginal hysterectomy
• Abdominal hysterectomy
• Laparascopic hysterectomy

Vaginal hysterectomy

During a vaginal hysterectomy, the womb and cervix are removed through an incision that is made in the top of the vagina.

Special surgical instruments are inserted into the vagina to detach the womb from the ligaments that hold it in place.

After the womb and cervix have been removed, the incision will be sewn up. The operation usually takes about an hour to complete.

A vaginal hysterectomy can either be carried out under a general anaesthetic (where you will be unconscious during the procedure) or a local anaesthetic (where you will be numb from the waist down).

A vaginal hysterectomy is usually preferred over an abdominal hysterectomy because it is less invasive and involves a shorter stay in hospital. The recovery time also tends to be quicker.

Abdominal hysterectomy

During an abdominal hysterectomy, an incision will be made in your abdomen (tummy). It will either be made horizontally, along your bikini line, or vertically from your belly button to your bikini line.

A vertical incision will usually be used if there are large fibroids (non-cancerous growths) in your womb or for some types of cancer.

After your womb has been removed, the incision is stitched up. The operation will take about an hour to perform and a general anaesthetic is used.

An abdominal hysterectomy may be recommended if your womb is enlarged by fibroids or pelvic tumours and it is not possible to remove it through your vagina.

It may also be recommended if your ovaries need to be removed.

Laparoscopic hysterectomy

Laparoscopic surgery is also known as keyhole surgery. Nowadays, a laparoscopic hysterectomy is the preferred treatment method for removing the organs and surrounding tissues of the reproductive system.

During the procedure, a small tube containing a telescope (laparoscope) and a tiny video camera will be inserted through a small incision in your abdomen.

This allows Dr. B C Shah to see your internal organs. Instruments are then inserted through other small incisions in your abdomen or vagina to remove your womb, cervix and any other parts of your reproductive system.

Laparoscopic hysterectomies are usually carried out under general anaesthetic.

A laparoscopic hysterectomy is less invasive than a vaginal or abdominal hysterectomy because the incisions that are made are much smaller. This means that your wounds will be smaller and your recovery time will be quicker.

Recovering from a hysterectomy

After having a hysterectomy, you may wake up feeling tired and in some pain. This experience is normal after this type of surgery.

You will be given painkillers to help reduce any pain and discomfort. If you feel sick after the anaesthetic, your nurse will be able to give you medicine to help relieve this.

You may have a drip in your arm and a catheter (a small tube that drains urine from your bladder into a collection bag).

If you had an abdominal hysterectomy, you may also have a drainage tube in your abdomen to take away any blood from beneath your wound. These tubes will usually stay in place for one-to-two days.

Dressings will be placed over your wounds. If you have had a vaginal hysterectomy, you may have a gauze pack inserted into your vagina. This is to minimise the risk of any bleeding after the operation and will usually stay in place for 24 hours. You may find it slightly uncomfortable and feel like you need to empty your bowels (do a poo).

The day after your operation, you will be encouraged to take a short walk. This helps your blood to flow normally, reducing the risk of complications developing, such as blood clots in your legs (deep vein thrombosis). 

After the catheter has been removed, you should be able to pass urine normally. Any stitches that need to be removed will be taken out five-to-seven days after your operation.

Your recovery time

The length of time it will take before you are well enough to leave hospital will depend on your age and your general level of health.

If you have had a vaginal hysterectomy, you may be able to leave between one and four days later. If you have have had an abdominal hysterectomy, it will usually be up to five days before you are discharged.

As a laparoscopic hysterectomy is a less invasive operation, you will usually be in hospital for a shorter period of time, providing there are no complications. 

A follow-up appointment will be arranged 6-12 weeks after your operation to check on your progress.

It takes about six-to-eight weeks to fully recover after having a hysterectomy. During this time, you should rest as much as possible and not lift anything heavy, such as bags of shopping. Your abdominal muscles and the surrounding tissues need time to heal.

Side effects

After having a hysterectomy, you may experience some temporary side effects as outlined below.

Bowel and bladder disturbances

After your operation, there may be some changes in your bowel and bladder functions when going to the toilet.

Some women develop urinary tract infections or constipation. Both can easily be treated. It's recommended that you drink one-to-two litres of fluid a day and increase the fruit and fibre in your diet to help with your bowel and bladder movements.

Vaginal discharge

After a hysterectomy you will experience some vaginal bleeding and discharge. This will be less discharge than during a period but it may last up to six weeks.

Visit Dr. B C Shah if you experience heavy vaginal bleeding, start passing blood clots or have an offensive-smelling discharge.

Menopausal symptoms

If your ovaries are removed, it is likely that you will experience severe menopausal symptoms after your operation. These may include:

• Hot flushes
• Anxiety
• Weepiness
• Sweating

You may have hormone replacement therapy (HRT) after your operation. This can be given in the form of an implant, injections or tablets. It usually takes around a week before having an effect.

Emotional effects

You may feel a sense of loss and sadness after having a hysterectomy. These feelings are particularly common in women with advanced cancer who have no other treatment option.

Some women who have not yet experienced the menopause may feel a sense of loss because they are no longer able to have children. Others may feel less "womanly" than before. In some cases, having a hysterectomy can be a trigger for depression.

If you have feelings of depression that won't go away, see Dr. B C Shah who will be able to advise you about various available treatment options.

Talking to other women who have had a hysterectomy may help by providing emotional support and reassurance. Dr. B C Shah or the hospital staff may be able to recommend a local support group for you.

The Hysterectomy Association also provides hysterectomy support services, including a one-to-one telephone support line, counselling and "preparing for hysterectomy" workshops.

Getting back to normal

Returning to work

How long it will take for you to return to work will depend on how you feel and what sort of work you do.

If your job does not involve manual work or heavy lifting, it may be possible to return after four-to-eight weeks.

Driving

Don't drive until you're comfortable wearing a seatbelt and can safely perform an emergency stop.

This can be anything from three-to-eight weeks after your operation. You may want to check with Dr. B C Shah that you are fit to drive before you start.

Exercise and lifting

After having a hysterectomy, the hospital where you were treated should give you information and advice about suitable forms of exercise while you recover.

Walking is always recommended and you can swim after your wounds have healed. Don't try to do too much because you will probably feel more tired than usual.

Don't lift any heavy objects during your recovery period. If you have to lift light objects, make sure that your knees are bent and your back is straight.

Sex

After a hysterectomy, it's generally recommended that you don't have sex until any vaginal discharge has stopped and you feel comfortable and relaxed, or after a minimum of six weeks.

You may experience some vaginal dryness, particularly if you have had your ovaries removed and you are not taking HRT.

Many women also experience an initial loss of sexual desire (libido) after the operation, but this usually returns once they have fully recovered.

At this point, studies show that pain during sex is reduced and that strength of orgasm, libido and sexual activity all improve after a hysterectomy.

Contraception

You no longer need to use contraception to prevent pregnancy after having a hysterectomy. However, you will still need to use condoms to protect yourself against sexually transmitted infections (STIs).

Complications of a hysterectomy

As with all types of surgery, a hysterectomy can sometimes lead to complications.

Some of the possible complications are described below.

General anaesthetic

It is very rare for serious complications to occur after having a general anaesthetic  (1 in 10,000 anaesthetics given).

Serious complications can include nerve damage, an allergic reaction and death (death is very rare; there is a 1 in 100,000 chance of dying after having a general anaesthetic).

Being fit and healthy before you have an operation reduces your risk of developing complications.

Bleeding

As with all major operations, there is a small risk of heavy bleeding (haemorrhage) after having a hysterectomy.

If you have a haemorrhage, you may need a blood transfusion (where you receive blood from a donor).

Bladder or bowel damage

In rare cases, damage to abdominal organs, such as the bladder or bowel, can occur. This can cause problems, such as infection, incontinence or a frequent need to urinate.

It may be possible to repair any damage during the hysterectomy. You may need a temporary catheter to drain your urine, or a colostomy to collect your bowel movements.

Infection

There is always a risk that an infection will develop after an operation. This could be a urinary tract infection, a chest infection or a vaginal infection. These aren't usually serious and can be treated with antibiotics.

Thrombosis

A thrombosis is a blood clot that forms in a vein and interferes with blood circulation and the flow of oxygen around the body. The risk of developing blood clots increases after having operations and periods of immobility.

You will be encouraged to start moving around as soon as possible after your operation. You may also be given a blood-thinning medication, such as warfarin, to reduce the risk of clots.

Vaginal problems

If you have a vaginal hysterectomy there is a risk that you will have problems at the top of your vagina where the cervix was removed. This could range from slow wound healing after the operation to prolapse in later years.

Ovary failure

Even if one or both of your ovaries are left intact, they could fail within five years of having your hysterectomy. This is because your ovaries receive some of their blood supply through the womb, which is removed during the operation.

Early menopause

If you have had your ovaries removed, it's likely that you'll have menopausal symptoms, such as hot flushes, sweating, vaginal dryness and disturbed sleep, soon after your operation.

This is because the menopause is triggered once you stop producing eggs from your ovaries (ovulating).

This is an important consideration if you're under the age of 40 because early onset of the menopause can increase your risk of developing brittle bones (osteoporosis). This is because the level of the hormone, oestrogen, decreases during the menopause.

Depending on your age and circumstances, you may need to take additional medication to prevent osteoporosis.