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Hysterectomy: Surgery to remove your uterus
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Hysterectomy — the surgical removal of your uterus — can mean survival if you have uterine cancer. Or if you're a woman with intolerable pelvic pain from endometriosis or heavy, irregular periods, a hysterectomy often means relief from troublesome symptoms.

Hysterectomy ranks as one of the most common surgical procedures among women. But when is a hysterectomy really necessary? Discover why you might need a hysterectomy, what's involved in the procedure and what your alternatives might be.

What is a hysterectomy recommended for?

Hysterectomy may be needed if you have one of the following conditions:

  • Gynecologic cancer. If you have a gynecologic cancer — such as cancer of the uterus or cervix — a hysterectomy may be your best treatment option. Depending on the specific cancer you have and how advanced it is, your other options might include radiation or chemotherapy.
  • Fibroids. Hysterectomy is the only certain, permanent solution for fibroids — benign uterine tumors that cause persistent bleeding, anemia, pelvic pain or bladder pressure. Nonsurgical treatments of fibroids are a possibility, depending on your discomfort level and tumor size. Many women with fibroids have minimal symptoms and require no treatment.
  • Endometriosis. In endometriosis, the tissue lining the inside of your uterus (endometrium) grows outside the uterus on your ovaries, fallopian tubes, or other pelvic or abdominal organs. When medication or conservative surgery doesn't improve endometriosis, you might need a hysterectomy.
  • Uterine prolapse. Descent of the uterus into your vagina can happen when the supporting ligaments and tissues weaken. Uterine prolapse can lead to urinary incontinence, pelvic pressure or difficulty with bowel movements. Hysterectomy may be necessary to achieve satisfactory repair of these conditions.
  • Persistent vaginal bleeding. If your periods are heavy and irregular or last many days each cycle, a hysterectomy may bring relief when the bleeding can't be controlled by nonsurgical methods.
  • Chronic pelvic pain. Occasionally, surgery is a necessary last resort for women who experience chronic pelvic pain that clearly arises in the uterus. However, many forms of pelvic pain aren't cured by hysterectomy, and this operative approach can be a tragic mistake. Seek careful evaluation before proceeding with such a radical strategy.

Hysterectomy ends your ability to become pregnant. If you think you might want to become pregnant, ask your doctor about alternatives to this surgery. In the case of cancer, hysterectomy might be the only option. But other conditions — including fibroids, endometriosis and uterine prolapse — have alternative treatments that you can try first.

How do you prepare for a hysterectomy?

Hysterectomy is an inpatient procedure — meaning you're admitted to the hospital to have it done. How long you'll be in the hospital depends on what type of hysterectomy you have and what your doctor recommends.

Plan for an extended recovery time once you get home. Full recovery could take several weeks. Before your surgery, arrange for time off work. Look into getting help at home if you think you'll need it.

How is a hysterectomy done?

To perform a hysterectomy, a surgeon detaches your uterus from the blood vessels and connective tissue that support it, as well as from the vagina. Depending on your situation, surgery may involve the removal of additional organs and tissue.

Types of hysterectomy surgery include:

  • Partial (subtotal) hysterectomy. Removes the uterus but leaves the cervix in place. By keeping the cervix, your risk of cervical cancer remains, so you'll still need regular Pap tests for screening.
  • Total hysterectomy. Removes the uterus, including the cervix.
  • Hysterectomy and bilateral salpingo-oophorectomy. Removes the uterus, cervix, fallopian tubes and ovaries. If you haven't already experienced menopause, removing your ovaries initiates it.
  • Radical hysterectomy. Extends farther, removing the upper portion of the vagina and some surrounding tissue and lymph nodes. Surgeons use this procedure for certain forms of cancer.

A hysterectomy typically is performed under general anesthesia, so you won't be awake during the surgery. The procedure itself lasts about one to two hours, although you'll spend some time beforehand getting ready to go into the operating room.

Abdominal vs. vaginal hysterectomy

Hysterectomy can be performed through an incision in your abdomen (abdominal hysterectomy) or through your vagina (vaginal hysterectomy). Which procedure is best for you depends on your specific situation.

Abdominal hysterectomy
In abdominal hysterectomy, the surgeon cuts through skin and connective tissue in your lower abdomen to reach your uterus. The surgeon uses one of two types of abdominal incisions for the hysterectomy. A vertical incision starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. A horizontal bikini-line incision (Pfannenstiel incision) lies about an inch above your pubic bone.

The advantage of an abdominal procedure is that your surgeon can see your uterus and other organs and has more room to operate than if the procedure is done vaginally. For this reason, your surgeon may opt for the abdominal procedure if you have large tumors or if your doctor suspects the presence of cancer.

On the other hand, abdominal hysterectomy can mean:

  • You'll be in the hospital longer.
  • You will experience greater discomfort than following a vaginal procedure.
  • You'll have a visible scar on your abdomen.

Vaginal hysterectomy
In a vaginal hysterectomy, the surgeon reaches your uterus by making a circular incision around the cervix. This approach is best for benign conditions that lead to hysterectomy when the uterus isn't too large. It's often the best approach for uterine prolapse. With a vaginal hysterectomy, you won't have any external scarring. You may also recover more quickly because you aren't waiting for a large abdominal incision to heal and the nerve signals from the top of the vagina aren't perceived in the same manner as those from the skin.

However, vaginal hysterectomy gives the surgeon less room to operate and no real opportunity to view your pelvic organs.

Laparoscopically-assisted vaginal hysterectomy allows your doctor to view your pelvis and to remove your uterus vaginally when it otherwise would require a large abdominal incision. The surgeon makes a small incision near your navel to insert a thin device (laparoscope) that allows the surgical team to see inside your abdomen. Through other tiny incisions, your surgeon uses special surgical instruments to detach the uterus and then remove it through your vagina.

After the hysterectomy

After surgery, you'll remain in the recovery room for a few hours. You'll be monitored for signs of pain and discomfort. You'll take medicine for pain and to prevent infection. You'll probably be up and walking around by the following day. You'll need to use sanitary pads for vaginal bleeding and discharge. It's normal to have bloody drainage for several days after a hysterectomy.

Understand that you won't be back to your usual self for at least four to six weeks. If you've had a vaginal hysterectomy, you might feel better long before this time, but it's important to adhere to activity restrictions. Get plenty of rest. Don't lift anything heavy for a full six weeks after the operation. Your doctor may recommend other restrictions, but eventually you'll return to your normal activities.

If you're premenopausal, having your ovaries removed initiates menopause. Discuss with your doctor ways to handle menopausal symptoms, such as hot flashes and vaginal dryness. If you're younger than age 45 and you had your ovaries removed, you're at increased risk of osteoporosis. Ask your doctor about an osteoporosis prevention program.

About six weeks after your surgery, you can resume sexual activity. Having a hysterectomy shouldn't affect this aspect of your life. This issue has been carefully studied, and women with a good sex life before hysterectomy maintain it afterward. Some women even experience an increase in sexual pleasure. This may be associated with relief from the chronic pain or heavy bleeding that was caused by a uterine problem.

Risks of hysterectomy

Hysterectomy is generally very safe, but with any major surgery comes the risk of complications. Such complications include blood clots, infection, excessive bleeding or an adverse reaction to the anesthesia.

Other risks of hysterectomy are:

  • Damage to your urinary tract, bladder or rectum during surgery, which may require further surgical repair
  • Loss of ovarian function
  • Early onset of menopause

Talk with your doctor about the risks of surgery as they apply to you.

What are some alternatives to hysterectomy?

If your condition is benign, you may have treatment options besides hysterectomy. Consider one of these treatments:

  • Drug therapy. Certain medications may help relieve heavy or irregular uterine bleeding. Many times women have hysterectomies because of bleeding related to hormonal imbalances — the uterus itself might be perfectly healthy. Correcting hormonal imbalances may be a better alternative than surgery.
  • Endometrial ablation. If you experience heavy or irregular uterine bleeding, this minimally-invasive procedure might relieve your symptoms. With a special device, a surgeon uses electricity, heat or cold to destroy the lining of your uterus (endometrium) and stop uterine bleeding. Be aware that this option typically ends your ability to become pregnant.
  • Uterine artery embolization. One option for treating fibroid tumors is uterine artery embolization, a procedure that involves blocking the blood supply to the tumor. Without blood, the fibroids shrink over time, which can reduce painful and uncomfortable symptoms, such as heavy bleeding or an enlarged abdomen.
  • Myomectomy. If you have fibroid tumors, a myomectomy can surgically remove the tumors while leaving your uterus intact. Getting rid of the tumors relieves abnormal bleeding and painful symptoms. Although there's a risk that the tumors could come back, this may be the best option if you want to have children.
  • Focused ultrasound surgery. An adapted version of a magnetic resonance imaging machine allows a doctor to visualize your anatomy, then locate and destroy (ablate) fibroid tumors inside your uterus without making an incision.

Perspectives vary

Because the uterus is strongly associated with femininity, you may feel a sense of loss after a hysterectomy. On the other hand, you may find hysterectomy provides relief of symptoms, an enhanced sense of well-being and a chance to get on with your life. The relief of symptoms may greatly enhance your quality of life.

Think about your reasons for hysterectomy and what it means to end your ability to become pregnant. Before proceeding with this surgery, make sure it's right for you. Don't hesitate to get a second opinion if you're not certain that hysterectomy is your best option.

March 10, 2006

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