In-Depth Overview of Hysterectomy Surgery

Hysterectomies are the most common surgery performed exclusively on women. Learn about the procedure, alternatives, and what to expect.


What Is a Hysterectomy?

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A hysterectomy is the surgical removal of all or part of a woman’s uterus, typically to treat cancer, chronic pain or heavy bleeding that has not been controlled by less invasive methods. For some women, structures other than the uterus are also removed, including part of the vagina, the cervix, the fallopian tubes, and ovaries.

The tissues removed depend upon the surgeon and the reason for surgery. For example, a woman who has cancer of the uterus may have the ovaries removed if there is a suspicion that cancer has spread there, while a woman who has chronic bleeding problems may have a satisfactory outcome with only a portion of the uterus being removed.

All types of hysterectomy end a woman's ability to become pregnant. Surgeries that include the removal of the ovaries cause menopause to set in after surgery, if the woman had not already entered menopause.


When Is It Necessary?

A hysterectomy is typically necessary when all other options including medication, therapies and even other surgeries have not been successful and the patient’s life is at risk or her quality of life is being harmed. Such as:

Fibroids: These tumors are not cancerous, but can cause pain, bleeding, cramping and general discomfort.

Endometriosis: This is a condition where the tissue that lines the uterus begins to spread to areas outside of the uterus, causing pain, cramping, miscarriage, infertility, and chronic bleeding.

Cancer: Cancer of the uterus or other areas of the female reproductive system may require a hysterectomy as part of treatment.

Chronic bleeding: Chronic bleeding can result from many different conditions that affect the uterus. Symptoms caused by chronic bleeding include anemia, weakness and chronic fatigue along with the worry and decrease in quality of life.

Chronic pain: Unexplained chronic pelvic pain is often the reason for a hysterectomy, especially when pain moves from “annoying” to “excruciating.” When the source of the pain cannot be isolated or is difficult to treat, many women opt for surgery to put an end to the pain.

Uterine prolapse: When the ligaments and muscles that support the uterus are unable to hold it in position, usually after having multiple vaginal births, it may begin to slip into the vaginal canal. In severe cases, the uterus may begin to protrude out of the vaginal opening, a significant source of discomfort and potential infection. In early cases, a pessary, a device to help hold the uterus in place, can be inserted surgically.

Hemorrhage: Uncontrollable uterine bleeding is a rare complication of a c-section, dysfunctional uterine bleeding, and other surgeries near the uterus. This type of bleeding is so severe that it is life-threatening. An emergency hysterectomy may be the only way to save the life of the patient, although other treatments may be attempted.


Hysterectomy Alternatives

Before having an invasive surgery like a hysterectomy, most women opt to try less dramatic courses of treatment, including medication, hormone therapy, and surgical treatments. Each woman is different, but the following treatments may be an option, rather than a hysterectomy.

Nerve block: An outpatient procedure typically performed by an anesthesiologist, who injects an anesthetic into the nerve that is responsible for conducting pain messages to the brain. When a nerve is blocked the pain cannot be transmitted to the brain, so it is no longer felt. The block is temporary but can be repeated.

Medication Therapy: Prescription medications are used to treat both the symptoms and causes of uterine problems. Pain medication can be given for chronic pain sufferers and hormone therapy can be used to reduce endometriosis symptoms.

Myomectomy: An outpatient surgery to remove fibroids, a myomectomy is performed using a telescopic instrument inserted through the cervix that is used to remove fibroids. If the fibroids are too large to remove through the cervix, a small abdominal incision can be made for the removal of the growths.

Ablation: A treatment for heavy or chronic bleeding, ablation is an outpatient technique where an instrument is inserted into through the cervix into the uterus to destroy the endometrial tissue. The endometrium is cut or seared to damage the tissue and end bleeding. This treatment is not for those who wish to remain fertile.

Balloon therapy: A balloon is inserted through the cervix into the uterus then inflated to fit the inside of the uterus. It is then filled with hot water for eight minutes, effectively destroying the endometrial lining of the uterus which is typically responsible for chronic bleeding. This procedure is not for anyone who wants to become pregnant.


Types of Hysterectomy

There are multiple types of hysterectomy surgeries. A hysterectomy can mean simply the removal of the uterus, or it can mean the removal of the uterus, cervix, and ovaries. Also, it can be performed in several ways. First, let's look at the types of hysterectomies:

Radical hysterectomy: The excision of the uterus and the upper one-third to one-half of the vagina. The surgeon usually also performs a bilateral pelvic lymph node dissection.

Total hysterectomy: The uterus and the cervix are removed.

Subtotal or partial hysterectomy: The upper portion of the uterus is removed, leaving the cervix and ovaries intact.

And, there are several ways the surgery can be performed -- some methods more invasive than others:

Laparoscopic assisted hysterectomy: This is any hysterectomy using laparoscopic (minimally invasive) techniques. The instruments are inserted through tiny incisions in the abdomen and vagina, in most cases.

Vaginal hysterectomy: This hysterectomy is performed entirely through an incision made in the vagina, there are no visible scars from this procedure.

Abdominal hysterectomy: This hysterectomy is performed using an incision in the abdomen that can be either vertical from the area of the pubic bone up toward the belly button, or it may be horizontal along the bikini line.


Important Questions to Ask

Before you decide to have hysterectomy surgery, be sure that your surgeon has answered your questions completely. This is a list of questions you may want to ask:

  • What structures do you intend to remove?
  • What approach will you use? Laparoscopic, open, vaginal, combination?
  • What side effects are considered normal?
  • What kind of discharge or bleeding is considered normal for the procedure?
  • What symptoms should alert me to go to the emergency room or call my surgeon?
  • What type of incision should I expect?
  • Where will the incision(s) be located?
  • How long will I be in the hospital?
  • How long should I take off of work?
  • When can I return to my normal level of activity?
  • Will I need Pap smears after surgery?
  • Are there any prescriptions that I will need after surgery that I can have filled before I am admitted to the hospital?

The Procedure

The hysterectomy surgical procedure can be performed several ways—vaginally, laparoscopically assisted, or opened through the abdomen (abdominal hysterectomy). Regardless of the approach, a hysterectomy is an inpatient procedure that is done using general anesthesia.

Generally speaking, laparoscopic patients heal the quickest, with a return to work and activity as quickly as two weeks, while patients having the open procedure required six to nine weeks to return to normal activity.

The approach varies with surgeon preference and the reason for the hysterectomy. A uterus with large tumors may not be able to be removed through the vagina or tiny laparoscopic incisions, but must be removed through the larger open incision. In most cases, the open approach is the least favored by surgeons, as blood loss is greater, recovery is longer and the risk of infection is higher.

Regardless of the approach used for the surgery, the procedure consists of separating the uterus from the ligaments and tissue that hold it in place and any scar tissue that may be present. It is then removed through the vagina or the abdominal incision.

Once the surgeon has inspected the tissue for any tumors or bleeding and determines that the surgery is complete, the instruments are withdrawn and any incisions are closed. Abdominal laparoscopic incisions may be closed with absorbable sutures and sterile tape while larger incisions will be held closed with staples or sutures that are removed weeks later by the surgeon.


Recovering From Hysterectomy

The recovery from a hysterectomy varies widely from patient to patient, primarily because of the different approaches used for the surgery and the different reasons the surgery is performed.

As an example, a person who has a portion of the uterus removed laparoscopically to treat chronic bleeding will probably have a much easier recovery than a patient who has the traditional type of hysterectomy used to treat cancer of the ovaries and uterus, as the surgery is harder on the body and the underlying condition causes exhaustion, pain, and significant emotional and physical stress.

Most hysterectomy patients return home within 48 hours of surgery with a prescription pain reliever. Laparoscopic patients are able to return to most of their usual activities within two weeks. Patients who have the open procedure with the larger incision typically require six to eight weeks and have significantly more restrictions due to the large incision. These patients should not lift anything greater than 10 pounds for at least six weeks after surgery.

Regardless of the type of hysterectomy, patients should refrain from soaking in tub baths and swimming for at least six weeks after the procedure. In addition, some discharge is to be expected during recovery, but unexplained heavy bleeding or pus should be reported immediately.

Most women are able to return to sexual intercourse without pain or discomfort by six or eight weeks after surgery, but the individual surgeon will have an opinion about when is most appropriate.


Life After Hysterectomy

For the majority of women who have a hysterectomy each year, quality of life is improved by the surgery as pain, bleeding, and concerns about pregnancy and disease are alleviated. Those in the minority, who find a hysterectomy to be a very negative experience, usually attribute those feelings to the inability to have children after the procedure. In those cases, it is not the surgery itself that causes feelings of depression, but the reality of not being able to bear children.

One of the negative side effects of having a total hysterectomy is the onset of menopause. Those who choose to have the ovaries removed will begin menopause after surgery, but those who keep their ovaries frequently experience menopause earlier than is typical.

After surgery, hormone replacement may be necessary. There are risks associated with hormone replacement, but those risks need to be balanced against the patient’s risk factors for osteoporosis and other conditions.

Women who retain their cervix after surgery should plan to continue having Pap smears as directed by their surgeon, as the risk of cervical diseases remains.


Weight Gain After Hysterectomy Surgery

Weight gain after a hysterectomy isn't a myth, many women do gain weight following this surgery. One research study showed an average gain of about 3 pounds in the year after surgery, while the control group of similar women who did not have surgery gained an average of 1.3 pounds. While this gain is not extremely large, if it is allowed to continue over time it could become significant.

Research also indicates that women who were premenopausal prior to surgery were at the highest risk of gaining weight in the year following surgery. Women who were overweight prior to surgery, as well as women who have experienced fluctuations in their adult weight, are at the highest risk of weight gain. It is also worth noting that a disproportionate number of women who require hysterectomy are overweight or obese at the time of surgery.

Adding exercise and tracking food intake is recommended after having a hysterectomy, particularly for women at the highest risk of gaining weight. Even small changes in lifestyle, such as going for a brisk walk once a day, can prevent weight gain and improve health after surgery.


Sex After Hysterectomy

Most women are concerned with the long-term effects of a hysterectomy on their sex life. While each person is unique, a hysterectomy does not always result in major changes in sex drive or the ability to enjoy sex.

Surgeons suggest waiting a minimum of six to eight weeks to return to sexual activity after a hysterectomy. After that time, sexual intercourse should be possible without pain or discomfort.

Most women feel very fatigued during the first weeks of recovery but as the patient feels more energized, interest in sex returns.

Sexual activity after a hysterectomy has been studied extensively, and most women who have a healthy sex life return to that level of activity. Some women find that they are more interested in sex after surgery, especially those who had concerns about pregnancy or chronic pelvic pain.

There are differences between the types of surgery. One study showed that women who had a hysterectomy that left the cervix in place were more likely to orgasm during sexual intercourse as the cervix plays a role in vaginal orgasms. The study also showed that the ability to have clitoral orgasms or external orgasms was not changed by surgery regardless of the presence of the cervix.

Some patients do experience a feeling of loss or depression after surgery, and some begin menopause, decreasing sex drive. If these symptoms are handled effectively, the patient can expect to experience a full and active sex life.

Some women will require a lubricant to have sex without discomfort after their hysterectomy, as the surgery can cause some vaginal dryness.

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Article Sources

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