Hysterectomy is the surgical removal of a women’s uterus or womb. If you have been advised to have a hysterectomy, you should understand fully the operation and the medical reasons for it.

WHAT IS HYSTERECTOMY
Hysterectomy refers to the removal of the uterus only. It is also referred to as Total Hysterectomy (Fig 1). Patients often inquire if the hysterectomy will be complete, implying the removal of uterus, fallopian tubes, and ovaries. The correct term to describe such an operation is Total Hysterectomy with Bilateral Salpingo-oophorectomy.

REASONS FOR HYSTERECTOMY

1. Menorrhagia (Heavy menstrual bleeding no controlled by medical methods)
2. Endometrial Hyperplasia
3. Leiomyomas or fibroids (tumors made of muscle and fibrous tissue) of the uterus with increasing size, bleeding, pain.
4. Defects in the pelvic supports
5. Adenomyosis of uterus
6. Severe endometriosis
7. Acute or chronic Pelvic inflammatory
8. Early malignant (cancerous) changes or changes that may lead to cancer of the uterus / Cervix / Ovary.

Endometrial Hyperplasia
Endometrial hyperplasia is an abnormal change in the inner lining of the uterus that occurs most often to women who are experiencing change of life, when there is prolonged production of estrogen. Although endometrial hyperplasia is benign, it may progress to a stage called adenomatous hyperplasia. If you have this condition, your chances of developing uterine cancer are increased.

The diagnosis can be confirmed by endometrial biopsy, which is done in the office, or by dilatation and curettage, commonly called a D & C. In either procedure, the doctor scrapes tissue from the lining of the uterus, which is then examined under a microscope by a pathologist.

If the tissue is found to be precancerous, removal of the uterus will probably be recommended in order to prevent the development of cancer at a later time.

Leiomyomas or Fibroids
When they cause pain, or profuse or prolonged menstrual bleeding, put pressure on your bladder or rectum, or begin to grow rapidly, they should be taken out. Although nearly all fibroids are benign - noncancerous - on rare occasions such rapid growth may indicate a malignant change.

Removal of the uterus will solve the problem of troublesome fibroids. If you are a young woman who may want to have children and your fibroids are not too large or numerous, you may be able to have a myomectomy, an operation in which the fibroids are removed and the uterus is left in place. This may not be a cure, however, because in some cases new fibroids will grow, making further surgery necessary.

DEFECTS IN PELVIC SUPPORTS
When the ligaments that hold your uterus in place are weakened by childbearing or loss of elasticity due to aging, they allow the uterus to drop from its original positon down into and even through the vaginal opening. This is called Uterine prolapse.

Similarly, the supportive tissues of the vaginal walls may loose their elasticity, allowing the urethra, bladder (urethero-cystocele) and rectum (rectocele) to bulge out under the vagina.

By having you strain down during a pelvic examination, your doctor can see the bulging of the vagina and how far down the vagina the uterus has fallen. Urethro-cystocele and rectocele can be treated by surgical repair that restores the vaginal wall. Uterine prolapse can be treated by removal of the uterus.

ADENOMYOSIS
If you have been having prolonged periods with heavy bleeding, or pelvic or abdominal pain and tenderness before, during, and after your period, your doctor may suspect adenomyosis to be the cause. In this condition, most common in women in their 40's, endometrial-like tissue grows inside the wall of the uterus, making it soft, enlarged, and tender.

The presence of adenomyosis can be confirmed only after the uterus is removed and tissue from the wall is examined under a microscope. The only effective treatment for adenomyosis is removal of the uterus.

ENDOMETRIOSIS
The lining of the uterus is called the endometrium. Cells similar to those that normally line the uterus may also develop outside the uterus. This condition is called endometriosis. These "implants" attach themselves to the ovaries, tubes, bladder, rectum, or other parts of the abdominal cavity, where they act just as if they were the lining of the uterus - thickening and bleeding each month according to your ovarian cycle.

Always benign, these implants may grow between one organ and another, sticking them together with tight bonds called adhesions. When endometriosis occurs in the ovaries, blood-filled cysts often form endometriomas and can cause considerable sudden pain and tenderness. Other symptoms of endometriosis include premenstrual and menstrual pain, prolonged or heavy periods, tenderness in the lower abdomen, sharp stabbing pain during intercourse, and lower back pain.

Because endometriosis is so closely tied to the ovarian cycle, an absolute cure involves the removal of the uterus and both tubes and ovaries. Depending on your age and the spread of the disease, less extensive surgery may be performed. If there are not too many implants, it may be possible to remove them and leave the reproductive organs in place. But as long as the ovaries continue to function, new areas of endometriosis can arise.

Pelvic Inflammatory Disease
Pelvic inflammatory disease (P.I.D.) may be caused by any one of a number of bacterial infections, including gonorrhea. When acute infections of the tubes and/or ovaries cause abnormal pain and tenderness, fever, and a vaginal discharge, they are usually treated with antibiotics and bed rest. If the infection responds to treatment, the tubes will usually recover. But if the infection was treated too late, or did not respond to antibiotics, abcesses may arise that can rupture into the abdominal cavity, causing peritonitis. This condition can be life-threatening, and emergency removal of both tubes and ovaries as well as the uterus may be necessary.

In Chronic PID, the moderate infection responded to antibiotics, yet left you with permanent closed tubes or adhesions in and around the tubes, leading to pelvic and abdominal pain and painful intercourse. Depending on the extent of the disease, it might be necessary to remove both tubes and ovaries, as well as the uterus.

ENDOMETRIAL CANCER
This is a malignancy of the lining of the uterus, which tends to occur in women over 40. In women past menopause, endometrial cancer may produce a watery, bloody discharge or bleeding, while women who have not gone through change of life may notice abnormal periods or spotting between periods.

Treatment depends on the extent of the malignancy. It can involve the removal of the uterus, and both tubes and ovaries. The tubes and ovaries are sometimes removed because they are the first organs to be involved if the cancer spreads, and because estrogen production may stimulate residual cancer cells to grow. In some cases, surgery may be combined with pre- and post-operative radiation treatment.

HYSTERCTOMY - VAGINAL / ABDOMINAL / LAPAROSCOPIC ?
Now that you understand exactly why your physician believes a hysterectomy is necessary for you, it is vital that you also obtain a clear mental picture of exactly what he or she will do – in other words, which organs will be removed and by what technique.

There are three ways doctors perform a hysterectomy today and your doctor will describe which method he or she will use in your own particular case. Your age and your pelvic examination, among other factors, will shape the doctors decision as to the best technique for you.

VAGINAL HYSTERECTOMY
The uterus is removed through the vaginal opening, and the only incision is made internally. For a vaginal hysterectomy to be performed, your doctor should be able to remove the uterus easily - a prolapsed uterus that has dropped down or into the vagina is a perfect candidate. Vaginal repair is often combined with a vaginal hysterectomy. There is no abdominal incision, no scar, less pain, and you will return home more quickly.

Besides the types of hysterectomy shown, there are other types of hysterectomy. One is called subtotal (or supracervical or partial) hysterectomy. Here only the uterus itself is removed while the cervix and all other reproductive organs are left in place. Another type of operation is the myomectomy in which most of the uterus remains intact with only the diseased portion of the uterus being removed. The ovaries are retained in both subtotal hysterectomies and in myomectomies.

EFFECTS OF HYSTERECTOMY
Hysterectomy ends a women’s ability to become pregnant or to menstruate. It does not cause hormone related problems or weight gain. Although the woman will no longer have menstrual periods, it is important to remember that this does not mean she will be undergoing hormonal changes related to menopause. After the hysterectomy, the ovaries still produce hormones. A natural menopause occurs when the ovaries stop to produce hormones.

If the ovaries are removed with the uterus prior to menopause, there will be hormone-related effects. These effects can usually be treated satisfactorily with estrogen or hormone replacement therapy (HRT).

SEX AFTER HYSTERECTOMY
Of course you’re apprehensive! You’re naturally worried about hurting something inside or tearing your stitches. And your husband/partner is just as apprehensive as you are – maybe more. Rest assured that such injuries aren’t likely to happen; once your physician has given you the okay, you’re healed enough for sex. A doctor will usually advise against sexual intercourse for about four to six weeks after surgery.

Hysterectomy, over the long term, actually could enhance the sex lives of more than a few women – particularly women who’ve found birth control precautions annoying, inhibiting or both. Other women who have endured debilitating pain and/or severe bleeding for years discover new, relaxed enjoyment of their sexuality – at last.

In healthy young women, estrogens produced by the body thicken the lining of the urinary tract, and the vagina. As estrogen levels fall with advancing years, the vagina becomes drier and less elastic, making intercourse less than enjoyable – sometimes even painful – whether you’ve had a hysterectomy or not. If you’ve had your ovaries removed during a hysterectomy, vaginal dryness can be sudden and severe. A lubricant (such as Lubic Gel) will help during intercourse, but it won’t provide long-lasting relief of vaginal symptoms. The most effective way to relieve vaginal dryness is with estrogen – yet another reason to discuss this option with your doctor.

BENEFITS OF HYSTERECTOMY
Hysterectomy can improve your health and well-being if you have had severe pain, bleeding or some other problems related to your uterus. Women who have had a hysterectomy no longer have any risk of the cancer of the uterus.

Discomfort or pain in the abdomen, back or pelvis before a hysterectomy may or may not be related to the uterus. If you have had these problems and are scheduled for a hysterectomy, ask your doctor if the operation might relieve any of these conditions.

RISKS AND COMPLICATIONS OF HYSTERECTOMY
Hysterectomy is a major operation, however the surgical risk is one of the lowest of any major surgery. Mild problems like fever, temporary difficulty in bladder emptying or having bowel function may occur, but are easily corrected.

Complications related to anesthesia may occur, as with any operation. As with any major abdominal or pelvic surgery, serious complications such as bleeding, severe infection, injury to adjacent viscera (bladder, ureters, rectum, intestine), postoperative hemorrhage, bowel obstruction or even death, can occur.

The risks and possible benefits of the operation must b evaluated before surgery is considered.

Questions for your doctor

The information here can serve as a basis for further discussion with your doctor, who will respond to questions you may have about the operation.