WHAT YOU SHOULD KNOW:
A hysterectomy is an operation to remove the uterus (womb). Most hysterectomies are not emergency operations, so you have time to think about your options. This information will help you understand your options and their meaning for you.
FUNCTIONS OF THE UTERUS AND OVARIES:
The uterus cradles and nourishes a baby from conception to birth, and aids in the delivery of the baby. It also produces the monthly menstrual flow, or period.
The ovaries have two main functions. One is to produce eggs or ova, which permit childbearing. The second is to produce female hormones or chemicals which regulate menstruation and other aspects of health and well-being, including sexual well-being.
If the egg that is released during a woman's normal cycle is not fertilized, the lining of the uterus is shed by bleeding (menstruation).
After a hysterectomy, a woman can no longer have children and menstruation stops. The ovaries generally continue to produce hormones, although in some cases they may have reduced activity.
Some hysterectomies also include the removal of the ovaries, so the supply of essential female hormones is greatly reduced. This can have various effects, as discussed later.
WHEN IS A HYSTERECTOMY PERFORMED?:
The most common reason a hysterectomy is done is for uterine fibroids. The next most common reasons are abnormal uterine bleeding, endometriosis, and uterine prolapse (including pelvic relaxation). Only 10% of hysterectomies are performed for cancer. The remainder of this information will focus on the use of hysterectomy for non-cancerous, non-emergency reasons.
Uterine fibroids (also known as uterine leiomyomata) are by far the most common reasons a hysterectomy is performed. Uterine fibroids are benign (non-cancerous) growths of the uterus. The cause is unknown. Although they are benign, meaning they do not cause or turn into cancer, uterine fibroids can cause medical problems, such as excessive bleeding. Pelvic relaxation is another condition that can require treatment with a hysterectomy. In this condition, the support muscles and tissues in the pelvic area will loosen. Symptoms such as urinary incontinence (unintentional loss of urine) and impaired sexual performance may happen. Urine loss tends to be aggravated by sneezing, coughing or laughing. Childbearing may increase the risk for pelvic relaxation, though the exact reasons are unknown.
A hysterectomy is also done to treat cancer of the uterus or very severe pre-cancers (called dysplasia). A hysterectomy for uterine cancer has an obvious prupose, that of removal of the cancer from the body. This procedures is the foundation for treatment for cancer of the uterus.
HOW IS A HYSTERECTOMY PERFORMED?
Most commonly, a hysterectomy is done by an incision (cut) through the abdomen (abdominal hysterectomy) or through the vagina (vaginal hysterectomy). This hospital stay generally tends to be longer with an abdominal hysterectomy than with the vaginal hysterectomy (4 vs. 6 days on average) and hospital charges tend to be higher as well. The procedures seem to take comparable lengths of time (about 2 hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.
WHAT ARE THE TYPES OF HYSTERECTOMIES?
There are now a variety of surgical techniques for performing hysterectomies. The ideal surgical procedure for each woman depends on her particular medical condition. Below, the different types of hysterectomies are discussed with general guidelines about each technique for the different types of medical situation. However, the final decision must be made from an individualized discussion between the woman and the physician who best understands her individual situation.
Remember, as a general rule, before any type of hysterectomy, women should have the following tests in order to select the optimal procedure:
Complete pelvic exam including manually examining the ovaries and uterus
Up-to-date pap smear
Pelvic ultrasound may be appropriate, depending on what the physician orders.
TOTAL ABDOMINAL HYSTERECTOMY:
This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedures is performed, and the size of the area being treated. Cancer of the ovary and uterus, endometriosis and large uterine fibroids are treated with total abdominal hysterectomy. Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain and only after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.
VAGINAL HYSTERECTOMY:
During this procedures, the uterus is removed through the vagina. A vaginal hysterectomy is used only for conditions such as uterine prolapse, endometrial hyperplasia or cervical dysplasia. These are conditions in which the uterus is not too large and in which the whole abdomen does require examination. Women who have not had children may not have a large enough vaginal canal for this type of procedure. If a woman has too large a uterus, cannot have her legs raised in the stirrup device for prolonger periods or has other reasons why the whole upper abdomen must be further examined, the doctor will usually recommend an abdominal hysterectomy (see above).
LAPAROSCOPY-ASSISTED VAGINAL HYSTERECTOMY:
This is similar to the vaginal hysterectomy procedure described above, but it adds the use of a laparoscope. A laparoscope is a very thin viewing tube with a magnifying glass-like device at the end of it. Certain women would be best served by having laparoscopy used during vaginal hysterectomy because it allows the upper abdomen to be carefully inspected during surgery. Examples of uses of the laparoscope would be for early endometrial cancer, to verify lack of spread, or if oopherectomy (emoval of the ovaries) is planned. Compared to simple vaginal hysterectomy or abdominal hysterectomy, it is a more expensive procedure, is more prone to complications, requires longer to perform and is associated with longer hospital stays. Just as with simple vaginal hysterectomy without a laparoscope, the uterus must not be excessively large. The physician will also review the medical sistuation to be sure there are no special risks prohibiting use of the procedure, such as prior surgery that could have increased the risk for abnormal scarring (adhesions). If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular abdominal hysterectomy is probably best. In general, laparoscopic vaginal hysterectomy is more expensive and has higher complication rates than abdominal hysterectomy.
SUPRACERVICAL HYSTERECTOMY:
A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a "stump". Women who have had abnormal pap smears or cancer of the cervix clearly are not appropriate candidates for this procedure. Other women may be able to have the procedure if there is no reason to have the cervix removed. In some cases the cervix is actually better left in place, such as some cases of severe endometriosis. It is a simpler procedure and requires less time to perform. It may give some added support of the vagina, decreasing the risk for the development of protrusion of the vaginal contents through the vaginal opening (vaginal prolapse).
RADICAL HYSTERECTOMY:
This procedure involves more extensive surgery than a total abdominal hysterectomy because it also includes removing tissues surrounding the uterus and removal of the upper vagina. Radical hysterectomy is most commonly performed for early cervix cancer. There are more complications with radical hysterectomy compared to abdominal hysterectomy. These include injury to the bowels and urinary system.
OOPHERECTOMY AND SALPINGO-OOPHORECTOMY
(REMOVAL OF THE OVARIES AND/OR FALLOPIAN TUBES):
Oophorectomy is the surgical removal of the ovary while salpingo-oophorectomy is the removal of the ovary and its adjacent fallopian tube. These two procedures are performed for cancer of the ovary, removal of suspicious ovarian tumors, or Fallopian tube cancer (whichi s very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Occasionally, a women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventative (prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast. Such familial disorders are also very rare.
WHAT ARE THE COMPLICATIONS:
Complications of a hysterectomy include infection, pain and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.
CARE AGREEMENT:
You have the right to help plan your care. To help with this plan, you must learn what is causing your pain and how it can be treated. You can then discuss treatment options with your caregivers Work with them to decide what care and treatments will be used to treat you. You always have the right to refuse a treatment.
WHAT ARE THE BENEFITS & RISKS OF HYSTERECTOMY?
The risks of hysterectomy include the risks of any major operation, although its surgical risks are among the lowest of any major operation. Hysterectomy patients may have a fever during recovery and some may have a mild bladder infection or wound infection. If an infection occurs, it can usually be treated with antibiotics. Less often, women may require blood transfusion before surgery because of anemia or during surgery for blood loss. Complications related to anesthesia may occur.
As with any major abdominal or pelvic operation, serious complications such as blood clots, severe infection, adhesions, postoperative (after surgery) hemorrhage, bowel obstruction or injury to the urinary tract can happen. Rarely, even death can occur.
In additional to the direct surgical risks, there may be longer-term physical and psychological effects, potentially including depression and loss of sexual pleasure. If the ovaries are removed along with the uterus prior to menopause (change of life), there is an increased risk of osteoporosis as well.
INFORMED CONSENT:
You have the right to understand your health problem. In words you can understand, you should be told what tests, treatments or procedures may be done to treat your problem. Your doctor should also tell you about the risks and benefits of each treatment.
You will be asked to sign a consent form. If you are unable to give your consent, someone who has permission (in writing) can sign this form for you. A consent form is a legal piece of paper that gives your doctor permission to do certain tests, treatments or procedures. This form should tell you exactly what will be done to you. Your doctor should tell you what the risks and benefits of each treatment are before you sign the form. Before giving consent, make sure all your questions have been answered so that you understand what may happen.
PRE-OP CARE:
You may be given medicine right away before surgery. This medicine may make you feel sleepy and more relaxed. You are taken on a stretcher to the room where your surgery will be done. Caregivers help you get comfortable on the bed. A belt may be put over your legs for safety. If you get cold, ask for more blankets.
GENERAL ANESTHESIA:
This is medicine given to keep you completely asleep and free from pain during surgery. It may be given as a liquid in your IV. Or, it is given as a gas through a face mask or a tube placed in your mouth and throat. This tube is called an endotracheal (end-o-tra-kee-ull) tube or "ET" tube. Usually you are asleep before caregivers put the tube into your throat. The ET tube is usually removed before you wake up.
Do not sign legal documents for 24 hours after having anesthesia. Also, do not drive or use heavy equipment. The medicine may make you drowsy and your thinking unclear.
HEART MONITOR:
This is also called an EKG or an electrocardiogram (e-lek-tro-kar-d-o-gram). It is a painless test to see how your heart is working. Sticky pads (3 or 5) are placed on different parts of your body. Each pad has a wire that is hooked to a TV-type screen. This screen shows a tracing of each heartbeat. Your heart is being watched all the time to make sure your body is handling surgery well.
PULSE OXIMETER:
This is a machine that tells how much oxygen is in your blood. A cord with a clip or sticky strip is placed on your ear, finger or toe. The other end of the cord is hooked to a machine. Caregivers use this machine to see if you need more oxygen.
VITAL SIGNS:
Vital signs include your temperature, blood pressure, pulse (counting your heartbeat) and respirations (counting your breaths). To take your blood pressure, a cuff is put on your arm and tightened. The cuff is attached to a machine which gives your blood pressure reading. Caregivers may listen to your heart and lungs by using a stethescope (steth-uh-skop). Your vital signs are taken so caregivers can see how you are doing.
DURING SURGERY:
Caregivers clean your abdomen with soap and water. This soap may make your skin yellow, but it will be cleaned off later. Sheets are put over you to keep the surgery area clean. After your hysterectomy, the incision will be closed with staples, thread, adhesive strips or a combination of these.
AFTER SURGERY:
After the surgery is completed, your your hospital stay is usually less than a week, depending on the type of hysterectomy and whether there are any complications. Since this is a major operation, discomfort and pain from the surgical incision are most pronounced during the first few days after surgery, but medication is available to minimize these symptoms. By the second or third day, most patients are up walking. Normal activity can usually be resumed in four to eight weeks. Each patient is an individual, so the pace of recovery will vary. Sexual activity can usually be resumed in eight weeks. During recovery, you may need to rest frequently at first. Plan ahead and ask friends, neighbors or relatives to help you when you get home. It will probably take a while to feel "peppy". Many women find some special exercises your doctor can prescribe helps them recover faster and feel better.