Hysterectomy is the surgical removal of the uterus. The ovaries may also be removed, although this is not necessary for fibroid treatment. Hysterectomy is a permanent solution for fibroids, and is an option if other treatments have not worked or are not appropriate.
A woman cannot become pregnant after having a hysterectomy. If the ovaries are removed along with the uterus, hysterectomy causes immediate menopause.
Types of Hysterectomies
Once a decision for a hysterectomy has been made, the patient should discuss with her doctor what will be removed. The common choices are:
- Total hysterectomy (removal of uterus and cervix).
- Subtotal, also called supracervical hysterectomy (removal of uterus with preservation of the cervix).
- Oophorectomy (removal of an ovary). Bilateral oophorectomy is the removal of both ovaries. Bilateral salpingo-oophorectomy is the removal of the fallopian tubes and ovaries). These procedures can be performed with either total or supracervical hysterectomy.
Types of Hysterectomy Procedures
Hysterectomy procedures include:
- Abdominal hysterectomy
- Vaginal hysterectomy
- Laparoscopically assisted vaginal hysterectomy (LAVH)
- Total laparoscopic hysterectomy
- Robotic-assisted laparoscopic hysterectomy
Total Abdominal Hysterectomy
Total abdominal hysterectomy (TAH) has been the traditional procedure. It is an invasive procedure that is best suited for women with large fibroids, when the ovaries also need to be removed, or when cancer or pelvic disease is present.
The surgeon makes a 5- to 7-inch incision in the lower part of the belly. The cut may either be vertical, or it may go horizontally across the abdomen, just above the pubic hair (a bikini cut). The bikini cut incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases or with very large fibroids. The patient may need to remain in the hospital for 3 to 4 days, and recuperation at home takes about 4 to 6 weeks.
The American College of Obstetricians and Gynecologists (ACOG) recommends vaginal hysterectomy as the first choice, when possible. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. The vaginal incision is closed with stitches.
LAVH, and Total Laparoscopic Hysterectomy
Newer minimally invasive procedures have become the preferred methods for hysterectomy. ACOG recommends laparoscopic hysterectomy as the second choice for minimally invasive procedures. Laparoscopic hysterectomies use a laparoscope to help guide and perform the surgery, and allows the ovaries to be easily removed at the same time. The laparoscope is a thin flexible tube through which a tiny video camera and surgical instruments are inserted.
A variation of the vaginal approach is called laparoscopic-assisted vaginal hysterectomy (LAVH). It uses several small abdominal incisions through which the surgeon severs the attachments to the uterus and, if needed, ovaries. In LAVH, part of the procedure is completed vaginally, as in the standard vaginal approach. In total laparoscopic hysterectomy, the entire procedure is performed via laparoscopy, with the uterus either removed through the vagina or placed in a plastic bag and broken up into small pieces so it can be removed via the small laparoscopic incisions. The FDA discourages the use of laparoscopic power morcellation with hysterectomy (see below in "Complications".)
Vaginal hysterectomy, LAVH, total laparoscopic hysterectomy, and robotic-assisted laparoscopic hysterectomy may have fewer complications, shorter hospital stays, and faster recovery times than abdominal hysterectomy.
Robotic-assisted hysterectomy is a type of laparoscopic hysterectomy, but the surgical instruments are attached to a robot. The surgeon uses a computer console in the operating room to guide the robot's movements.
The American College of Obstetricians and Gynecologists (ACOG) advises that robotic hysterectomy is best suited for complex hysterectomies. Before choosing robotic hysterectomy, it is important to find a surgeon who has extensive training and experience with this technique.
Minor complications after hysterectomy are very common. Many women develop minor and treatable urinary tract infections. There is usually mild pain and light vaginal bleeding post operation. More serious complications are uncommon but can include infection, blood clots, or injury to adjacent organs.
Laparoscopic power morcellation is a procedure that is sometimes used during laparoscopic hysterectomy or myomectomy. The power morcellator is a rapidly spinning cutting device that breaks up the uterus into smaller fragments that can be removed through small abdominal incisions. It can push many of these small pieces of the uterus throughout the abdominal cavity.
In 2014, the FDA discouraged the use of laparoscopic power morcellation because of evidence that this procedure can spread cancer through the pelvis and abdomen in women who have undetected uterine sarcoma, a type of uterine cancer. As many as 1 in 350 women who undergo hysterectomy or myomectomy for uterine fibroids have this type of cancer. A black box warning was required on all product labels and several of these devices have been withdrawn from the market since. With even more evidence on the risk of spreading cancer, in 2017 the FDA reaffirmed its 2014 decision.
Power morcellators should never be used in women who are peri- or post-menopausal, or in women who have suspected or known uterine cancer. Younger women who are considering a fibroid procedure using power morcellation should discuss with their doctors all possible risks.
Ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:
- For 1 to 2 days after surgery, you will be given medications to prevent nausea and painkillers to relieve pain at the incision site.
- As soon as the doctor recommends it, usually within a day of the operation, you should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and speed recovery.
- Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major discomfort for the first few days.
- Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery.
- Do not lift heavy objects, douche or take baths, climb stairs or drive for several weeks following surgery.
- Discuss with your surgeon when you will be able to have sex after the procedure. The vaginal incision is the weakest part of the surgery and needs to heal completely before being tested.
Women who have had abdominal hysterectomies should discuss with their doctors when exercise programs more intense than walking can be started. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may have an on-going feeling of overall weakness, for some time. Some women do not feel completely well for as long as a year while others may recover in only a few weeks.
If a woman has had her cervix removed, she no longer needs annual Pap smears, unless she has had a prior history of abnormal Pap testing, or had cancer found at the surgery. However, women who have had any type of hysterectomy should continue to receive routine pelvic and breast exams, and mammograms.
Premature Menopause after Hysterectomy
Surgical removal of the ovaries causes immediate menopause. If the ovaries are not removed, they will usually continue to secrete hormones until the natural age of menopause (average age 51 to 52 years), even after the uterus is removed.
Because hysterectomy removes the uterus, a woman will no longer experience menstrual periods, even if she has not become menopausal. Studies show that women who have had hysterectomies become menopausal on average 1 to 3 years earlier than would naturally occur.
Your doctor may recommend you take hormone therapy (HT) after your hysterectomy. Women who have had a hysterectomy are given estrogen-only therapy (ET), which may be administered as pills or as a skin patch that releases the hormone into the bloodstream. It can also be given locally to treat specific symptoms such as vaginal dryness (see below). Hot flashes and vaginal dryness are the most common menopausal symptoms. Hot flashes are often more severe after surgical menopause than in menopause that occurs naturally.
Sexuality after Hysterectomy
Sexual intercourse may resume 6 to 12 weeks following surgery. The effect of hysterectomy on sexuality varies among women. Most studies show no negative impact on sexuality after hysterectomy. A small percentage of women notice a negative impact on their sex drive or response. Other women report increased sexual drive and pleasure because they are free from the problems that prompted hysterectomy.
A vaginal lubricant can help reduce vaginal dryness.Vaginal moisturizing agents are available over the counter and may be effective. Dryness may be more of an issue due to loss of the cervical mucus. In studies done on the subject, a low-dose vaginal estrogen treatment applied directly into the vagina is the most effective treatment for vaginal dryness. It will need to be prescribed by your doctor. Topical vaginal estrogen is available in a cream, tablet, or ring that is inserted into the vagina.