Understanding Hysterectomy

Fears, alternatives and misconception

Written by Paragi Shah, DO, Board Certified OB/GYN

There are three common reasons hysterectomies are performed:

1. Abnormally heavy uterine bleeding caused by uterine fibroids (the most common reason hysterectomies are performed), perimenopausal bleeding, or a condition known as adenomyosis where the lining of the uterus becomes imbedded within the muscles of the uterus, causing heavy bleeding.
2. Chronic pelvic pain often caused by endometriosis, an abnormal condition where some of the lining of the uterus gets deposited in the pelvic cavity causing severe menstrual cramps.
3. Female cancers, such as uterine, ovarian and cervical cancer. These only account for about 10% of hysterectomies performed.

What is the difference between a subtotal hysterectomy and the total hysterectomy?
In a subtotal hysterectomy, the uterus is surgically removed, but the cervix, which is the opening of the uterus, is left intact. This is also called a partial hysterectomy. In a total hysterectomy, also known as a complete hysterectomy, both the uterus and the cervix are surgically removed.

What are the different procedures used for hysterectomy?
There are various surgical techniques, and the ideal surgical procedure for each woman depends on her specific medical condition,. The following different types of hysterectomy are basic definitions and descriptions. Again, the final decision of which procedure is best for the patient should be discussed with her physician.

Total abdominal hysterectomy
This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix, through a large abdominal incision. A woman cannot bear children after this procedure, so it is not generally performed on women of childbearing age, unless absolutely necessary.

Vaginal hysterectomy
During this procedure, the entire uterus is removed through the vagina. Vaginal hysterectomy is appropriate for uterine prolapse and precancerous conditions of the cervix and uterus. Women who have not had vaginal delivery may not have a large enough vaginal canal for this surgery.

Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
During this procedure the upper two thirds of the uterus is separated from surrounding tissues laparoscopically (with a scope through the belly button), then the lower third of the uterus is detached vaginally in order to remove the entire uterus through the vaginal canal.

Supracervical hysterectomy
A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a "stump." This type of procedure can be performed through an abdominal incision or laparoscopically. The downside of this procedure is that there is always a chance of developing cervical cancer; therefore, this is done on very selective patients with low risk for cervical cancer.

Radical hysterectomy
The radical hysterectomy procedure involves more extensive surgery than a simple 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 cervical, uterine and ovarian cancers. There are often more complications with radical hysterectomies compared to a simple hysterectomy. These include injury to the bowels and urinary system.

Oophorectomy and salpingo-oophorectomy (removal of the ovaries and/or Fallopian tubes)
Salpingo oophorectomy means removal of one or both salpinx (fallopian tubes) and oophor (ovaries). This procedure can be performed at the same time in any of the previously mentioned hysterectomies. It is the removal of these ovaries that puts a premenopausal women in menopause.

As a general rule, before any type of hysterectomy, women should have the following tests in order to choose the best procedure:

• Complete pelvic exam including manually examining the ovaries and uterus
• An up-to-date Pap-smear
• Pelvic ultrasound, depending on what the physician finds
• A decision regarding whether or not to remove the ovaries at the time of hysterectomy and, if ovaries are removed, whether hormone replacement will be necessary

What are the possible complications of a hysterectomy?
Complications of a hysterectomy include infection, pain and bleeding in the surgical area and damage to surrounding organs (i.e. bowels, bladder, major blood vessels). An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.

What are the alternatives to a hysterectomy?
This depends on why the hysterectomy is recommended. If heavy bleeding is the reason for hysterectomy, the following are the alternatives to consider:

Endometrial ablation – The lining of the uterine wall is “burned” causing the lining to scar in order to reduce heavy menstrual blood flow. This is an outpatient procedure with a recovery period from anywhere to a few days to a couple of weeks, compared to the traditional hysterectomy with the downtime of about 4 to 6 weeks.

Uterine fibroid embolization – In this procedure, a catheter is placed through the groin and a material is injected into the vessel to block the vessel that is “feeding” the fibroid, causing the excessive bleeding. Again, this procedure has minimal downtime compared to a traditional hysterectomy.

What are the biggest misconceptions about hysterectomies?
A hysterectomy does not always include the removal of the ovaries and tubes. A woman will not go into menopause unless she is pre-menopausal and both of her ovaries are removed at the time of hysterectomy. A hysterectomy does not physically decrease one’s sex drive. Many times, however, a patient may not see herself as a “complete woman” after the procedure which may affect intimacy between her and her partner. Some have expressed that, during sex, they don’t feel the stimulation as much or that having intercourse is painful. In some rare cases, the vaginal canal is slightly shortened due to the procedure and may cause discomfort. But many patients will also comment that prior to the hysterectomy the pelvic pain and the excessive bleeding were so severe that they couldn’t even think about sex. Again, a patient should feel comfortable in discussing these concerns with her physician.

When do I ask for a second opinion?
I believe when it comes to any major surgery, a patient should feel comfortable with the physician’s recommendation. If you feel your physician is too absolute in his or her decision to perform a “traditional” hysterectomy without discussing other possible options or you feel your questions or concerns were not completely addressed, it might be time to get a second opinion. Go back to your primary care physician to get another name of a gynecologist or ask other friends or relatives for recommendations.

Remember, you, the patient, have the ultimate say in how to address your condition, but do listen to what your physician has to say. Surround yourself with medical professionals and supportive people (close family and friends) who have your best interest at heart.

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